3rd Qtr Physician 2016 Oncology Case Study #2
17yoM CIGNA SI-PPO/OAP
Provider specialty: Physician Assistant
Request Initiated: 7/16/16
CPT: 78816 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; whole body
ICD-10: R63.4 Abnormal weight loss, R50.9 Fever, unspecified
Nurse Reviewer Note
Cheryl/MDO/Diagnostic Medical Care requested PET 78816 for
Reason for imaging: fever and night sweats, weight loss since January 2016. R/O Lymphoma
FOV: Symptoms began in January LOV: 06/02/16
SX: Nausea, vomiting, weight loss (over 25 lbs), abdominal pain. Cough. Intermittent fever, over 101. Night sweats.
TX: Tamilful. Steroids.
PMH: No hx of cancer. Testicular torsion. Testicular surgery done September 2014. Cervical fusion in 2013.
Prior Imaging: 06/19/16 MRI brain w/w/o: Normal.
06/02/16 Xrays abdomen: Normal.
CT abdomen/pelvis was normal.
CT neck normal.
CT chest: Normal
Upper endoscopy was normal.
02/25/16 Abdominal US: IMP: Borderline splenomegaly. No liver lesions.
Labwork: Elevated bilirubin 1.8 H. Uric acid 7.7 H.
ACDS Reviewed
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