Findings
Chest
- Mild anterior mediastinal fat stranding
- Mild dependent atelectasis
- Scattered pulmonary micronodules
- Post CABG changes
- Moderate coronary artery calcification
- Thoracic aortic atherosclerosis without aneurysm
- No pneumothorax
Abdomen/Pelvis
- Anterior left hepatic lobe laceration measuring 3.2 cm in depth with small adjacent hematoma but no evidence of active hemorrhage
- 2 cm rounded hypoattenuating lesion in the left hepatic lobe
- Hepatomegaly with diffusely decreased attenuation of the liver compatible with steatosis
- Small, < 1 cm, laceration in the anterior spleen with small adjacent hematoma but no evidence of active hemorrhage
- Cholecystectomy
- Mildly edematous appearance of the pancreatic tail with adjacent fat stranding
- Intermediate attenuation lesions in the right and left adrenal glands, each measuring up to 2.5 cm
- Tiny nonobstructing calculus in the interpolar left kidney
- Subcentimeter hypoattenuating lesion in the upper pole of the right kidney which is too small to characterize
- Small volume hemoperitoneum layering in the anatomic pelvis
MSK
- Acute nondisplaced fracture of the left aspect of the manubrium
- Acute nondisplaced fractures of the left lateral third, fourth, and fifth ribs
- Right neck, upper anterior chest wall, and upper ventral abdominal wall soft tissue contusions
- Multilevel degenerative changes of the spine, most pronounced at L3-L4 and L4-L5
Diagnosis
Liver laceration (grade III)
Spleen laceration (grade I)
Adrenal hematomas
Pancreatic trauma
Sample Report
Laceration in the left hepatic lobe measuring greater than 3 cm in depth with small adjacent hematoma but no evidence of active hemorrhage. An adjacent hypoattenuating lesion could represent a contusion or indeterminate liver lesion. This finding can be reassessed at follow-up imaging as discussed below.
Spleen laceration measuring less than 1 cm in depth with small adjacent hematoma but no evidence of active hemorrhage.
Bilateral intermediate attenuation adrenal lesions likely representing hematomas. Recommend follow-up adrenal protocol CT in 3 months to ensure resolution.
Mildly edematous appearance of the pancreatic tail and adjacent fat stranding concerning for pancreatic injury. Recommend correlation with lipase values.
Nondisplaced manubrial fracture with anterior mediastinal fat stranding concerning for associated mediastinal hematoma. No evidence of aortic trauma.
Acute nondisplaced fractures of the left lateral third through fifth ribs. No pneumothorax.
Seatbelt pattern of soft tissue contusion involving the right neck, upper chest, and upper abdomen.
Discussion
References