CT Scan Report

CT Scan Report: - Body Parts: Thorax Clinical Information: - Indication: Persistent cough, haemoptysis, and unexplained weight loss in a 55-year-old male. Suspicion of pulmonary malignancy. - History: Patient has a 20-year history of smoking (20 pack-years). No prior imaging studies of the chest. No known history of TB or HIV. No recent trauma. Technique: - Non-contrast and contrast-enhanced CT scan of the thorax was performed using a standard oncology protocol. Intravenous omnipaque contrast was administered. Images were acquired with 1.25mm slice thickness in axial, coronal, and sagittal planes. Findings: - A spiculated mass measuring approximately 3.5 x 2.8 cm is noted in the superior segment of the left lower lobe, demonstrating heterogeneous enhancement post-contrast. Several enlarged mediastinal lymph nodes are present, with the largest measuring 1.8 cm in the subcarinal region. No evidence of pleural effusion or pneumothorax. No obvious bone destruction. Comparison to previous imaging is not available. Impression: - Left lower lobe pulmonary mass highly suspicious for malignancy with associated mediastinal lymphadenopathy. Recommendations: - Recommend urgent referral to pulmonology for further evaluation, including bronchoscopy and biopsy. PET-CT for staging may be considered. Review by an oncologist is advised. Radiologist: - Name: Dr. Thomas Kelly - Date: 1 November 2024