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신경과·신경외과

당당한사슴123
당당한사슴123

의학용어 잘 아시는 선생님 계신가요? 의무기록 해석 부탁드립니다.

의무기록 해석에 어려움이 있어 질문 남깁니다.

의학용어 잘 아시는 분 계신다면 번거로우시겠지만 하나하나 해석 부탁드립니다.

∙ 2016.02.24 ABDOMEN & PELVIS MDCT-Contrast

Findings & Conclusion

1. About 13.4cm sized mixed cystic and solid mass with scattered fatty & calcified component and enhancing solid portion in right ovary.

- Probable immature teratoma.

2. About 6.8cm sized mixed cystic and solid mass with fatty & calcified.

component without hypervascularity.

- Probable mature teratoma.

3. Hemoperitoneum.

4. No definite evidence of peritoneal seeding nodules.

5. Subsegmental atelectasis, LLL.

∙ 2016.03.02 Whole body fusion PET-torso

[Conclusion]

1. Suggesting post of change in pelvic cavity and abdominal wall.

2. Mildly increased FDG uptake in above mentioned lymph nodes, metastasis less likely. Rec) follow-up

3. A small nodular lesion in LLL of lung with equivocal significance.

Rec) follow-up chest CT

Pathologic Report

2016.02.25. [Ovary]

1. Ovary and salpinx, right, salpingoophorectomy :

Immature teratoma, right ovary, presence of yolk sac tumor component with

1) size : 14×9×8cm

2) lymphovascular invasion : not identified.

3) no definitive capsular invasion.

4) clear resection margin.

[Results of immunohistochemistry]

Pancytokeratin : positive.

AFP : positive.

GFAP : negative.

S-100 protein : focal positive.

2. Ovary, left, cystectomy : Mature cystic teratoma.

3. Ovary, left, #2, cystectomy : Consistent with Corpus luteal cyst.


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