Male 24 years old Reason: 24y/o aam with pmh transverse myelitis chronic UTI with SPT presenting with tachycardia, leukocytosis, and right groin, back pain. Evaluate for abscess/acute infectious process History: Right groin/pain, +SIRS Patient's deformities and artifacts from metallic spine prosthesis limit optimal evaluation of the abdomen and pelvis.ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Atrophic left kidney. Punctate stone in the lower pole of the left kidney, unchanged.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.CALCIFICATIONS IN ABDOMINAL AORTA AND ITS BRANCHES: BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:PROSTATE, SEMINAL VESICLES: Hypodense area in the prostate measuring 2.2 x 2.2 cm image #111, series #3, suspicious for an abscess. MRI may be helpful for further evaluation. BLADDER: Suprapubic catheter within the bladder. Bladder wall is diffusely thickened. Calcifications in the region of the prosthetic urethra may represent stones in the urethra. Low-density within the prostate is unchanged. An abscess in that location cannot be excluded. Bladder stone is again noted. It measures 9 mm.LYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: Fat stranding and skin thickening in the posterior subcutaneous tissues of the pelvic wall. These likely represent decubitus ulcers.OTHER: No significant abnormality noted
Limited study due to patient's deformities and artifacts from the metallic spine hardware.Left nephrolithiasis. Stone in the bladder.Possible stones in the prostatic urethra and large hypodensity within the prostate suspicious for an abscess. These findings were discussed with Trsiha Sheth at the time of dictation.