PATIENT ID : MR102562 PATIENT NAME : TOM CHEN AGE
PATIENT ID : MR102562 PATIENT NAME : TOM CHEN AGE : 048Y SEX : Male REF. PHY. : STUDY DATE : 25-May-2026 40 Lugogo By-PassRoad,Kampala,Uganda. TEL: 0800 388 111,0393 236 444 WHATSAPP: +256 700 861 778,+256 759 922 444 EMAIL: info@rubyhospitalkampala.com RADIOLOGY REPORT EXAM: NON-ENHANCED HRCT SCAN OF THE CHEST FINDINGS: NON-ENHANCED CT SCAN: Minimal traces of bilateral pleural effusion with underlying basal atelectatic changes suggest possibility of active infective aetiology. Bilateral apical fibrotic pleural thickening and subpleural fibrotic linear parenchymal opacities with fibroatelectatic bands noted involving bilateral lung apices and basal segments of bilateral lower lobes - sequelae to old infection. Subcentimetre sized lymph nodes noted in mediastinum and bilateral axillary regions - not significant by size. Prominent bilateral pulmonary vascular markings are noted. Mild mosaic pattern of attenuation is noted in bilateral lung fields. No calcified mediastinal lymph nodes. No calcified lung nodules are seen. The ascending aorta, the aortic arch, the descending aorta, the SVC, the heart shows no definite abnormality. The pulmonary arteries show no filling defect to suggest a pulmonary embolus. The trachea and the main bronchi are unremarkable. The oesophagus is normal in size and shape. No evidence of significant hilar, mediastinal or axillary adenopathy. Rest both the lung fields appear normal. The osseous structures in the thoracic spine and the visualized, the sternum, the clavicles the visualized osseous structures in the shoulders show no evidence of osteolytic or osteoblastic lesions. Age related vascular calcification and degenerative changes noted in visualized spine. No obvious focal lesion is noted in the visualized thyroid gland. There is no focal lesion in the scanned areas of the rest liver, spleen, and bilateral adrenal glands. Small simple hepatic cyst noted.PATIENT ID : MR102562 PATIENT NAME : TOM CHEN AGE : 048Y SEX : Male REF. PHY. : STUDY
根据您提供的胸部非增强高分辨率CT（HRCT）报告，影像学发现可归纳为以下几点：
1. **活动性感染可能**：双侧少量胸腔积液伴基底段肺不张，提示可能存在活动性感染性病因。
2. **陈旧性感染后遗改变**：双肺尖胸膜增厚、胸膜下纤维条索影及纤维不张带，累及双肺尖及双下叶基底段，符合陈旧性感染后改变。
3. **其他非特异性发现**：
* 纵隔及双侧腋窝可见小于1cm的淋巴结，按大小标准无显著临床意义。
* 双肺血管纹理增粗、增多。
* 双肺野可见轻度马赛克样密度减低区。
* 未见钙化性肺结节或纵隔淋巴结钙化。
* 心脏、大血管、肺动脉主干未见明确异常。
* 所见甲状腺、肝脏、脾脏、肾上腺未见明确局灶性病变，仅见一单纯性肝囊肿。
* 脊柱可见与年龄相关的血管钙化及退行性改变。
**核心结论**：该CT影像学表现提示存在**活动性感染**（可能为肺炎或胸膜炎）与**陈旧性感染后纤维化**（如陈旧性肺结核）并存。建议结合患者的临床症状（如发热、咳嗽、咳痰、胸痛、呼吸困难等）、实验室检查（如血常规、C反应蛋白、降钙素原、结核感染T细胞斑点试验等）进行综合判断，以明确病因并指导治疗。
