Male 71 years old Reason: Assess RUQ for gallbladder pathology given gallbladder wall thickening on CT History: Abdominal pain LIVER: Liver measures 16.6 cm in length. Main portal vein patent with normal directional flow, velocity measures 22 cm/s. BILIARY TRACT: Gallbladder contracted making evaluation for wall thickening suboptimal. No definite additional secondary signs of acute cholecystitis. Gallbladder did not have this appearance on October 2015 ultrasound exam. Per ultrasound technologist negative sonographic Murphy's sign. No intrahepatic or extrahepatic biliary duct dilatation.PANCREAS: Not well seen in entirety but visualized portions unremarkable.KIDNEYS: The right kidney measures 11.5 cm. The left kidney measures 10.1 cm. Heterogeneous rounded lesion involving lower pole of left kidney measuring approximately 3.9 x 3.8 cm. Lesion does not have the appearance of a simple cyst. No hydronephrosis.SPLEEN: The spleen measures 5.7 cm. in length. OTHER: Pleural effusions, evaluation for ascites suboptimal.
1. Left lower pole solid appearing renal lesion measuring up to 3.9 cm suspicious for neoplasm.2. Contracted gallbladder making assessment for wall thickening suboptimal, differential considerations for appearance include hypoalbuminemia, recent meal and/or underlying chronic cholecystitis. No definite additional secondary signs of acute cholecystitis.