Exam 3: Radiology

Case -AUDIT REPORT T3.2 ULTRASOUND, RENAL LOCATION: Outpatient, Hospital PATIENT: Derrick Smith PHYSICIAN: Ronald Green, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: Renal ultrasound CLINICAL SYMPTOMS: Anuria RENAL ULTRASOUND: The right kidney measures 12.9 6.4 5.3 cm. The left measures 11.8 5.0 6.5 cm. There is no evidence for hydronephrosis within either of the kidneys. Focal density is seen within the midportion of the right kidney, which may relate only to a prominent column of Bertin; however, those do appear slightly different from the adjacent parenchyma and cannot exclude the possibility of mass in this area. Correlation with renal CT is recommended. There is a large cyst associated with the lower pole of the right kidney measuring 8.1 8.0 5.2 cm.Within the left kidney, there are two echogenic shadowing foci. One is within the upper pole measuring 4 mm and, in the lower pole, the second is seen measuring 3 mm to 4 mm. Both of these are compatible with small left renal calculi. Urinary bladder demonstrates an unremarkable sonographic appearance well distended. It demonstrates an approximately 66 cc post-void residual. IMPRESSION: 1. Density noted within the midportion of the right kidney, which may relate only to a prominent column of Bertin; however, the possibility of underlying mass cannot be excluded. Renal CT is recommended. 2. Large lower pole acquired cyst involving the right kidney. 3. At least two left renal calculi are identified. 4. Post-void residual, as given. T3.2: SERVICE CODE(S): 76775____________________________________________ ICD-10-CM DX CODE(S): R34_________________________________________ INCORRECT/MISSING CODE(S): _____________________________________

Case -T3-1C RADIOLOGY REPORT, CHEST LOCATION: Outpatient, Hospital PATIENT: Robert Hadley PHYSICIAN: Ronald Green, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: Chest CLINICAL SYMPTOMS: Abnormal chest x-ray PORTABLE AP (ANTERIOR POSTERIOR) CHEST, FINDINGS: Comparison is made with the portable AP chest of December 9. Heart size and pulmonary vascularity within normal limits and stable. Right hilar mass appears slightly more prominent, which could be due to difference in technique. Chest CT (computerized tomography) may be helpful for further evaluation. There is a right perihilar infiltrate and/or perhaps atelectasis, which is new. Elevation of the right hemidiaphragm is new. Right internal jugular catheter with tip in the lower superior vena cava. Diffuse demineralization of the visualized bones. No pleural effusions. T3-1C: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T3-2A CT SCAN, SINUSES LOCATION: Outpatient, Hospital PATIENT: Lillian Parker PHYSICIAN: Ronald Green, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: CT (computerized tomography) of sinuses CLINICAL SYMPTOMS: Chronic sinus infection with change in mental status COMPUTED TOMOGRAPHIC EXAMINATION OF THE PARANASAL SINUSES was performed utilizing thin axial images computed for high-resolution bone algorithm 3-D. Apparently direct coronal images could not be obtained. Therefore, coronal reconstructions were performed from the original data set. The study was performed under my supervision and is presented to me today for evaluation. Independent work station not required. Frontal sinuses are well aerated. There may be some mucosal thickening at the base of each frontal sinus. Most of the ethmoid sinuses show mucosal thickening. Several ethmoid sinuses are filled with abnormal soft-tissue density, although most ethmoid sinuses are at least partially aerated. Bilaterally, the sphenoid sinuses show a considerable amount of mucosal thickening. Right sphenoid sinus is larger than the left. It is possible that there may be fluid level within either of the sphenoid sinuses. Bilaterally, the maxillary sinuses show mucosal thickening, particularly posteriorly. I cannot comment about the drainage pathways of the maxillary sinuses. Unfortunately, there is movement artifact in the images, and this causes considerable misregistration of the coronal reconstructions. There is a nasal airway inserted on the right. I believe the right middle turbinate has most probably been surgically removed in the past. There may be surgically created small patency connecting the left middle meatus and the left maxillary sinus on image 19. I do not appreciate overt bone erosion. It is presumed that the findings represent inflammatory change. T3-2A: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T3-2D RADIOLOGY REPORT, CHEST LOCATION: Inpatient, Hospital PATIENT: Paul Storm ATTENDING PHYSICIAN: Ronald Green, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: Chest CLINICAL SYMPTOMS: Aspiration pneumonia CHEST, SINGLE VIEW: Comparison is August 21. Cardiac silhouette is prominent. An NG tube has been placed, and the tip is located just barely within the stomach. However, the side hole is still within the distal esophagus. Suggest advancement. Lung markings are unchanged. Opacity noted in the right lung base unchanged, and may be due to atelectasis and/or some scarring. Need to follow to document clearance. Multilevel spurring of the spine. Aortic atherosclerotic disease. There is some minimal blunting of the posterior sulcus on the left, perhaps due to pleural thickening and/or effusion. T3-2D: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T3-1D RADIOLOGY REPORT, CHEST LOCATION: Outpatient, Hospital PATIENT: Vance Roche PHYSICIAN: James Noonar, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: Chest CLINICAL SYMPTOMS: Cardiomegaly CHEST, TWO VIEWS: Comparison is made to the x-ray taken 30 days previously. There is cardiomegaly. Overt failure is not identified. There is only a moderate degree of inspiration. Osseous structures show old compression deformity of the lower thoracic spine. Calcification is identified within a tortuous aorta. That portion of the abdomen seen is unremarkable. IMPRESSION: 1. Cardiomegaly. There is poor inspiratory effort, but overt failure is not suggested grossly at this time. 2. ASVD (arteriosclerotic vascular disease). 3. Old compression deformity of the thoracic spine. 4. Progress studies should be obtained as felt to be clinically warranted. T3-1D: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -AUDIT REPORT T3.1 CT SCAN, ABDOMEN AND PELVIS LOCATION: Outpatient, Hospital PATIENT: Fran Webster PHYSICIAN: Larry Friendly, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: CT of abdomen and pelvis DIAGNOSIS: Sepsis CT OF ABDOMEN AND PELVIS TECHNIQUE: The patient was scanned from the dome of the diaphragm through the symphysis pubis. Oral contrast was administered. No intravenous contrast was administered due to elevated renal function tests. FINDINGS: No prior CT examination is available for comparison. Lack of intravenous contrast causes significant limitation and evaluation of the solid body organs. The oral contrast was administered; however, the majority of it remains within either the stomach or the proximal portion of the duodenum. The majority of the bowel is not opacified. That causes further limitation. As visualized, the liver, spleen, pancreas, and adrenal glands appear grossly unremarkable. There is evidence of calcification involving the gallbladder wall. There is free fluid present within the upper and lower portions of the abdomen and pelvis. Some fluid is seen to surround the gallbladder as well. There is also abnormal stranding present and fluid present within the retroperitoneum. This includes the pararenal and perirenal spaces. That also includes the presacral space. The etiology of all of this fluid is indeterminate. There is apparent irregularity of the kidneys bilaterally, and definitive evaluation is difficult due to the adjacent stranding and fluid. Obvious gross adenopathy is not seen; however, visualization is limited. There are noted to be several tiny gas collections associated with the left colon. These appear to extend outside the colonic wall. This may relate only to diverticula associated with the colon; however,we cannot exclude the possibility of tiny areas of extraluminal gas. Close clinical correlation is suggested. Bilateral pleural effusions are present. There is dense consolidation present within both lung bases which may relate to either atelectasis or infiltrate. Indeterminate pulmonary nodule is seen within the anterior aspect of the right lung base. There is body wall edema present. IMPRESSION: 1. Prominent amount of fluid is identified within both the abdomen and pelvis. Some of this is felt to be within the peritoneum. There is a prominent amount of fluid seen in the retroperitoneum, as well. This includes stranding and fluid adjacent to both kidneys. Abnormal fluid is also seen in the presacral space. Etiology of all of this fluid is indeterminate. Possibility of infectious etiology cannot be excluded. 2. Calcification of the gallbladder wall. There is pericholecystic fluid.Whether this relates to the gallbladder disease or is merely a part of adjacent fluid cannot be determined. 3. There are several small areas of gas collection adjacent to the left side of the colon. This may relate only to gas in diverticula; however, I cannot exclude the possibility of small amounts of free intraperitoneal air. Close clinical correlation is suggested. 4. Bilateral pleural effusions with bibasilar pulmonary opacities. 5. Indeterminate pulmonary nodule within the right lung base. Follow-up for that finding in 3 months is recommended. T3.1: SERVICE CODE(S): 74178___________________________________________ ICD-10-CM DX CODE(S): R65.2, J90, J98.4_____________________________ INCORRECT/MISSING CODE(S): ____________________________________

Case -T3-2B CT SCAN, BRAIN LOCATION: Outpatient, Hospital PATIENT: Dianna Evans PHYSICIAN: Alma Naraquist, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: CT (computerized tomography) of the brain CLINICAL SYMPTOMS: Atraumatic subdural hematoma CT OF THE BRAIN: The exam is significant for extensive subdural fluid accumulation in the left frontoparietal region, extending approximately 3 cm (centimeter) from the inner diploe with associated mass effect causing marked effacement and shift of the left lateral ventricle. There is approximately 1.5 to 2 cm of shift from left to right. CONCLUSION: Subdural fluid accumulation with mass effect and shift. Dr. Naraquist was notified, and arrangements were made to have the patient transferred to a tertiary care center for neurosurgery. T3-2B: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): _______________________________________________

Case -T3-1B CT SCAN, BRAIN LOCATION: Inpatient, Hospital PATIENT: Darrin O'Connor ATTENDING PHYSICIAN: Timothy Pleasant, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: Brain CT (computerized tomography) CLINICAL SYMPTOMS: Stroke COMPUTED TOMOGRAPHIC EXAMINATION OF THE BRAIN was performed without contrast material. I have no comparison. There are patchy areas of low density involving the cortex, underlying white matter, part of the lenticular nucleus, and head of the caudate nucleus on the left. Involved cortex is mainly the anterior portion of the parietal lobe laterally. There is some extension into corona radiata on the left, particularly in the parietal lobe region. There is no hemorrhage. There is no significant mass effect. Remainder of brain parenchyma shows normal density, considering the age of the patient. No evidence of raised intracranial pressure. Atrophic changes are consistent with the age of the patient. Lateral and third ventricles are prominent but probably consistent with the atrophy. IMPRESSION: Subacute infarction involving multiple focal and some central branches of the left middle cerebral artery. No hemorrhage. Report was called to Dr. Pleasant, and patient was admitted for further treatment. T3-1B: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T3-2C RADIOLOGY REPORT, CHEST LOCATION: Outpatient, Hospital PATIENT: Will Jamison PHYSICIAN: Ronald Green, MD RADIOLOGIST: Morton Monson, MD CLINICAL SYMPTOMS: Cough and fever PA & LATERAL CHEST, 9:15 AM: The previous film is from 12/27/02. There is no pneumonia. The lung fields are clear. There are no effusions. The heart and the vascular markings are normal. Bony structures are unremarkable. IMPRESSION: Normal chest x-ray T3-2C: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________

Case -T3-1A RENAL ULTRASOUND Report the professional service for the following radiology services: LOCATION: Outpatient, Hospital PATIENT: Sally Cinder PHYSICIAN: Timothy Pleasant, MD RADIOLOGIST: Morton Monson, MD EXAMINATION OF: Renal ultrasound, Complete CLINICAL SYMPTOMS: Renal failure RENAL ULTRASOUND: Clinical information states renal failure Right kidney is 9.5 5.6 4.9 cm (centimeter). The size and parenchymal thickness are within normal limits. No cystic or solid mass right kidney seen. No dilatation of calyces to suggest obstruction of collecting system. Left kidney is 10.9 5.4 5.5 cm. It shows parapelvic cyst midportion of kidney. The cystic lesion measures 7.1 6.3 6.2 cm. Usually cysts are not of significance. No solid lesion is seen. No dilatation of calyces is noted. In the urinary bladder region, no structure resembling bladder is seen. Presumably it is nondistended. IMPRESSION: 1. Kidney size and renal parenchyma thickness normal bilaterally. 2. Cystic lesion, left kidney, likely not of clinical significance. 3. No cystic lesion, right kidney. 4. Neither kidney shows solid lesion; neither kidney shows evidence of dilated calyces or renal pelvis to suggest obstruction. 5. Urinary bladder not seen and therefore not evaluated. T3-1A: SERVICE CODE(S): ___________________________________________________ ICD-10-CM DX CODE(S): ______________________________________________