19.05.

2017 BULETININVESTIGATII

BULETININVESTIGATIIIMAGISTICE


NUME:DUMITRACHEELENA
CNP:2570207211665
DATANASTERII:07/02/1957
DATAEXAMINARII:12/05/2017
MEDICTRIMITATOR:ENECATALINAELENA

EXAMINARE:CT2regiunicucontrast

REZULTAT:
ExaminareaCTatoraceluisiabdomenuluisuperior,efectuatanativsicusubstanta
decontrastadministrata,evidentiaza:
procesexpansivrotundovalar,cudiametredeaproximativ78/65mminplanaxial,
custructuraneomogena,incluzandariihiopocaptante,dezvoltatinsegmenteleapical
simediobazalalelobuluipulmonarinferiordrept.Formatiuneaesteplacatalapleura
parietotoracicacostovertebraladreaptasilaceamediastinalaposterioaradreapta,
pecareoinfiltreaza,invadandgrasimeamediastinalasicelputinaparentperetele
esofaguluitoracic,careapareinamontemoderatdilatat.Eamansoneazabronhia
lobarainferioaradreaptasiorigineasegmentareloracesteia,pecareleingusteazain
majoritate,panalaaamputaramurilededicatesegmentelormentionateanterior.
Procesulexpansivtrimiteprelungiriinfiltrativespreparenchimulpulmonardinjur,
amprenteazapereteleposterioralatriuluistangsiatingepleuradiafragmatica
insegmentulapicalalLSDexistaoplajadeconsolidatiealveolaraneomogena,
carecontinesiesteinconjuratadenumeroasetraiectebronsiectatice,careareo
compnentatisularacuaspectnodularsicaretrimitenumeroaseprelungiriinfiltrative
retractileinparenchimuldinjursisprepleuraapicaladreapta,careaparetractionata
adenopatieneomogencaptanta,cudiametruldemaxim21mm,sesitueazala
nivelulmediastinuluianteriordebronhiaprimitivadreaptalaemergenta
altilimfoganglionimediastinalisuntvizibilipresilaterotrahealbilateral,infereastra
aortopulmonara,lojaBaretty,presiretrocarenal,avanddiametredepanalamaxim
13mm
adenomegaliiinhilurilepulmonarebilateral,cudiametredepanalaaproximativ20
mmindreaptasi10mminstanga
segmentelevizualizatealesistemuluiarterialpulmonarcapteazaomogensubstanta
decontrastadministrataintravenos
acumularefluidapleuraladreaptacugrosimeamaximaastratuluidelichidde
aproximativ20mm(masuratoareefectuataposterobazal,pacientafiindpozitionatain
decubitdorsal)

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19.05.2017 BULETININVESTIGATII

faramodificaripleuropulmonarestangivizibileCT
lamafluidapericardicacugrosimedemaxim13mmbordeazaconturulinferolateral
dreptalcordului
ficatularedimensiuniglobalcrescutesiaspectsteatozicparcelar,farasase
evidentiezeCTprocesefocalizatepropriuziselanivelulparenchimuluisau
nusevizualizeazacolecistul
usoaradistensieaunoradintrecailebiliareintrahepaticesiaductuluibiliarprincipal,
careareuncalibrudepanalaaproximativ11mm,farasaprezinteinsadecalibrari
brustesauanomaliidecontinutvizibileCT
lanivelulglandeisuprarenalestangiseremarcaunnodulcustructuratisulara
neomogenasiprizadecontrastprezenta,cudiametredeaproximativ24/15mm
chistcorticalrenalstangdeaproximativ11mmdiametru.Rinichiulstangprezinta
deasemenitractionaricapsularecelmaiprobabilcusubstratcicatricealsibifiditate
bazinetoureterala.Inrest,aspectulmorfologicrenalesteCTnormalbilateralsinu
suntevidentedilatatiialeSPC.Nefrogramasiurogramasuntprezentesimetric,
bilateral
splinaaredimensiuninormalesiprezintalapolulsuperior,subcapsularlateral,o
micaariehipocaptantaprecocesicuincarcareprogresivadesubstantadecontrast
glandasuprarenaladreaptasipancreasfaramodificaripatologicevizibileCT
nusaudecelatadenomegaliipatologicesauacumularifluideperitonealein
abdomenulsuperior
nusaudecelatmodificaridestructuraosoasacuaspectcerttumoralsecundarla
nivelulpieselorscheleticedinariadeexaminare
aortaabdominalaestedilatataneuniformpetottraiectulsiprezintadepuneri
parietalepartialcalcificate,precumsimodificaridetiptromboticjuxtaparietale
dispuserelativcirumferential,careingusteazalumenulsaucirculantcupanala
aproximativ50%sicaresepropagadeclivlanivelulartereiiliacecomunestangi.

Concluzii:
ProcesexpansivLIDcareinfiltreazamediastinulposteriorsifoarteprobabil
esofagultoracic,careestemoderatdilatatinamonte.
Arielezionalaalveolointerstitialaapicalapulmonaradreaptacusubstratincert,cel
maiprobabilfibrocicatriceal.
Adenomegaliimediastinalesihilarepulmonarebilaterale.
Pleureziedreapta.
Minimapericardita.
Formatiunenodularasuprarenalianastangacusubstratincert,posibilsecundar.
Hepatomegaliesteatozica.
UsoaradistensieaunorCBIHsiaCBPincontextuluneicolecistectomii.
Ariehipocaptantasubcapsularasplenicapolarasuperioara,celmaiprobabilcu
substratischemic.
Chistcorticalrenalstang.
Bifiditatebazinetoureteralastanga.
Ateromatozaaortica,inprincipalabdominala,segmentincareexistadefecte
marginalederepletiecusubstantadecontrastceproducingustarilumenale
semnificativealeacesteia.

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19.05.2017 BULETININVESTIGATII

Medicexaminator:MedicRadiologPavelescuRaluca
Codparafa:292032

Codformular:F5.801Tiparitde:2570207211665Inregistratde:GereaLoredana
Datatiparirii:19May201711:04:16

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