Republic of the Philippines

DEPARTMENT OF HEALTH
CENTER FOR HEALTH DEVELOPMENT-1
ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Parian, City of San Fernando, La Union

PHIC Accredited Healthcare Mother-Baby Friendly “A No Smoking Facility”

Tel: (072) 607-6418/6422 Telefax: (072) 700-3719; e-mail address: itrmc2010@yahoo.com / itrmc2017@gmail.com
CERTIFIED ISO 9001: 2015 since October 2016
MD-RADc-054-Ø
SOCOTEC CERTIFICATE No. SCP000121Q

CT REPORT
NAME: LOPEZ, LARRY JOHN PECLEY PATIENT ID: JD20230807003
REQUESTING DEPARTMENT: OPD AGE: 23Y 8M 28D SEX: MALE
REQUESTING PHYSICIAN: PASCUA CHRISTOPHER JAN DATE OF EXAMINATION: August 7, 2023
EXAMINATION REQUESTED: CT-Scan Temporal ACCESSION NUMBER: 20230807CT0032

INTERPRETATION
CLINICAL DATA: Chronic otitis media r/o cholesteatoma formation, left ear; 5 years history of
bleeding in the left ear; 5 months history of otalgia and headache; weekly removal of ear discharge
TECHNIQUE : Non-contrast axial 16–multislice CT scan of the temporal bone with coronal and sagittal
reconstructions
COMPARISON : None

FINDINGS:

LEFT EAR
Soft tissue/fluid density almost completely fills the middle ear cavity, mastoid air cells, and external
auditory canal with associated partial erosion of the scutum and mastoid part of the left temporal bone.
The ossicles appear intact.
The tympanic membrane is thickened by up to 0.99 mm.
The cochlea and semicircular canals are intact.

RIGHT EAR
The mastoid air cells and middle ear are adequately aerated.
The Prussak space is patent.
The scutum, malleus, and incus are unremarkable.
The tympanic membrane is not thickened.
The cochlea and semicircular canals are intact.
The vestibular aqueduct is not enlarged.
The internal auditory canal is not widened.
The petrous bone and petrous apices are intact.
The external auditory canal is patent.

IMPRESSION:
Cholesteatoma, left

Thank you for the referral.

*The above mentioned report is subjective medical opinion only based on the objective imaging findings and should be correlated with the clinical,
biochemical, microbiological and other parameters before it can be used as a basis for management.
Page 1 of 2
 Republic of the Philippines
DEPARTMENT OF HEALTH
CENTER FOR HEALTH DEVELOPMENT-1
ILOCOS TRAINING AND REGIONAL MEDICAL CENTER
Parian, City of San Fernando, La Union

PHIC Accredited Healthcare Mother-Baby Friendly “A No Smoking Facility”

Tel: (072) 607-6418/6422 Telefax: (072) 700-3719; e-mail address: itrmc2010@yahoo.com / itrmc2017@gmail.com
CERTIFIED ISO 9001: 2015 since October 2016
MD-RADc-054-Ø
SOCOTEC CERTIFICATE No. SCP000121Q

CT REPORT
NAME: LOPEZ, LARRY JOHN PECLEY PATIENT ID: JD20230807003
REQUESTING DEPARTMENT: OPD AGE: 23Y 8M 28D SEX: MALE
REQUESTING PHYSICIAN: PASCUA CHRISTOPHER JAN DATE OF EXAMINATION: August 7, 2023
EXAMINATION REQUESTED: CT-Scan Temporal ACCESSION NUMBER: 20230807CT0032

INTERPRETATION

Reported By: JACKIE LOU A. TE-GURION, MD Approved By: MENCHIE L. DE GUZMAN, MD, FPCR,
FUSP, FCTMRISP
Date and Time: 08 Aug 2023 12:05 PM Date and Time: 10 Aug 2023 07:57 PM
*The above mentioned report is subjective medical opinion only based on the objective imaging findings and should be correlated with the clinical,
biochemical, microbiological and other parameters before it can be used as a basis for management.
Page 2 of 2