AI Scribe for Radiologists

CLINICAL HISTORY:
62-year-old male with 6-month history of intermittent right upper quadrant pain, elevated liver enzymes (ALT 142, AST 98), and 15-pound unintentional weight loss. History of hepatitis C (treated, SVR achieved). Evaluate for hepatocellular carcinoma.

TECHNIQUE:
Multidetector CT of the abdomen and pelvis performed with administration of 100 mL IV contrast (Omnipaque 350) using a triphasic hepatic protocol (non-contrast, arterial phase at 20 seconds, portal venous phase at 70 seconds, delayed phase at 3 minutes). 5mm slice thickness with coronal and sagittal reformations.

COMPARISON:
Abdominal ultrasound from 3 months prior (05/12/2024) showing heterogeneous liver echotexture.

FINDINGS:

Liver:
- Liver demonstrates nodular contour and surface irregularity consistent with cirrhosis
- Segment 7/8: 3.2 x 2.8 cm heterogeneous mass with arterial hyperenhancement and portal venous/delayed washout (LI-RADS 5 - definite HCC)
- Segment 5: 1.4 cm arterial enhancing nodule with washout (LI-RADS 4 - probably HCC)
- No additional suspicious lesions identified
- No bile duct dilatation, common bile duct measures 6 mm

Portal Venous System:
- Main portal vein is patent with hepatopetal flow
- Mild splenomegaly (13.5 cm) consistent with portal hypertension
- Small volume ascites in perihepatic spaces

Gallbladder and Biliary Tree:
- Gallbladder wall thickening (4 mm) likely secondary to hypoalbuminemia
- No cholelithiasis or pericholecystic fluid

Pancreas, Spleen, Adrenals:
- Pancreas: normal size and attenuation, no mass or ductal dilatation
- Spleen: enlarged at 13.5 cm, homogeneous enhancement
- Adrenal glands: normal

Kidneys and Ureters:
- Both kidneys enhance symmetrically, no hydronephrosis
- Simple cortical cyst right kidney (2 cm, Bosniak I)

Bowel and Mesentery:
- No bowel wall thickening or obstruction
- No enlarged mesenteric lymph nodes

Peritoneum and Retroperitoneum:
- Minimal ascites in perihepatic spaces
- No retroperitoneal lymphadenopathy

Vasculature:
- Abdominal aorta: normal caliber, no aneurysm
- IVC: patent

Bones:
- No suspicious lytic or blastic lesions
- Mild multilevel degenerative changes

IMPRESSION:
1. Hepatocellular carcinoma (HCC):
   - Segment 7/8: 3.2 cm mass (LI-RADS 5 - definite HCC)
   - Segment 5: 1.4 cm nodule (LI-RADS 4 - probably HCC)

2. Cirrhotic liver with evidence of portal hypertension (splenomegaly, ascites)

3. Patent portal venous system - no tumor thrombus

4. No extrahepatic metastatic disease identified

RECOMMENDATIONS:
- Multidisciplinary tumor board discussion for treatment planning (transplant evaluation, resection candidacy, vs. locoregional therapy)
- AFP level if not recently obtained
- Consider MRI liver with hepatobiliary contrast agent for additional characterization if impacts management
- Triphasic CT chest to complete staging evaluation

CRITICAL FINDINGS:
Multifocal hepatocellular carcinoma - findings communicated to Dr. Smith (referring provider) by phone at 14:35 on 08/15/2024.

Electronically signed by: John Radiologist, MD
Date/Time: 08/15/2024 14:40