Patient Information
Patient Demographics
Name: Sister Dorris Jones
Age: 60 years
Date of Birth: 2/12/1965
Medical Record Details
MRN: #009876543
Primary Care Physician: Dr. Sarah Williams
Insurance: Medicare
Emergency Contact
Name: Mother Superior Clare
Relationship: Religious Order Superior
Phone: (555) 123-4567
Recent Imaging Summary

6/15/2024

CT Abdomen with Contrast - CURRENT Patient: Dorris Jones, DOB 2/12/1965 Date of Scan: 2023-04-15 Exam: CT Abdomen and Pelvis with IV Contrast Findings: The CT scan of the abdomen and pelvis demonstrates a distended gallbladder containing multiple gallstones of varying sizes. The largest stone measures approximately 1.5 cm. The gallbladder wall is thickened and edematous, suggestive of cholecystitis. No significant biliary ductal dilatation or evidence of choledocholithiasis is seen. The liver and pancreas appear unremarkable. Impression: Cholelithiasis with acute cholecystitis. No evidence of biliary ductal obstruction or choledocholithiasis. Recommendations: Consultation with a surgeon for consideration of cholecystectomy. Additional Notes: The patient's medical history and clinical presentation should be considered in conjunction with these imaging findings. If symptoms persist or worsen, further imaging evaluation may be warranted. Radiologist: Dr. John Doe Date: 2023-04-15 Please note: This is a sample report and may not be applicable to all cases. The specific findings and recommendations will vary depending on the individual patient's clinical presentation and imaging results.

6/10/2024

Abdominal Ultrasound Impression: Multiple gallstones: The ultrasound image reveals the presence of multiple gallstones within the gallbladder. These appear as echogenic foci with posterior acoustic shadowing. Thickened gallbladder wall: The gallbladder wall appears thickened, suggesting inflammation (cholecystitis). No biliary ductal dilatation: The common bile duct is not dilated, indicating no evidence of obstruction. Recommendations: Clinical correlation: The ultrasound findings should be correlated with the patient's clinical presentation and symptoms. Consideration of cholecystectomy: Given the presence of multiple gallstones and thickened gallbladder wall, cholecystectomy may be considered to prevent future complications. Additional Notes: The ultrasound findings are consistent with cholelithiasis with cholecystitis. The patient's medical history and clinical presentation should be considered in conjunction with these imaging findings. Date: 2023-04-10 Sonographer: Chaqueita Blackthorn Please note: This is a sample report and may not be applicable to all cases. The specific findings and recommendations will vary depending on the individual patient's clinical presentation and imaging results.

5/23/2024

Echocardiogram Impression: Cardiac Structure: Normal-sized heart with normal biventricular function. Normal left ventricular wall thickness and ejection fraction. No regional wall motion abnormalities. Normal right ventricular size and function. Normal pericardial effusion. Valves: Normal aortic valve function. Normal mitral valve function. Normal tricuspid valve function. Normal pulmonary valve function. Other: Normal cardiac rhythm. No evidence of pericardial effusion or tamponade. Conclusion: Normal echocardiogram. No evidence of valvular heart disease, cardiomyopathy, or other significant cardiac abnormalities. Sonographer: Sarah Jones Date: 2022-04-15 Please note: This is a sample report and may not be applicable to all cases. The specific findings and recommendations will vary depending on the individual patient's clinical presentation and imaging results.

5/20/2024

Chest X-ray Impression: Normal cardiac silhouette. Lungs are clear with no evidence of infiltrates, nodules, or masses. No pneumothorax or pleural effusion. The costophrenic angles are sharp. The diaphragm is well-defined. The mediastinum is normal in width. Conclusion: Normal chest radiograph. Radiologist: John Doe Date: 2023-04-12 Please note: This is a sample report and may not be applicable to all cases. The specific findings and recommendations will vary depending on the individual patient's clinical presentation and imaging results.

CT Abdomen Results: Positive for Cholecystitis
Exam Details
Date: 6/15/2024
Indication: Right upper quadrant pain, fever
Key Findings
Gallbladder wall thickening (9mm)
Pericholecystic fluid
Multiple gallstones present
Radiologist Impression
Findings consistent with acute cholecystitis
No evidence of perforation
Recommendations
Surgical evaluation for possible cholecystectomy
Medical management with antibiotics in interim
Other Diagnostic Scans Performed
Chest X-ray (5/20/2024)
Clear lung fields. No evidence of pneumonia, effusion, or cardiomegaly. Heart size within normal limits. Conclusion: Normal chest radiograph.
Abdominal Ultrasound (6/10/2024)
Multiple echogenic foci within gallbladder consistent with gallstones. Mild wall thickening noted. Common bile duct of normal caliber. Conclusion: Cholelithiasis.
Echocardiogram (5/23/2024)
Normal left ventricular size and function. Ejection fraction 60%. No significant valvular abnormalities. Conclusion: Normal cardiac function.
Laboratory Findings Supporting Diagnosis
Laboratory values obtained on 6/15/2024 demonstrate a significantly elevated white blood cell count and inflammatory markers consistent with acute infection, supporting the radiologic diagnosis of cholecystitis.
Treatment Plan and Next Steps

Current Treatment
IV Antibiotics: Piperacillin/Tazobactam 3.375g IV q6h

Consultations
General Surgery consult requested for evaluation for cholecystectomy

Monitoring
Vital signs q4h, daily CBC and LFTs to track response

Pending Procedures
Possible laparoscopic cholecystectomy within 24-48 hours
Summary and Physician Notes
Clinical Assessment
Sister Dorris Jones presents with acute cholecystitis confirmed by CT abdomen. Clinical presentation correlates with imaging findings, including RUQ pain, fever, and elevated inflammatory markers.
Diagnostic Interpretation
CT findings of gallbladder wall thickening, pericholecystic fluid, and gallstones are definitive for acute cholecystitis. Previous ultrasound had identified gallstones but not acute inflammation.
Management Plan
Patient to be managed with IV antibiotics while awaiting surgical evaluation. Given her age and stable condition, laparoscopic cholecystectomy is likely appropriate. Will review all imaging with surgical team.
Follow-Up Planning
Surgical follow-up within 24 hours. Consider HIDA scan if surgery delayed and diagnosis questioned. Post-operative imaging not routinely indicated unless complications arise.