6/15/2024
CT Head without Contrast - CURRENT Patient: Shakira, DOB 3/15/2023 (3 months) Date of Scan: 6/14/2024 Exam: CT Head without Contrast Findings: The CT scan of the head demonstrates bilateral subdural hematomas of varying ages (acute and subacute). There is evidence of cerebral edema with partial effacement of the cortical sulci. Multiple retinal hemorrhages are noted on accompanying ophthalmologic examination. No skull fractures are identified. The ventricular system appears normal in size and configuration. Impression: Bilateral subdural hematomas of varying ages, highly concerning for non-accidental trauma (shaken baby syndrome). Cerebral edema consistent with traumatic brain injury. No evidence of skull fracture. Recommendations: Immediate neurosurgical consultation for management of increased intracranial pressure and subdural hematomas. Complete skeletal survey to evaluate for additional injuries. Ophthalmology consultation for detailed assessment of retinal hemorrhages. Child protective services notification as per hospital protocol for suspected non-accidental trauma. Additional Notes: Findings are highly consistent with non-accidental trauma/shaken baby syndrome. MRI brain with diffusion weighted imaging recommended once patient is stabilized to better characterize the extent of parenchymal injury. Radiologist: Dr. Sarah Mitchell Date: 6/14/2024
6/12/2024
Skeletal Survey X-Ray Patient: Shakira, DOB 3/15/2023 (3 months) Findings: Multiple rib fractures: Posterior rib fractures at different stages of healing are visible at the 5th, 6th, and 7th ribs bilaterally, suggestive of non-accidental trauma. Metaphyseal corner fractures: Classic metaphyseal lesions identified at the distal femurs and proximal tibias bilaterally, highly specific for abusive injury in infants. Long bone fractures: Spiral fracture of the right humerus, in early healing stage (approximately 7-10 days old). No spinal fractures: The vertebral bodies appear normal without evidence of compression or traumatic injury. Impression: Multiple skeletal injuries at different stages of healing, highly consistent with non-accidental trauma/shaken baby syndrome. Pattern and distribution of fractures are pathognomonic for inflicted injury in an infant of this age. Findings correlate with the head CT results showing subdural hematomas. Recommendations: Follow-up skeletal survey in 2 weeks to better characterize healing fractures and potentially identify additional injuries not currently visible. Continued child protective services involvement. Orthopedic consultation for management of fractures. Radiologist: Dr. James Wilson Date: 6/12/2024
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.