Findings
Chest
- Patchy groundglass opacities throughout the right lung
- Mild dependent groundglass opacities in the left lower lobe
- Moderate right hemothorax
- Apically directed right thoracostomy tube is slightly kinked against the posterior rib margin
- No pneumothorax
Abdomen/Pelvis
- Large liver laceration measuring 16 x 7 cm with involvement of hepatic segments III, IVB, V, VI, and VII. No evidence of active hemorrhage
- Moderate volume of perihepatic hemoperitoneum tracking inferiorly into the anatomic pelvis
- Tiny locule of pneumoperitoneum in the right upper quadrant
MSK
- Ballistic fragment adjacent to the L2 spinous process
- Acute highly comminuted right tenth rib fracture
- Right chest wall subcutaneous emphysema
Diagnosis
Liver laceration (grade V)
Sample Report
Sequela of gunshot wound to the right upper quadrant with a large liver laceration involving greater than three hepatic segments and moderate perihepatic hemoperitoneum. Tiny locule of pneumoperitoneum likely relates to the penetrating injury. No evidence of active hemorrhage.
Moderate right hemothorax without pneumothorax, which raises concern for associated injury to the right hemidiaphragm.
An apically direct right thoracostomy tube is slightly kinked against the posterior rib margin. Recommend correlation with tube function.
Patchy groundglass opacities in the right lung likely represent a combination of contusion, aspiration, and atelectasis.
Acute comminuted right tenth rib fracture.
Retained ballistic fragment overlying the L2 spinous process.
Discussion