Radiologic Example 1

View the suggested abstraction.

Name: Sarah O. Luckless
Hospital No.: 000001
Age: 68
Sex: Female
Race: White

Examination Desired: Chest Film

Reason for Exam: Chronic respiratory problems


CHEST, PA AND LATERAL, 10/8/91: an approximately 2 to 3 cm irregular poorly marginated mass is located in left midlung laterally. A few strands are seen extending from it toward the left hilum. The patient is noted to have low diaphragm, and an increased AP diameter. This is suggestive of chronic obstructive pulmonary disease. The lungs are clear of any infiltrate and any other definite mass lesions. The heart is not enlarged.


  1. 2 to 3 cm irregular, poorly marginated mass, left midlung laterally, probably adenocarcinoma. There are some dense streaky strands extending from this mass toward the left hilum.
  2. Chronic lung disease.

Recommendation: Tomogram might be helpful.

Date: 10/8/91
Exam: Chest Radiologist: I.C. pic, MD