Clinical IRR Onc/Rad Onc Case Study #2
Case Scenario:
51 yo Male CIGNA SI-PPO/OAP
CPT: 78815 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization: skull base to mid-thigh
ICD-9: 193 - Malignant neoplasm of thyroid gland
Addtional Clinical Nurse Review Note:
LOV: 1-10-12
Reason: Initial staging
Cell type and location: thyroid carcinoma with two lymph node involvement
DOD: 12/29/11
Size of primary tumor: 3 cm
Staging of newly diagnosed cancer: staging
Primary therapy: pretx
Information on recurrence: primary cancer
Prior Imaging: CT neck 12/19/11- left lobe of thyroid 2.9x2/2 cm solid and systic appearing lesion- does appear to have focal calcifications. Non-specific hypodense lesions in both right and left lobe.
PE: wnl
Current relevant S/Sx and duration: none
Labs/Tumor Markers: none
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