Diagnostic and Laboratory Procedures
Diagnostic and Laboratory Procedures
Diagnostic and Laboratory Procedures
HEMATOLOGY SECTION
Sedimentation Rate 57mm/hr 0-10
IMMUNOLOY SECTION
CRP 54.34mg/L - <5.0
CLINICAL CHEMISTRY
Electrolytes
Sodium 134.6mmol/L 135 – 148
Potassium 3.82mmol/L 3.50 – 5.30
Chloride 104.0mmol/L 98 – 107
Ionized Calcium 1.12mmol/L 1.13 – 1.32
Multislide CT scan (256 slices) of the CERVICAL and THORACIC SPINE (PLAIN)
There is osteolytic bone destruction of T1, T2 and T3 vertebral bodies with severe compression deformity
of T1 vertebral body, with paravetebral abscess formation (C7-T3 level) with intraspinal extension and significant C7-T2 spinal canal
stenosis with cord compression. There is an area of consolidation at the upper lobe with air bronchograms and small nodular
calcifications. There are pulmonary nodules (up to 1.4 cm) at both upper lungs. There are slightly enlarged bilateral supraclavicular
(up to 1.3 cm), paratracheal and ateropulmonary (up o 1.5 cm) lymph nodes. The rest of the cervical and thoracic vertebras are
intact.
IMPRESSION:
1. Osteolytic bone destruction of T1, T2, and T3 vertebral bodies with severe compression deformity of T1 vertebral body, associated
paravertebral abscess formation (C7-T3 level) with intraspinal extension and significant C7-T2 spinal canal stonsis with cord
compression. Consider Tuberculous spondylitis (Pott’s disease). Metastasis less likely. Please correlate clinically.
2. Area of consolidation at the left upper lobe with air bronchograms and small nodular calcifications. Consider tuberculoma/PTB.
Rule out pulmonary malignancy.
4. Slightly enlarged bilateral supraclavicular (up to 1.3 cm), paratracheal and aortopulmonary (up to 1.5 cm) lymph nodes.
CT-SCAN REPORT
EXAMINATION: SPINE-LUMBAR
CLINICAL DATA
Partial Destruction involving the vertebral bodies of T1, T2, and T3 with an accompanying soft tissue mass extending from the lower
endplate of C6 to the lower endplate of T3. This measures approximately 5.6 x 8.3 x 6.9 cm. The findings are compatible with a Pott’s
disease with a large paravertebral soft tissue abscess, with insinuation of the soft tissue mass into the spinal canal of T1, T2, and T3.
There is apparent extrinsic compression of the spinal cord along its ventrolevolateral aspect.
Airspace consolidation in the left upper lobe. There are tree-in-bud nodular opacities and noncalcified nodules scattered in the left
lung and in the right upper lobe. These are compatible with a chronic infection such as tuberculosis with multiple enlarged lymph
nodes in the mediastinum and left hilum.