Veterinary Imaging Consultations
Final Report for Exam: 2028271
Patient ID: 0000000
Patient Name: Fido X
Sex: F ALTERED
Birthdate: 20150307
Wt: 43.2lbs
Hospital Name: Veterinary Hospital
Doctor Name: Jane Smith, DVM
Date of Exam: 20170305
Reader: Stephanie Essman, DVM, MS, DACVR
Confirmation Date: 3/6/2017 4:04:56 AM UTC
HISTORY
Consult Type: FILMINTERP, SIG: DOB: 20150307, Age: 2 Y, Sex: F ALTERED, Wt: 43.2 lbs, Breed: Lab, Species: CANINE, Images: 3, Case Details: Pt was HBC this evening. Extensive degloving injury to the right front leg with open elbow luxation. Road rash on the left lateral dorsal thorax. Pt is tachypneic and shocky on presentation. Rads- no rib fx seen. No intrathoracic hemorrhage noted.
Will monitor Pt for difficulty breathing overnight and repeat rads if concerned for pulmonary contusions.
FINDINGS
Thorax: A three-view thoracic study is available for interpretation. There is a focal unstructured interstitial pattern present within the peripheral aspect of the left caudal lung lobe. This has a ventral distribution on the right lateral image indicated by a slight increase in opacity superimposed over the apex of the heart. The rest of the lungs are unremarkable without evidence of pulmonary trauma. The heart is normal in shape, but the pulmonary vessels are decreased in size and thready in appearance. On the right lateral image, there is a scant amount of air present in the pleural space noted just adjacent to the apex of the heart and diaphragm. Overt evidence of pleural effusion is not detected. The mediastinum and trachea are normal. The diaphragm is intact. In the visible abdomen, good serosal detail is present. The stomach is filled with ingesta with particulate mineral material. There is no radiographic evidence of osseous trauma. No additional abnormalities are noted.
CONCLUSION
1. Focal pulmonary contusion of the left caudal lung lobe.
2. Scant pneumothorax.
3. Hypovolemia/shock resulting in decreased pulmonary vascular size.
4. Dietary indiscretion.
RECOMMENDATIONS
A thoracocentesis may not be warranted in this patient based on the subtle degree of air present in the pleural space, but this should be clinically correlated. It is also important to remember that pulmonary contusions can worsen over 24–48 hours; therefore, radiographs may need to be repeated to further monitor pulmonary changes. Otherwise, supportive therapy could be implemented as needed.
Read By:
Stephanie Essman, DVM, MS, DACVR
Contact Information:
Please do not hesitate to contact me with additional questions! I can be reached at xxxxxxxxxxx@xxxxxx.com or (800) 555-1212. Please note this contact information is for veterinarian use only. Pet owners, please contact your veterinarian for questions regarding this report.
Thank you very much for this referral. Please let me know if I can be of further assistance.