Small left sided pleural effusion.
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ICD-10-CM DX CODE:
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Radiology Report, Chest
LOCATION: Outpatient, Hospital
PATIENT: Lorenz Miller
PHYSICIAN: Ronald Green, MD
RADIOLOGIST: Morton Monson, MD
EXAM: Chest
CLINICAL SYMPTOMS: Primary, malignant neoplasm of the hilus of the lung.
TWO VIEWS, CHEST: Frontal and lateral views obtained of the chest. These are submitted on September 3 for interpretation. Comparison is made with a portable view of the chest, July 27. Blunting of the left posterior costophrenic sulcus suggests small pleural effusion on the left. Abnormal opacity, right perihilar/suprahilar region, is best seen on the frontal view. The patient has a history of lung cancer. Opacity was noted there previously. Previously noted bibasilar opacities appear essentially resolved. Oral contrast is noted within the abdomen.
IMPRESSION: Persistent opacity, right perihilar/suprahilar region, presumably reflecting the patient’s clinical history of lung cancer. This was noted previously. Suspect small pleural effusion on the left. Basilar regions otherwise appear cleared since the prior study.
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Ultrasound, Fallbladder
LOCATION: Outpatient, Hospital
PATIENT: Mary Lou Moe
PHYSICIAN: Larry Friendly, MD
RADIOLOGIST: Morton Monson, MD
EXAM OF: Gallbladder ultrasound
CLINICAL SYMPTOMS: Abdominal pain
GALLBLADDER ULTRASOUND: Findings: A right pleural effusion is present. A normal gallbladder is not identified. In the region of the gallbladder fossa, there is an echogenic structure that does produce prominent posterior shadowing. This is not peristalsis, and there is adjacent peristalsis of bowel. Common bile duct is 7 mm, which is upper normal.
IMPRESSION: Normal gallbladder is not identified. It is thought that there is a WES (wall echo shadow that occurs in patients with contracted gallbladders) sign consistent with a gallbladder packed with stones, but the differential diagnosis does include the absence of a gallbladder with echogenic bowel in the area. Clinical correlation is suggested.
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1. Radiology Report, Line PlacementLOCATION: Outpatient, HospitalPATIENT: George BarrPHYSICIAN: Gary Sanchez, MDRADIOLOGIST: Morton Monson, MDEXAMINATION OF: Chest, single viewCLINICAL:…
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