Friday, September 21, 2012
Sample/Practice/Free Radiology Coding Reports/Charts
Radiology Report 1:
Chest DX 2 Views Inc Lat (Chest X-ray two views)
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.
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
CPT: 73100-50 (OR) 73100-RT, 73100-LT
Radiology Report 3:
Abdomen & Pelvis CT with Contrast
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
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
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.
Posted by Anand at 8:19 AM