Get Answer: Patient Name Richard Question Guide
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This question relates to patient name richard and requires a structured academic response.
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Original Question
Patient Name: Richard Brasher DOB: 11-10-51 Ordering Physician: Nathaniel Baker, MD Gender: M Interpreting Physician: Samuel Timms, MD Date of Service: 12-16-XX Indication: R/O brain mets Exam: MRI of brain w/ contrast History: Male patient with metastatic small cell lung cancer. Stereo protocol. Technique: Axial T1 post contrast images of the brain was obtained following uneventful administration of 7 mL of intravenous Magnevist. Findings: There is a peripherally enhancing lesion involving the right anterior inferior temporal lobe measuring 1.2 x 1.2 cm. There is minimal adjacent edema without significant mass effect around this lesion. There is an additional area of focal enhancement along the base of the right sphenoid wing 12 x 6 mm. When comparing to the previous CT of the head, no bony destruction or sclerosis noted. There is a tiny hypointense lesion in the left deep cerebral white matter which corresponds to focus of FLAIR signal abnormality on the previous brain MRI. There is no midline shift or hydrocephalus. Paranasal sinuses are clear. Impression: Stable 1.2 cm peripherally enhancing malignant lesion in the right anterior inferior temporal lobe with minimal adjacent edema Enhancing lesion in the greater wing and base of the right sphenoid bone may represent a developing metastasis but is of uncertain significance. Give the correct CPT and ICD-10 codes.
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