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SUBJECT: HIM205 CHART AUDITING

 

 

 

AUDIT REPORT T3.1 CT SCAN, ABDOMEN AND PELVIS

LOCATION: Outpatient, Hospital

PATIENT: Fran Webster

PHYSICIAN: Larry Friendly, MD

RADIOLOGIST: Morton Monson, MD

EXAMINATION OF: CT of abdomen and pelvis

DIAGNOSIS: Sepsis

CT OF ABDOMEN AND PELVIS TECHNIQUE: The patient was scanned from the dome of the diaphragm through the symphysis pubis. Oral contrast was administered. No intravenous contrast was administered due to elevated renal function tests.

FINDINGS: No prior CT examination is available for comparison. Lack of intravenous contrast causes significant limitation and evaluation of the solid body organs. The oral contrast was administered; however, the majority of it remains within either the stomach or the proximal portion of the duodenum. The majority of the bowel is not opacified. That causes further limitation. As visualized, the liver, spleen, pancreas, and adrenal glands appear grossly unremarkable. There is evidence of calcification involving the gallbladder wall. There is free fluid present within the upper and lower portions of the abdomen and pelvis. Some fluid is seen to surround the gallbladder as well. There is also abnormal stranding present and fluid present within the retroperitoneum. This includes the pararenal and perirenal spaces. That also includes the presacral space. The etiology of all of this fluid is indeterminate. There is apparent irregularity of the kidneys bilaterally, and definitive evaluation is difficult due to the adjacent stranding and fluid. Obvious gross adenopathy is not seen; however, visualization is limited. There are noted to be several tiny gas collections associated with the left colon. These appear to extend outside the colonic wall. This may relate only to diverticula associated with the colon; however,we cannot exclude the possibility of tiny areas of extraluminal gas. Close clinical correlation is suggested. Bilateral pleural effusions are present. There is dense consolidation present within both lung bases which may relate to either atelectasis or infiltrate. Indeterminate pulmonary nodule is seen within the anterior aspect of the right lung base. There is body wall edema present.

IMPRESSION:
1. Prominent amount of fluid is identified within both the abdomen and pelvis.
Some of this is felt to be within the peritoneum. There is a prominent amount of fluid seen in the retroperitoneum, as well. This includes stranding and fluid adjacent to both kidneys. Abnormal fluid is also seen in the presacral space.
Etiology of all of this fluid is indeterminate. Possibility of infectious etiology cannot be excluded.
2. Calcification of the gallbladder wall. There is pericholecystic fluid.Whether this relates to the gallbladder disease or is merely a part of adjacent fluid cannot be determined.
3. There are several small areas of gas collection adjacent to the left side of the colon.
This may relate only to gas in diverticula; however, I cannot exclude the possibility of small amounts of free intraperitoneal air. Close clinical correlation is suggested.
4. Bilateral pleural effusions with bibasilar pulmonary opacities.
5. Indeterminate pulmonary nodule within the right lung base. Follow-up for that finding in 3 months is recommended.

T3.1:
SERVICE CODE(S): 74178
ICD-10-CM DX CODE(S): R65.2, J90, J98.4
INCORRECT/MISSING CODE(S):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
CMA – HIMBC MED 107