Sample Radiology Charts

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Radiology Case Study 1:

Abdomen CT Without Contrast

INDICATIONS

___________Abdominal pain

This examination was performed without oral or IV contrast which limits interpretation.  Spiral scans were obtained from the lower thorax to the symphysis pubis. There is borderline cardiomegaly.

The liver, spleen, gallbladder and poorly visualized pancreas are unremarkable on this study without IV contrast.  The stomach is not adequately distended for evaluation.  There are no calculi in either kidney or evidence of obstructive uropathy.  There is no significant retroperitoneal or pelvic lymphadenopathy.  The bowel is unopacified but grossly normal.

There is a 6.9 by 7.2 cm fluid density mass in the midline of the pelvis compressing the dome of the urinary bladder.  The left lateral wall is slightly thickened.  There is no associated calcifications or fat to suggest a dermoid.  This may be ovarian origin or a possible mesenteric cyst.  The uterus is unremarkable.

Impression

1.  6.9 by 7.2 cm fluid density mass in the midline of the pelvis of undetermined origin, possibly ovarian.

 Note: this finding may represent the previously described hypovascular cystic mass in the left adnexa as seen by ultrasound on September 5, 2003.  Re-evaluation by ultrasound and/or CT scan with contrast may have additional information.  The measurement obtained on the

current examination is slightly larger than that noted by ultrasound previously.

ICD: 789.00

CPT: 74150

Radiology Case Study 2:

Chest DX 1 View

INDICATIONS: Cough

History:  cough

Chest:

A single frontal view reveals the heart to be within normal limits.  Trachea is midline.  Lung fields are clear.  Bony thorax, hemidiaphragms, and costophrenic  angles are normal. 

Impression. No Infiltrate. 

ICD: 786.2

CPT: 71010

Radiology Case Study 3:

Facial Bones DX Min 3 Views

INDICATION: Assault

History:  "trauma."

Facial bones:

Multiple views show the bony structures to be intact.  The paranasal sinuses are well-aerated. There is  no  soft tissue mass  nor air-fluid level.  There  are no fractures. 

Impression:  No fractures seen.

ICD: 959.09, E968.9

CPT: 70150

Radiology Case Study 4:

Right Hand DX Min 3 Views

INDICATIONS: Pain

History: " pain ".

Right hand :

Multiple views reveal the bony structures and soft tissues to be intact.  The  joint spaces are preserved.  There are no fractures, dislocations, nor radiopaque foreign bodies.

Impression: No fractures nor dislocations.

ICD: 729.5

CPT: 73130-RT

Radiology Case Study 5:

BILATERAL SCREENING MAMMOGRAM

CLINICAL: NONE

No prior exams were available for comparison. The tissue of both breasts is extremely dense, which lowers the sensitivity of  mammography. No significant masses, calcifications, or other findings are seen in either

breast.

IMPRESSION: NEGATIVE MAMMOGRAM

There is no mammographic evidence of malignancy. A 4 year screening mammogram is recommended.

ICD: V76.12

CPT: 77057