74-year-old female with fluid collection versus obstruction ABDOMEN:LUNG BASES: New right-sided pleural effusion and right lower lobe airspace opacities which may represent atelectasis versus early pneumonia.LIVER, BILIARY TRACT: Mild splenomegaly. Cholelithiasis is unchanged.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: Left adrenal adenoma, unchanged.KIDNEYS, URETERS: Moderate right hydronephrosis with hydroureter slightly worsened compared to previous study.Subcentimeter cyst off the left lower pole kidney.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Mild dilatation of the proximal small bowel loops measuring up to 4.2-cm. distal small bowel loops in the pelvis are decompressed. These findings are suggestive of mild and likely partial small bowel obstruction. No evidence of abscess.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:UTERUS, ADNEXA: Not visualized.BLADDER: Not visualized.LYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: Right lower quadrant ostomy with ileal conduit.BONES, SOFT TISSUES: No significant abnormality notedOTHER: Ill-defined fluid collection in the right side of the pelvis and one the small bowel loops likely measures 3.9 x 3 cm. This is difficult to differentiate from the nonopacified small bowel loops. Small amount of free fluid is also likely present in the pelvis. Further evaluation of this collection with MRI of the pelvis may be helpful, if clinically indicated.
Partial small bowel obstruction.Ill-defined possible small bowel obstruction which is difficult to differentiate from surrounding unopacified bowel loops on the right side of the pelvis. Further evaluation of this collection with pelvic MR may be helpful, if clinically indicated.Slight interval worsening of the right-sided moderate hydronephrosis and hydroureter.New right-sided pleural effusion and dependent air space opacities which represent atelectasis versus early pneumonia.Dr. Famakinwa was notified and acknowledged at the time of dictation. 