Radiologist CT Thorax Abdomen Pelvis Report Template

CT THORAX ABDOMEN PELVIS **Scan date:** 11 2024 **CLINICAL INFORMATION** - 65-year-old male with new onset abdominal pain and weight loss. - Concern for possible malignancy. **PRIOR IMAGING** - CT Abdomen Pelvis 05/2023: No significant abnormalities noted. No masses or adenopathy. Liver 15 cm craniocaudal dimension. **Technique** - Multi-detector CT scanner. - IV contrast administered. - Oral contrast administered. - Images acquired in portal venous phase. **FINDINGS** **Unenhanced findings** - No evidence of acute haemorrhage or calcifications within the abdomen or pelvis. - Mild degenerative changes of the lumbar spine are noted. **Post-contrast findings** - Liver demonstrates a hypodense lesion in segment VI, measuring 2.5 x 2.0 cm, showing peripheral enhancement with central non-enhancement, suspicious for hepatocellular carcinoma. No other focal liver lesions are identified. - Pancreas is normal in size and attenuation. No pancreatic duct dilatation. - Spleen is normal in size and homogeneity (10 cm craniocaudal dimension). - Adrenal glands are normal. - Kidneys are normal in size, shape, and enhancement pattern. No hydronephrosis or calculi. - Small bowel and large bowel loops appear unremarkable, with no evidence of obstruction or inflammatory changes. **General abdomen and pelvis findings** - No free fluid or pneumoperitoneum. - No lymphadenopathy in the retroperitoneum or pelvis. - Prostate gland appears mildly enlarged, homogeneous. - No suspicious bone lesions. **Thorax/chest/other findings** - Lungs are clear, with no focal consolidation, pleural effusion, or pneumothorax. - No mediastinal or hilar lymphadenopathy. - Heart size is within normal limits. - Mild atherosclerotic changes of the aorta are noted. **CONCLUSION** - Hypodense lesion in liver segment VI, 2.5 x 2.0 cm, consistent with hepatocellular carcinoma. - No other signs of metastatic disease in the chest, abdomen, or pelvis. - Recommend MRI liver for further characterisation of the lesion. Incidental moderate coronary artery calcification demonstrated. If the patient has associated symptoms of angina, recommend management as per chest pain guidelines, including cardiology referral if appropriate. If the patient is asymptomatic, routine cardiology referral not required, GP and/or referring clinician to consider reviewing modifiable cardiovascular risk factors and managing as per guidelines for primary prevention. Moderate aortic valve calcification. This may indicate the presence of aortic valve stenosis. Consider echocardiography if clinically appropriate.