ICD 10

[Pages:2]10/7/21, 11:07 AM

Office Location: 1729 North Ocean Ave, Medford, 11763 Office Phone: (631)289-4800 Office Fax: (631)289-3826

PATIENT NAME: Grasman, Margherita PATIENT PHONE NUMBER: PATIENT ID: 606401 DOB: 10/11/1948 DATE OF EXAM: 06/01/2016

R. Phys. Name: Johnson, Barbara R. Phys. Address: 100 Maple Avenue, Smithtown, 11787 R. Phys. Phone: (631)265-7671

LS SPINE XRAY W/OBLIQUES

HISTORY: back pain x 3 weeks. No trauma

Views: AP, lateral and bilateral oblique views were obtained.

Findings: There are 5 nonrib-bearing lumbar type vertebral bodies. . Bones are

significantly osteopenic. The vertebral bodies are normal in height without a fra

cture. No

destructive osseous lesion is seen.

Alignment is unremarkable.

There is severe loss of disc height and vacuum phenomenon at L3-L4. There is posterior

osteophytic spurring. Moderate degenerative disc disease is seen at the remaining lumbar

levels. There is mild remodeling of the superior L1 endplate.

There is prominent facet arthrosis at the lower lumbar spine.

SI joints are not widened. Prominent atherosclerotic calcifications are seen within the

aorta.

IMPRESSION:

Moderate degenerative disc disease throughout the lumbar spine with more advanced

degenerative changes at L3-L4.

Prominent atherosclerotic calcification throughout the aorta.

ICD 10 -

Degenera

tion lumbar spine, M51.36

Signed by: Cono Gallo

Signed Date: 6/5/2016 2

:12 PM

SIGNED BY: Cono Gallo M.D., Ext. 9551 06/05/2016 02:12 PM

IMPRESSION:

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10/7/21, 11:07 AM

Moderate degenerative disc disease throughout the lumbar spine with more advanced

degenerative changes at L3-L4.

Prominent atherosclerotic calcification throughout the aorta.

ICD 10 -

Degeneration lumbar spine, M51.36

Signed by: Cono Gallo

Signed Date: 6/5/2016 2:12 PM

SIGNED BY: Cono Gallo M.D., Ext. 9551 06/05/2016 02:12 PM

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