Case 3 Diagnostic Imaging Report 1

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Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
DIAGNOSTIC IMAGING REPORT
Patient Name: Putul Barua
Patient ID: 135799
Room #: CCU-4
X-ray #: 10-0460
Referring Physician: Simon Williams, MD, Pulmonology
Reason for Exam: Hemoptysis.
Date of Exam: 01/10/2015
Procedure: CT scan of chest without contrast.
FINDINGS: CT scan of the chest was performed in 7 mm axial sections with no intravenous contrast
enhancement. Comparison is made to previous CT scans done during his admission last year. There is interval
resolution of the previously noted cavitary lesions in both upper lobes. However, there is evidence of chronic
residual infiltrates or scarring in both upper lobes as well as in the mid and lower lung fields posteriorly. Heart
again appears enlarged. There is evidence of mild bilateral pleural thickening. No interval pulmonary
parenchymal or pleural-based massed lesions. No mediastinal or hilar masses, no lymphadenopathy, no pleural
effusions, and no significant lesions of the bony thorax.
IMPRESSION: Significant interval improvement with evidence of interval resolution of the previously
described bilateral upper lobe cavitary lesions in the lungs since his previous CT scans. There are residual
chronic infiltrates or scarring in both upper lobes. There is also evidence of residual scarring or infiltrates in the
mid and lower lung fields posteriorly. The heart is enlarged. No other significant findings.
_________________________
Donna Harrison, MD
DH:vw
D: 01/10/2015
T: 01/10/2015
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