LOCATION: Outpatient hospital.
PATIENT: Kevin Melander
PHYSICIAN: Ronald Green, MD
RADIOLOGIST: Morton Monson, MD

EXAMINATION OF: Head CT without contrast.

CLINICAL SYMPTOMS: Seizure-like episode pre-bleed.

HEAD CT WITHOUT CONTRAST: FINDINGS: Seven scans were obtained through the brain without intravenous contrast. The study was requested emergently. Comparison is made with the study from earlier this same day at 2:50 am. This study was done at 10:20 am. A small hematoma is again seen in the left frontal region anterior to the frontal bone and extending along the supraorbital region. There is again acute hematoma seen extending anterolaterally on the left. This may reflect epidural versus subdural hematoma. On image 11, this measures approximately 6 cm in AP diameter. On image 12, this measures approximately 1.8 cm in width. Overall size appears generally similar, although there are some technical differences between the studies. Comparing the right with the left, there is some effacement of the cortical sulci on the left. Overall findings are generally similar.

IMPRESSION: No definite interval change in head CT without contrast. There is again left-sided acute epidural versus subdural hematoma. There is some effacement of cortical sulci on the left compared with the right extending superior to the hematoma. There is again left frontal/supraorbital hematoma just anterior to the left frontal bone.

Report only the radiologist's portion of the service.

 

CPT Code: __________________

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