Demographics:
58 years old, Female
Indication:
Trauma
Findings
Chest
- Endotracheal tube terminates above the carina
- Mildly dilated, fluid-filled esophagus
- Mild ectasia of the ascending aorta measuring up to 4.2 cm in diameter
- Mild dependent bilateral lower lobe opacities
Abdomen/Pelvis
- Splenic laceration measuring > 3 cm in depth with surrounding hemoperitoneum. No evidence of active hemorrhage or pseudoaneurysm
- Small volume perihepatic hemoperitoneum. Focal notching in the medial margin in the inferior tip of the right hepatic lobe is favored chronic
- Scattered subcentimeter hepatic hypodensities, which are too small to characterize. Likely small calcified granuloma in segment 6
- Bilateral subcentimeter renal hypodensities, too small to characterize
- Gastric suction tube terminates in the gastric fundus
- Bladder is decompressed around a Foley catheter, with gas in the bladder likely relating to instrumentation
MSK
- Acute fractures of the left third through tenth ribs with segmental fractures of the left seventh through ninth ribs
- Partially imaged acute comminuted fracture of the distal left humerus with subcutaneous emphysema
- Circumscribed lucency in the left iliac wing, which may be congenital, postprocedural, or sequela of remote trauma
- L1 and L2 vertebral venous malformations (hemangiomas)
- Severe S-shaped thoracolumbar scoliosis with multilevel fusion of the posterior elements
Diagnosis
Splenic laceration
Sample Report
Grade III splenic laceration with surrounding hemoperitoneum. No evidence of active hemorrhage or pseudoaneurysm formation.
Acute fractures of the left third through tenth ribs including segmental fractures of the seventh through ninth ribs.
Partially images acute comminuted fracture of the distal left humerus with adjacent locules of soft tissue gas raising concern for open fracture.
Fluid-filled esophagus, which places the patient at risk for aspiration.
Dependent bilateral lower lobe pulmonary opacities may relate to atelectasis and/or aspiration.
Discussion
References