T3-2B CT SCAN, BRAIN

question 3

Essay

T3-2B CT SCAN, BRAIN
CT OF THE BRAIN: The exam is significant for extensive subdural fluid accumulation in the left frontoparietal region, extending approximately 3 cm (centimeter) from the inner diploe with associated mass effect causing marked effacement and shift of the left lateral ventricle. There is approximately 1.5 to 2 cm of shift from left to right.
CONCLUSION: Subdural fluid accumulation with mass effect and shift.
Dr. Naraquist was notified, and arrangements were made to have the patient transferred to a tertiary care center for neurosurgery.
T3-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): _______________________________________________

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