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PATIENT: **** ***** DOB: */*/**** FILE #: ***** PHYSICIAN: REFERRING EXAM: MRI CHEST WITHOUT CONTRAST DATE: 1/1/2011 Report approved on NationalRad | Headquartered: ******* | Diagnostic Imaging Services: Nationwide | ***.***.**** | www.NationalRad.com CLINICAL INFORMATION 69-year-old female with a history of smoking, asthma and bronchitis now with productive cough intermittently for several months. COMPARISON None. CONTRAST None. TECHNIQUE CT chest without contrast was performed from the thoracic inlet through the upper abdomen using 5 mm contiguous axial slices and 2-D coronal and sagittal reformats. FINDINGS The visualized thyroid gland is unremarkable. The lungs are hyperinflated. There are scattered foci of septal thickening and groundglass opacity in the bilateral upper lobes with associated tiny cysts. There is an additional tiny focus of reticular nodular density in the super segment of the left lower lobe. The remaining lungs are clear. There is mild tracheomegaly and bilateral bronchiectasis. The airways are patent. There is no adenopathy, effusion or pneumothorax. There is mild cardiomegaly with calcification of the coronary arteries. There is moderate atherosclerosis without aneurysm or leak. The pulmonary arteries are normal in caliber. There is a Page 2 of 2 Report approved on NationalRad | Headquartered: Florida | Diagnostic Imaging Services: Nationwide | 877.734.6674 | www.NationalRad.com moderate hiatal hernia. There is diffuse diverticulosis. The remaining visualized upper abdomen is unremarkable. There is diffuse spondylosis. There are mild chronic midthoracic compression fractures. IMPRESSION 1. Nonspecific patchy ground glass opacification and septal thickening bilateral upper lobes and superior segment of left lower lobe likely infectious or inflammatory in etiology. 2. Hyperinflation consistent with COPD. 3. Tracheomegaly and bilateral bronchiectasis. 4. No adenopathy or effusion. 5. Mild cardiomegaly, diffuse atherosclerosis. 6. Diffuse diverticulosis. 7. Moderate hiatal hernia.

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Predicted CPT Code:

71550

Procedures of the Chest.

Predicted ICD-10 Code

J44.9

Chronic obstructive pulmonary disease, unspecified

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