Patient Case Number: IMG03-Salmon, Bianca
Patient Name: Bianca Salmon
Ordering Physician: Benjamin McNally, MD
Interpreting Physician: Manuel Hernandez, MD
Date of Service: 02-17-XX
Exam: CT angiogram of the chest w/ and w/o contrast Clinical History: Hypoxia, fever 2 x days, severity 7/10 Comparison Study(s): None
CT angiogram of the chest was obtained before following intravenous administration of 100 cubic centimeters of Omnipaque 350. Post processing was performed utilizing MIP and 3-D volume rendering technique.
The study is non-diagnostic for pulmonary embolism due to inadequate bolus. Aorta is normal in caliber without aneurysm or dissection. There are no pleural or pericardial effusions. No enlarged mediastinal, hilar, or axillary lymphadenopathy. There is patchy infiltrate involving the lingula as well as a right lung base worrisome for pneumonia.
There is a 4mm noncalcified nodule involving the right lung base. Scans through the abdomen are unremarkable.
Electronically Signed By: Manuel Hernandez, MD
I need to assign the diagnoses codes for this case