Radiology Reports

Sample/Practice/Free Radiology Coding Reports/Charts

Radiology Report 1:

Chest DX 2 Views Inc Lat (Chest X-ray two views)

INDICATIONS: Cough

Clinical history: cough

Upright PA and lateral radiographs of the chest were obtained.  The lungs are

clear.  The cardiovascular silhouette, pulmonary vascularity, mediastinum,

hilar regions, diaphragmatic leaflets, costophrenic angles and osseous

structures are within normal limits.

Impression: normal chest.

ICD: 786.2

CPT: 71020

Radiology Report 2:

Bilateral Wrist DX AP & Lateral

INDICATIONS: fracture wrist

Clinical history: rule out fracture

Three views of both wrists were done.  There is a greenstick type fracture of

the distal left radial shaft with 14 degrees ventral angulation of the distal

fracture fragment.  Associated soft tissue swelling is present.  The remainder

of the osseous structures are intact and satisfactorily aligned.

Impression: distal radial shaft fracture with 14 degrees ventral angulation

distal fracture fragment

ICD: 813.21

CPT: 73100-50 (OR) 73100-RT, 73100-LT

Radiology Report 3:

Abdomen & Pelvis CT with Contrast

INDICATIONS: trauma

Clinical history: stab wound right flank

Spiral CT evaluation of the abdomen and pelvis was done with oral contrast

prior to and after intravenous contrast.  5 mm contiguous axial slices were

obtained from the lung bases to the pubic symphysis.  There is mild pleural

thickening on the left posteriorly some linear scarring in both bases,

presumably due to previous inflammatory disease which should be correlated

clinically.  The spleen, gallbladder, pancreas, adrenals, kidneys,  bowel, and

bladder appear normal. The liver shows homogeneously decreased attenuation

compared with that of the spleen.  There are no focal liver masses.  The left

lobe of the liver is somewhat prominent. There is no ascites or significant

adenopathy.  Soft tissue injury is noted in the posterior aspect of the right

quadratus lumborum muscles and the surrounding fat beginning on image number 42 at the level of the L2 and extending inferiorly to image number 59 at the level

of L5.  There is a linear area of decreased attenuation oriented horizontally

in the posterior aspect of the right quadratus lumborum muscle in the area of

contrast, thought to be due to fat outlining a more posterior hematoma just

inside the posterior fascial plane of the quadratus lumborum muscle on the

right side.  A dressing overlays the stab wound site.

Impression: no internal injuries.  Soft tissue swelling and configuration of

soft tissues overlying the right quadratus lumborum muscle as seen on images 42

through 59 consistent with hematoma and edema.  Enlarged left hepatic lobe with

overall fatty infiltration of the liver.  Please correlate clinically.  Minimal

pleural thickening left lower hemithorax posteriorly.  Linear scarring in both

bases.

ICD: 879.2,  922.2,  571.8,  E920.8

CPT: 74160,  72193

Radiology Report 4:

Right Hand DX Min 3 Views

INDICATIONS: fracture metacarpal-phalynx

Clinical history: fracture metacarpal/phalanx

Three views of the right hand were done.  There is soft tissue swelling over

the third metacarpal head.  There is deformity of the head of the right first

distal metacarpal with widening, heterogeneity, and areas of sclerosis,

consistent with degenerative changes along with a soft tissue swelling and

deformity suggesting arthritis. There is also sclerosis and heterogeneity about

the dorsal aspect of the right first proximal phalanx, also consistent with

degenerative changes.  A tiny bone fragment noted in the region of the

triquetrium with associated soft tissue swelling consistent with an avulsion

fracture.  Please correlate clinically.

Impression: degenerative changes right MP joint.  Avulsion fracture triquetrium.

ICD: 814.03, 715.94, E928.9

CPT: 73130-RT

Radiology Report 5:

 Left Knee DX AP & Lateral

INDICATIONS: r/o fracture

Clinical history: rule out fracture

A.P. and lateral views of the left knee were done.  The lateral view is rotated

making it extremely difficult to exclude a suprapatellar effusion.  If this is

suspected clinically a straight lateral view is recommended for confirmation. 

There are the view tiny calcific densities adjacent to the tibial spines which

are most likely due to degenerative changes.  There is no obvious fracture. 

There is a tiny  (2.8 by a 0.1 mm) bony density adjacent to the anterior aspect

of the proximal fibula approximately 5 cm distal to the upper margin of the

bone most likely due to prior trauma.

Impression: no acute post-traumatic sequelae.  Degenerative changes.

ICD: 715.96

CPT: 73560-LT