SUBJECT: HIM205 CHART AUDITING T3-1B CT SCAN, BRAIN LOCATION:
SUBJECT: HIM205 CHART AUDITING
T3-1B CT SCAN, BRAIN
LOCATION: Inpatient, Hospital
PATIENT: Darrin OConnor
ATTENDING PHYSICIAN: Timothy Pleasant, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION OF: Brain CT (computerized tomography)
CLINICAL SYMPTOMS: Stroke
COMPUTED TOMOGRAPHIC EXAMINATION OF THE BRAIN was performed without contrast material. I have no comparison.
There are patchy areas of low density involving the cortex, underlying white matter, part of the lenticular nucleus, and head of the caudate nucleus on the left. Involved cortex is mainly the anterior portion of the parietal lobe laterally. There is some extension into corona radiata on the left, particularly in the parietal lobe region. There is no hemorrhage. There is no significant mass effect.
Remainder of brain parenchyma shows normal density, considering the age of the patient. No evidence of raised intracranial pressure. Atrophic changes are consistent with the age of the patient. Lateral and third ventricles are prominent but probably consistent with the atrophy.
IMPRESSION: Subacute infarction involving central branches of the left middle cerebral artery. No hemorrhage.
Report was called to Dr. Pleasant, and patient was admitted for further treatment.
T3-1B:
SERVICE CODE(S):
ICD-10-CM DX CODE(S):
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