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CT of 6/4/08

Jun 19, 2008 - 0 comments

Exam:  CT soft tissue Neck, with contrast

CPT Code(s) 70491 - CT scan, soft tissue neck; with contrast MATL(s)
Clinical:  Swelling in Neck
The patient complains of swelling to the neck.

CT Scan of the Neck with Contrast:

Technique:  Standard technique was utilized for this exam.

Findings:  

Metallic BB's are placed over the right lower face and right anterior neck at the level of the thoracic inlet.

Scans through the skull base are unremarkable without evidence of enhancing mass or large intracranial hemorrhage.  The soft tissue of the oral pharynx, hypopharynx and larynx are symmetric without evidence of distinct mass.

The parotid and submandibular glands are symmetric.  The thyroid gland is enlarged, with a right lobe predominance.  No distinct thyroid masses are detected on these images.  Note that the BBs are placed directly under the right parotid gland and the right lobe of the thyroid gland.  There are several Shotty lymph nodes noted throughout the neck, the submental region, as well as in the subcutaneous soft tissues of the lower neck posteriorly/upper back.  There is no evidence of pathologic lymph node enlargement.

Scans through the upper lung zones are unremarkable.  The visualized airway is unremarkable.

There is a patchy opacification of the right inferior mastoid air cells.  The left-sided mastoid air cells are clear.  The visualized paranasal sinuses are clear.  The is no evidence of osseous erosion or agressive osseous lesion.

Impression:  

1)  Metallic BB markers were placed in the area of described abnormality and correspond to underlying prominent right thyroid lobe and the right parotid gland.  The appearance of the right parotid gland is unremarkable.  The appearance of the right thyroid lobe, although asymmetrically prominent relative to the left is without evidence of discrete mass on CT.

2)  Shotty cervical lymph nodes noted without evidence of pathologic lymph node enlargment.

3)  There is patchy opacification of the right inferior mastoid air cells


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Blood Test (TSH only)

Jun 19, 2008 - 0 comments

TSH:  0.557

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Blood Test

Jun 19, 2008 - 0 comments

Comprehensive Metabolic Panel
Glucose 88 (65-100)
BUN 12 (8-25)
Creatinine 0.7 (0.6-1.3)
Cal. BUN/Creat 17 (6-28)
Sodium 138 (133-146)
Potassium 4.1 (3.5-5.3)
Chloride 105 (97-110)
Carbon Dioxide 26 (18-30)
Calcium 9.6 (8.5-10.5)
Protein, total 7.3 (6.0-8.4)
Albumin 5.0 (2.0-5.0)
Calculated Globulin 2.3 (2.0-3.8)
Calculated A/G Ratio 2.2 (0.9-2.5)
Bilirubin, total 0.9 (0.1-1.3)
Alkaline Phosphatase 67 (30-132)
SGOT (AST) 21 (5-35)
SGPT (ALT) 17 (7-56)

Complete Blood Count
WBC 9.0 (4.0-11.0)
RBC 4.70 (3.80-5.10)
Hemoglobin 15.1 (11.5-15.5)
Hematocrit                 45.0 (34.0-45.0)
MCV 96 (80-100)
MCH 32.2 (27.0-34.0)
MCHC 33.7 (32.0-36.4)
RDW 13.5 (11.0-15.0)
Neutrophils 69 (40-74)
Lymphocytes 24 (19-48)
Monocytes 5 (3-11)
Eosinophils 2 (0-7)
Basophils                 0 (0-2)
Platelet Count 206 (130-400)

Free T4 (Thyroxine) 1.45 (NG/DL  0.73-1.95)
Ultrasensitive TSH 1.040 (UIU/ML 0.300 – 5.100)
Thyroid Peroxidase ab <10 (IU/ML <35)
1

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