Which dx for hypertension applies to this report and other diagnoses as well? I'm not sure if to use dx 416.0 for hypertension and 434.91 for CVA--thanks!
Examination: CT Angio Chest w&w/o contrast
History: 78-year-old woman with history of CVA. Now with hypertension and tachycardia. Unequal blood pressure in the arms. Elevated D-dimer, possible subclavian stenosis
.
Technique: Multiple contiguous 1.25 mm axial images were obtained from thoracic inlet to the midabdomen after administration of intravenous contrast material, as per departmental PE protocal.
Comparison is made with prior study from May 9, 2011
Findings:
There is no central, interlobar or segmental pulmonary embolism. The subsegmental vessels are not well visualized. There is atherosclerotic disease and thrombosis involving the proximal left subclavian artery just above the origin, although more distally to vessel is patent, unchanged from prior study. There is no thoracic lymphadenopathy. The heart is normal in size and there is no pericardial effusion. There are streaky opacities in both lower lobes which likely represents atelectasis. There is no consolidation, pleural effusion or pneumothorax.
There are multiple small nodules in the thyroid bilaterally, similar to prior study. Correlation with thyroid function tests is recommended. There is a porcelain gallbladder with a small amount of pericholecystic fluid. A gastric tube is noted. The remainder of the visualized upper abdominal organs are normal. There are degenerative changes of the thoracic spine.
Impression:
1. No pulmonary embolism
2. Atherosclerotic disease and thrombosis involving the proximal left subclavian artery, although more distally the vessel is patent
3. Multiple small nodules in the thyroid bilaterally, correlation with thyroid function tests is recommended
4. Porcelain gallbladder and a small amount of pericholecystic fluid
Examination: CT Angio Chest w&w/o contrast
History: 78-year-old woman with history of CVA. Now with hypertension and tachycardia. Unequal blood pressure in the arms. Elevated D-dimer, possible subclavian stenosis
.
Technique: Multiple contiguous 1.25 mm axial images were obtained from thoracic inlet to the midabdomen after administration of intravenous contrast material, as per departmental PE protocal.
Comparison is made with prior study from May 9, 2011
Findings:
There is no central, interlobar or segmental pulmonary embolism. The subsegmental vessels are not well visualized. There is atherosclerotic disease and thrombosis involving the proximal left subclavian artery just above the origin, although more distally to vessel is patent, unchanged from prior study. There is no thoracic lymphadenopathy. The heart is normal in size and there is no pericardial effusion. There are streaky opacities in both lower lobes which likely represents atelectasis. There is no consolidation, pleural effusion or pneumothorax.
There are multiple small nodules in the thyroid bilaterally, similar to prior study. Correlation with thyroid function tests is recommended. There is a porcelain gallbladder with a small amount of pericholecystic fluid. A gastric tube is noted. The remainder of the visualized upper abdominal organs are normal. There are degenerative changes of the thoracic spine.
Impression:
1. No pulmonary embolism
2. Atherosclerotic disease and thrombosis involving the proximal left subclavian artery, although more distally the vessel is patent
3. Multiple small nodules in the thyroid bilaterally, correlation with thyroid function tests is recommended
4. Porcelain gallbladder and a small amount of pericholecystic fluid
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