Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

CT Angiogram of Abdominal Aorta Transcription Sample Report

DATE OF STUDY:  MM/DD/YYYY

STUDY PERFORMED:
CT angiogram.
  
REASON FOR STUDY:
Status post SMA stent, belly pain, abdominal pain.

ORDERING PHYSICIAN:
John Doe, MD

PRIMARY CARE PHYSICIAN:
Jane Doe, MD

PROCEDURE TECHNIQUE:
Standard CT angiogram of the abdominal aorta with run-off to the iliac arteries was performed. Optiray 130 mL was used for contrast.

PROCEDURE FINDINGS:
1.  Mesenteric vessels.  The celiac artery has a mild stenosis at the ostium.  The superior mesenteric artery has a widely patent stent within the proximal portion to the ostium.  There is very minimal restenosis in the stent.  There is no lesion distally or proximally.  The inferior mesenteric artery is patent with no evidence for stenosis.
2.  Renal arteries.  The left renal artery has a widely patent left renal artery stent.  There is no restenosis of the stent.  The vessel bifurcates immediately after the stent.  The right renal artery is widely patent as well.  It comes out superior to the left.  There is an accessory renal artery to the right kidney, which comes off in the mid abdominal aorta.  It is free of any significant disease, feeds the inferior pole of the right kidney.
3.  Abdominal aorta.  The abdominal aorta has diffuse plaquing throughout with mild to moderate calcification.  There is no dissection, no aneurysm noted.
4.  Iliac arteries.  The left common iliac artery has a widely patent stent; it is just proximal to the internal iliac artery.  There is no stenosis in the stent.  The internal iliac artery is patent with mild disease.  The external iliac artery is patent with no significant disease.  The left common iliac artery has calcified plaquing but no significant stenosis.  The right internal iliac artery is widely patent.  The right external iliac artery is patent.

CONCLUSION:
1.  Patent superior mesenteric artery stent.
2.  Patent left renal artery stent.
3.  Two renal arteries to the right kidney, which are both free of significant disease.
4.  Patent left common iliac artery stent.

Radiology overread is pending.