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Generate impression based on findings. | Status post left mastectomy for breast cancer in 2006, presents today for routine follow up. No current breast complaints. Two standard and three implant displaced views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular de... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Lymphoma CHEST:LUNGS AND PLEURA: Interval improvement in previously noted tree in bud opacities bilaterally.Interval improvement in scarlike opacity within the right major fissure. Right middle lobe micronodule no longer measurable.MEDIASTINUM AND HILA: No significant abnormality noted.CHEST WALL: No significant abnorm... | New subcentimeter segment 5 low-attenuation hepatic focus; would pay special attention to this lesion on future surveillance scans.Interval near resolution of tree in bud inflammatory lung findings.Otherwise stable examination. |
Generate impression based on findings. | Female 33 years old Reason: evaluate for obstruction History: hx of roux en Y, vomiting, constipation x 1 month, was diagnosed with SBO on 1/1/14 OSH ABDOMEN:LUNG BASES: Respiratory motion limits evaluation of the lung bases.LIVER, BILIARY TRACT: The patient is status post cholecystectomy and there is mild prominence o... | 1.Postsurgical changes related to Roux-en-Y gastric bypass with mild prominence of the biliary limb, which could reflect mild obstruction. 2.Prominence of the common bile duct and intrahepatic biliary ducts most likely reflects postoperative sequelae from prior cholecystectomy. |
Generate impression based on findings. | 8-year-old female with supracondylar fracture, AVN.VIEWS: Right elbow AP/lateral (two views), 1/6/2015, 916 hours. Healed supracondylar fracture in anatomic alignment. Irregularity of the capitellum consistent with history of AVN. | Healed supracondylar fracture. |
Generate impression based on findings. | Female 59 years old Reason: intraabdominal abscess History: bacteremia ABDOMEN:LUNG BASES: A central venous catheter tip is seen at the cavoatrial junction.LIVER, BILIARY TRACT: Nodular hepatic contour, hepatomegaly and widening of the fissures suggests chronic liver disease. There is persistent prominence of the commo... | 1.No evidence of intraabdominal abscess or explanation for the patient's bacteremia evident.2.Unchanged dilatation of the common duct without evidence of choledocholithiasis, suggestive of a benign stricture as previously described on the M.R.C.P. examination from 12/30/2014.3.Findings consistent with chronic liver dis... |
Generate impression based on findings. | Right lower quadrant pump is partially visualized on the scout view. Catheter is seen entering the spinal canal at the L2-L3 level. Catheter courses dorsally in the subdural space with tip at the T10-T11 level. Contrast injection demonstrates opacification of the subdural space.Vertebral body heights and alignment in ... | 1. Spinal catheter tip is at the T10-T11 level and is subdural in location. 2. Incidentally seen is enlargement of the left thyroid lobe with hypodense nodule measuring 1.7 cm. Consider ultrasound for further evaluation as clinically indicated.Dr. Ali discussed findings with Dr. Malik at 1030 hrs on 1/6/2015. |
Generate impression based on findings. | Pain. Healing? Again seen is a plate and screw device affixing the first metatarsophalangeal joint in near-anatomic alignment. I see no hardware complications. The articulation is narrowed but remains visible at this time. Mild osteoarthritis affects the interphalangeal joints | Orthopedic fixation of the first metatarsophalangeal joint as described above. |
Generate impression based on findings. | Reason: metastatic lung CA to liver, pancreas, lung. followup scan History: weight loss CHEST:LUNGS AND PLEURA: Postsurgical scarring with volume loss and radiation reaction in the right hemithorax.Multiple bilateral pulmonary metastases, increased in size and number.Left upper lobe reference nodule (series 5/33): 13 x... | Interval progression of disease in the lungs, liver, pancreas and gastrohepatic lymph nodes. |
Generate impression based on findings. | 50 year old female with nausea, vomiting, and abdominal pain. Evaluate for gastroparesis. The patient was unable to tolerate the exam and only immediate images were obtained which are nondiagnostic. | Nondiagnostic gastric emptying study. |
Generate impression based on findings. | 57 years old, Female, Reason: 57 yo female with history of jejunal mass seen on July 2014 MRI/MRE. Please evaluate for internal change. Per radiologist, please us Volumen as oral contrast. History: Intraabdominal mass, abnormal MRI abdomen ABDOMEN:LUNG BASES: Centrilobular emphysema.LIVER, BILIARY TRACT: Hepatic hypode... | 1.Exophytic mass of the proximal jejunum appears unchanged in size given differences in modality.2.Stable hepatic hypodensity, likely benign.3.Fibroid uterus. |
Generate impression based on findings. | Female 50 years old; ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: 2.5 x 2.3 cm hepatic segment 8 lesion with hypoattenuated appearance relative to background liver on noncontrast imaging. Discontinuous peripheral nodular enhancement seen in arterial phase of postcontrast imaging. Progress... | Outside exam read:1. Findings compatible with a hepatic segment 8 hemangioma as described. Additional subcentimeter flashfilling hemangioma also suggested in region of hepatic dome. |
Generate impression based on findings. | Right knee pain status post quad rupture in 2014. Four views of the right knee are provided. The patella is low lying, and there is heterotopic ossification within the extensor mechanism anterior to the distal femoral metadiaphysis, compatible with the stated history of prior quadriceps tendon rupture. Lucencies within... | Findings compatible with prior quadriceps tendon rupture and osteoarthritis as described above. |
Generate impression based on findings. | 62 year-old female with hyperparathyroidism. Following injection, intraoperative probe localization was performed. No images were acquired. | Successful injection for intraoperative identification of parathyroid adenoma. |
Generate impression based on findings. | Evaluate ankle Fracture Three views of the left ankle reveal a nondisplaced spiral fracture of the distal fibula that extends down to the joint line. There is also a posterior malleolar fracture in anatomic alignment. The fracture lines are indistinct consistent with healing. No change in position from previous. | Healing ankle fractures in anatomic alignment |
Generate impression based on findings. | Ms. Turner is a 53 year old female who presents for short-term follow-up for a mass in the left breast. No family history of breast cancer. Three standard views of both breasts and two left Spot compression views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scat... | Interval decrease in size of left lateral breast asymmetry, probably due to involution of a benign cyst. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient... |
Generate impression based on findings. | Frontal sinus: There is mild mucosal thickening along the left frontal ethmoidal recess. The frontal sinus and right frontoethmoidal recess are clear. Anterior ethmoids: Trace mucosal thickening is present in scattered bilateral anterior ethmoid air cells.Maxillary sinuses: There is scattered trace mucosal thickening ... | 1. Very minimal scattered sinus inflammatory changes without CT evidence of acute sinusitis.2. Minimal leftward nasal septal deviation.3. Multiple dental caries with suggestion of periodontal and endodontal disease, for which correlation with dental exam is recommended. |
Generate impression based on findings. | Male 11 months old Reason: out toeing hip contracture History: outtoeing hip contractureVIEWS: Pelvis AP and frog leg 1/6/15 (two views) Both round, smooth and normally formed femoral heads are well directed to a normally developed acetabulum. | Normal examination. |
Generate impression based on findings. | Female 88 years old Reason: Patient came in with severe sepsis of unclear source, wish to examine for abscess/fluid collections. Has CKD so unable to receive IV contrast History: Severe sepsis with unclear source ABDOMEN:LUNG BASES: New small bilateral pleural effusions with associated compressive atelectasis. There is... | 1.No specific finding seen to account for the patient's sepsis.2.New small bilateral pleural effusions with associated compressive atelectasis.3.Large sliding type hiatal hernia. |
Generate impression based on findings. | Smoldering myeloma. Screening to rule out lytic lesions. SKULL: There are small lucencies within the calvarium that I suspect represent venous lakes rather than myelomatous deposits.CERVICAL SPINE: I see no discrete lytic lesions. Degenerative arthritic changes affect the cervical spine, particularly at the lower cervi... | No definite lytic lesions. Small lucencies in the skull are favored to represent venous lakes. Degenerative arthritic changes as described above. |
Generate impression based on findings. | Female; 67 years old. Reason: missing lap sponge History: missing lap sponge Single AP oblique view of the skull demonstrates a bandlike radiopacity projecting over the left temporoparietal region, which after discussion with the surgical resident in the operating room (Dr. Fuller) likely represents a known surgical dr... | No evidence of retained surgical foreign body. A bandlike opacity projecting over the left temporoparietal region is likely a drain, after discussing the finding with Dr. Fuller in the operating room. These findings were discussed with Dr. Fuller and the circulating nurse (Marvin Glenn) both in the operating room by te... |
Generate impression based on findings. | Reason: target ventricles for surgery today History: hydrocephalus, aqueductal stenosis There are bilateral ventriculostomy tubes coursing through the frontal lobes into the lateral ventricles with tips near the region of the foramen of Monro. Additionally there is a right parietal entry ventriculostomy tube coursing i... | 1.Since the previous exam the lateral ventricles and third ventricle have decreased in size.2.Hyperdense fluid within the lateral ventricles is suspected to represent a small amount of blood.3.A small calcification is present in the left lateral ventricle which is likely dystrophic or related residua from old congenita... |
Generate impression based on findings. | Male 69 years old Reason: HCC on observation, evaluate for disease progression CHEST:LUNGS AND PLEURA: Trace fluid again seen in the right major fissure.MEDIASTINUM AND HILA: Aortic valve replacement. Severe coronary arterial calcifications. Dense atherosclerotic calcifications of the thoracic aorta and its branches. P... | Disease progression with interval increase in size of the index and non-index arterially enhancing hepatic lesions. Although these lesions do not meet strict criteria for an HCC and do not demonstrate washout, they have enhancement and washout characteristics similar to the primary lesion seen on the 6/23/2011 examinat... |
Generate impression based on findings. | Restaging recently diagnosed Hodgkin lymphoma on ABVD chemotherapy. HIV positive.RADIOPHARMACEUTICAL: 13.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 75 mg/dL. Today's CT portion grossly demonstrates right chest Port-A-Cath with tip in the SVC. Multiple surgical clips are seen in both the right axilla a... | 1.Complete interval resolution of previous hypermetabolic tumor activity without FDG avid tumor currently in the neck, chest, abdomen or pelvis.2.Extensive coronary calcifications, notably in the LAD. Please correlate clinically as to the need for further evaluation such as with myocardial perfusion scintigraphy.I pers... |
Generate impression based on findings. | 79-year-old female, rule out fracture There is dextrolumbar scoliosis and multiple number vertebral body osteophytes. Degenerative changes also affect the SI joints. No fracture is evident. | Scoliosis with associated arthritic changes as detailed above. |
Generate impression based on findings. | 26-year-old male with pain Again seen is attempted fusion with screws through the base of the first metacarpal and medial cuneiform. A K wire extends across the first MTP joint in near-anatomic alignment with interval correction of hallux valgus deformity. | Postoperative changes as described above without evidence of complication. |
Generate impression based on findings. | Status post fracture. History of non-ossifying fibroma of the distal radius.VIEWS: Left wrist AP lateral and oblique 1/6/15 (3 views) There is a refracture of the non-ossifying fibroma of the distal metaphyses of the left radius. Alignment is near-anatomic. | Refracture of non-ossifying fibroma of the distal metaphysis of the left radius. |
Generate impression based on findings. | Female 64 years old; Reason: assess for metastatic disease History: right inguinal swelling CHEST:LUNGS AND PLEURA: Visualized lung fields without significant change. Biapical pleural scarring, stable. Small scarring/tree in bud appearance in anteromedial aspects of lingula and right middle lobe without significant cha... | 1.Worsening right inguinal adenopathy as described. Additionally, asymmetric enlargement of right pectineus muscle and mildly enhancing soft tissue foci seen along course of right femoral vessels, insinuating into adjacent pectineus musculature, suspicious for additional enlarging lymph nodes, underlying neoplastic mus... |
Generate impression based on findings. | 75-year-old with history of ADH status-post lumpectomy. A mass is seen near lumpectomy bed on follow-up imaging. Right ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a hypoechoic mass measuring 6 x 3 mm at the 12 o’clock position without increased vascularity, 1 cm from the nipple. ... | Successful ultrasound-guided core biopsy of the right breast lesion and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Reason: Pt with known lung cancer and ?rml infiltratte overlying known cavitary lesion on cxr. please clarify if pna is present. History: sob, fever, known lung ca CHEST:LUNGS AND PLEURA: Right lower lobe cavitating mass (image 50 mass demonstrates interval increase in size now measuring 4.6 cm x 3.3 cm previously meas... | 1.Increasing size of cavitating right lower lobe mass and adjacent right hilar mass.2.New peripheral wedge-shaped opacity posterior in the right upper lobe with surrounding groundglass compatible with either infection or infarction.3.Increasing mediastinal and right hilar lymphadenopathy.4.New right pleural effusion.5.... |
Generate impression based on findings. | 7 month old female, replaced feeding tube.VIEW: Chest and abdomen AP, 12/30/2014, 14:12 hours. Enteric tube with weighted tip is at the pylorus/duodenal bulb. A second enteric tube tip is in the gastric body. Central line terminates at the right atrium. IVC stents and right lower extremity central line again noted. Abd... | Feeding tube tip at the pylorus/duodenal bulb. |
Generate impression based on findings. | Female; 48 years old. Reason: humerus fx, ongoing pain History: humerus fx, ongoing pain Three views of the right humerus demonstrate a comminuted fracture of the mid humeral diaphysis with approximately 30 degrees of posterior angulation of the distal fracture fragment. The fracture also demonstrates slight varus alig... | Comminuted humerus fracture as described above. |
Generate impression based on findings. | 7 month old female with replaced feeding tube.VIEW: Chest and abdomen AP (two view) 12/30/2014, 1400 hrs. Enteric tube with weighted tip is coiled in the stomach with tip in the mid gastric body. A second enteric tube tip is in the distal gastric body. Central line terminates at the right atrium. IVC stents and right l... | Feeding tube tip in the stomach. |
Generate impression based on findings. | Ms. Corley is a 62 year old female with a personal history of right breast lumpectomy in June 2014 for IDC with neuroendocrine features. She has no current breast related complaints. Three standard views of both breasts, two right spot magnification views and two left magnification views were performed digitally and re... | Expected postsurgical changes in the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diag... |
Generate impression based on findings. | 83-year-old female who presents for short-term follow-up for high probability benign calcifications in the left breast. Personal history of rheumatoid arthritis. History of breast cancer in half sister diagnosed in her 40s. No current breast complaints. Three standard views of both breasts and two magnified views of th... | Stable high probability benign calcifications in the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 12 months, given the lack of change over the past year. Results and recommendation were discussed with ... |
Generate impression based on findings. | There are post-operative findings related to a subtotal cranial vault reconstruction. There are biparietal surgical osteotomies and focal defect at the superior convex margin of the sagittal suture. There is slight focal convexity at the apex. Additional scattered small osseous defects of the calvarium likely represen... | Post-operative findings related to a subtotal cranial vault reconstruction with improvement in the previous scaphocephalic configuration of the calvarium. |
Generate impression based on findings. | Female; 48 years old. Reason: post reduction History: post reduction Two views of the right humerus demonstrate interval placement of overlying cast material, which limits evaluation of fine bone detail. Again seen is a comminuted fracture of the mid humeral diaphysis, which has been slightly reduced when compared to p... | Comminuted fracture of the humerus as described above. |
Generate impression based on findings. | Male 50 years old; Reason: 50 yo male with hx of appendiceal cancer; please do CT scan and evaluate for abnormalities and or recurrence History: appendiceal cancer CHEST:LUNGS AND PLEURA: Mild right basilar atelectasis. Left basilar opacity has the appearance of rounded atelectasis.MEDIASTINUM AND HILA: Mildly prominen... | 1. Status post exploratory laparotomy and biopsies. Two subcapsular posterior right hepatic lobe implants are stable/mildly decreased compared to prior study. Hypoattenuating rim enhancing fluid extending along the inferior aspect of the right hepatic lobe has increased compared to prior study. This may represent enlar... |
Generate impression based on findings. | Female 64 years old Reason: Persistent nausea, vomiting, increased NG output after surgery. Previous imaging suggestive of partial SBO. History: As above ABDOMEN:LUNG BASES: Trace bibasilar dependent atelectasis. Previous described pulmonary embolus not seen on today's examination.LIVER, BILIARY TRACT: Cholelithiasis w... | 1.Small bowel obstruction with two transition points seen within the pelvis as detailed above, likely due to adhesive disease and with associated development of interloop fluid.2.Postsurgical changes related to cystectomy and Indiana pouch formation with interval removal of the nephroureteral stents.3.New mild left-sid... |
Generate impression based on findings. | Male; 41 years old. Reason: eval for fx History: severe pain Three views of the left humerus demonstrate mild expansion with underlying ground-glass matrix of the left humerus diffusely and an appearance typical for fibrous dysplasia. There is an acute transverse fracture of the distal diaphysis of the left humerus wit... | Pathologic fracture of the distal left humerus through fibrous dysplasia. |
Generate impression based on findings. | Reason: 65M with AML acutely altered and unresponse, plts 8 History: AMS The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized... | No evidence for acute intracranial hemorrhage mass effect or edema. |
Generate impression based on findings. | Male; 41 years old. Reason: r/o compression fx History: acute on chronic lumbar back pain s/p hitting back on toilet today Five views of the lumbar spine demonstrate no acute fracture. There is moderate degenerative disk disease affecting L5-S1. The remaining disk spaces are within normal limits. Alignment of the lumba... | Degenerative disk disease at L5-S1. No acute fracture is evident. |
Generate impression based on findings. | Status post left patellar fracture Again seen is a comminuted fracture of the patella with fracture fragments in near anatomic alignment. The fracture line extends to the articular surface of the patella, and there is a moderate-sized joint effusion. The bones appear slightly demineralized. Mild osteoarthritis affects ... | Patellar fracture appearing similar to that seen on the prior study. |
Generate impression based on findings. | 69-year-old female with history of no cancer. Malignant neoplasm of the submandibular gland. CHEST:LUNGS AND PLEURA: Multiple bilateral pulmonary nodules, with measurements as follows:Reference left upper lobe pulmonary nodule (4/25) measures 8 x 10 mm, unchanged.In the right upper lobe anterior nodule which abuts the ... | Multiple bilateral pulmonary nodules, most of which have slightly increased in size of the interval, consistent with progression of disease. |
Generate impression based on findings. | Male; 75 years old. Reason: r/o fracture History: knee pain Three views of the left foot demonstrate soft tissue swelling along the dorsum of the foot. There is deformity of the proximal phalanx of the fifth toe, most likely due to old healed fracture. Severe osteoarthritis affects the first MTP joint. No acute fractur... | Soft tissue swelling and osteoarthritic changes as described above. We see no acute fractures. |
Generate impression based on findings. | 65 years old, Female, Reason: 65 y/o woman with recurrent ovarian cancer receiving chemotherapy. Evaluate for treatment response and extent of disease. History: Recurrent ascites. CHEST:LUNGS AND PLEURA: Multiple bilateral pulmonary micronodules, pleural-based right middle lobe nodule, and likely a lymph node within th... | 1.Improvement in volume of malignant ascites.2.Decrease in size of reference peritoneal nodule.3.Improved bowel wall thickening and dilatation. |
Generate impression based on findings. | Female 74 years old; Reason: 74 yo female with hx of schwannoma and right retroperitoneal mass ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Stable well-circumscribed hepatic segment 8/5 hyperattenuating lesion, most likely a cyst, image 33 series 3. Mild intrahepatic and extrahepatic bili... | 1. Mild interval enlargement of right retroperitoneal mass, biopsy-proven schwannoma.2. New left gonadal vein thrombus. 3. Left adnexal enhancing nodularity again visualized and without significant change in size, while may reflect exophytic/subserosal uterine fibroid, confirmation with dedicated pelvic sonography reco... |
Generate impression based on findings. | Pain. Healed? A plate and screws affix a fracture of the medial malleolus in near anatomic alignment. The fracture line is less distinct on the current study than on the prior study suggesting some interval healing. I see no hardware complications. Ossification along the anterior aspect of the tibial plafond may repres... | Orthopedic fixation of healing medial malleolar fracture. |
Generate impression based on findings. | 15-year-old male with pyuria, no urine output for 24 hours. Evaluate for hydronephrosis, stones, bladder anatomic abnormality. BLADDER Wall Thickness: Not assessed. Contents: Foley catheter present in a decompressed bladder. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: No... | Two nonobstructing left renal stones, the larger measuring 8 mm.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4: Grade 3 and parenchyma... |
Generate impression based on findings. | Severe pain and tenderness right big toe. Assess for fracture/dislocation. Although these are nonweightbearing views, there is a mild to moderate hallux valgus deformity. I see no fracture or dislocation. There are small enthesophytes at the Achilles insertion on the calcaneus which are not necessarily of any current c... | Hallux valgus deformity without fracture or dislocation. |
Generate impression based on findings. | Postop images, cervicalgia Again seen is a plate with screws entering the C5, C6, and C7 vertebral bodies. I see no hardware complications. There is interposed bone graft at C5/6 and C6/7 that appears similar to that seen on the prior study accounting for slight positional differences. Small osteophytes project from th... | Postoperative changes of ACDF appearing similar to those seen on the prior study. |
Generate impression based on findings. | Male 58 years old Reason: 58M with portal hypertension, lymphoma, recurrent rectal cancer. eval for metastatic disease History: rectal cancer, eval for metastatic disease CHEST:LUNGS AND PLEURA: There are a few scattered pulmonary nodules. The dominant nodule is located in the left lower lobe measuring 1.1 x 0.9 cm (im... | 1.Rectal mass with retroperitoneal lymph nodes and left lower lobe pulmonary nodule.2.Cirrhosis with thrombosis of the superior mesenteric vein and possibly the right portal vein. Dedicated liver imaging with liver MRI is suggested to detect HCCI personally reviewed the Images and/or procedure with the Resident/Fellow ... |
Generate impression based on findings. | Follow-up Again seen is a side plate and screws affixing a fracture of the distal fibula in near anatomic alignment. The majority of the fracture line is indistinct, suggesting healing, appearing similar to the prior study accounting for slight positional differences. There is soft tissue swelling along the lateral asp... | Orthopedic fixation of healing distal fibular fracture. |
Generate impression based on findings. | 63-year-old male with aggressive prostate cancer, bone METs and refractory constipation. Assess narcotic-induced constipation after conservative measures; indication for Relistor? Nonobstructive bowel gas pattern. No visible stool. Diffuse sclerotic osseous metastases again seen. | No visible stool. |
Generate impression based on findings. | 64 years old, Male, Reason: hx of bladder cancer s/p cystectomy w/ neobladder urinary diversion, evaluate for mets with delayed imaging ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Fatty infiltration of the liver is again seen. No focal liver lesion identified.SPLEEN: No significant abnorma... | 1.No evidence of recurrent or metastatic disease.2.Mild pancreatic ductal dilatation, increased from prior exam. This may be related to changes of chronic pancreatitis; however, if there is clinical suspicion for pancreatic head mass, MRCP or ERCP is recommended to further evaluate.3.Hepatic steatosis. |
Generate impression based on findings. | 70 year-old female with right breast mass identified on screening mammography. Right ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a mixed echogenicity mass measuring 14 mm at the 9 o’clock position without increased vascularity, 3 cm from the nipple. The lesion was readily visible... | Successful ultrasound-guided core biopsy of the right breast lesion and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Knee pain There is moderate osteoarthritis of the knee, with tricompartment osteophytes and mild narrowing of the medial tibiofemoral compartment. I suspect that there is also a small joint effusion. | Osteoarthritis. |
Generate impression based on findings. | 85 year old female with dysphasia. Evaluate for esophageal pathology vs motility disorder. Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions.Exam limited by patient immobility. Within these limits, single contrast evaluation of the esophagus and gastric car... | 1.Findings compatible with gastroesophageal reflux were observed.2.Breakup of the primary wave with stasis indicating moderate motility disorder. |
Generate impression based on findings. | Reason: lung CA, metastatic, on systemic therapy. FOllowup scan to assess disease History: none CHEST:LUNGS AND PLEURA: Right lower lobe infrahilar mass (image 69 series 5) slightly decreased in size now measuring 4.5 cm x 2.1 cm previously measuring 4.8 cm x 2.5 cm.Stable subpleural right middle nodule (image 82 serie... | 1.Mild interval decrease in the right lower lobe mass.2.No new suspicious pulmonary nodules or masses. |
Generate impression based on findings. | Female 69 years old Reason: evaluate for abscess, hernia, mass, bowel ischemia History: severe RUQ tenderness in pt with hx CHF, ESRD, GI bleed, hernia ABDOMEN:LUNG BASES: Calcified and noncalcified pulmonary micronodules suggest prior granulomatous disease. The heart is enlarged. There are annular calcifications of th... | 1.Left rectus sheath hematoma with active hemorrhage as detailed above.2.Cirrhotic liver morphology and associated ascites.3.Chronic fractures of the superior and inferior left pubic rami as well as the right inferior pubic ramus.4.Cardiomegaly. |
Generate impression based on findings. | 52-year-old with history of left mastectomy for breast cancer in 2002. No current breast complaints. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 39-year-old male with a history of an undescended left testis. The patient reports that he had corrective surgery at 5. RIGHT TESTIS: The right testicle is normal in morphology, echogenicity, and size, measuring 3.2 x 1.9 x 4.5 cm. Color and spectral Doppler evaluation demonstrates normal blood flow.LEFT TESTIS: The le... | The left testis is not visualized in the scrotum or inguinal region. |
Generate impression based on findings. | Female, 38 years old. Reason: Assess for SMA (Superior mesenteric artery syndrome) History: nausea and vomiting, abdominal pain relieved only by lying down flat. Double contrast visualization of the esophagus showed no morphologic abnormalities of the mucosal surfaces or mural contours. During the exam, no significant ... | Normal examination of the esophagus, stomach, duodenum, small bowel and proximal colon. No evidence of SMA syndrome. No signs of proximal dilatation or adhesions to explain the patient's symptoms. |
Generate impression based on findings. | Postoperative changes are seen from previous posterior surgical fusion of L3 through L5, with bilateral pedicle screws at these levels as well as bilateral connecting rods. Instrumentation results in extensive streak artifact which limits evaluation. There is bone graft material which appears confluently fused along t... | 1. Postoperative changes from previous L3 through L5 posterior surgical fusion. Minimal grade 1 anterolisthesis of L3 on L4 and trace retrolisthesis of L4 on L5. No evidence of acute fracture or instrumentation complication.2. Spondylotic changes as detailed above, most prominent at L2-L3 where there is likely moderate... |
Generate impression based on findings. | 45-year-old with known right breast cancer receiving neoadjuvant chemotherapy. Please check size. A targeted right ultrasound was performed for the known malignancy. The right breast mass at 9 o'clock now measures 0.8 x 0.7 x 0.8 cm. Previously this measured 1.1 x 1.0 x 0.7 cm on 12/1/2014, and 2.5 x 1.2 x 1.6 cm befor... | Continued interval decrease in size of known right breast cancer.BIRADS: 6 - Known cancer.RECOMMENDATION: T - Take Appropriate Action - No Letter. |
Generate impression based on findings. | 62 year old female. Reason: 61 y/o F with dysphagia to solids and liquids, history of gastric bypass surgery 2012, rule out stricture or other etiology History: as above Double contrast visualization of the esophagus showed Mild broad impression on the right aspect of the esophagus above the level of the thoracic outle... | 1. Postsurgical changes of a roux-en-Y gastric bypass, with a small gastric pouch and mild dilation of the afferent limb. The anastomosis is patent measuring 8-14 mm.2. Gastroesophageal reflux with slow clearing.3. No esophageal stricture. Mild broad impression on the right aspect of the esophagus above the level of th... |
Generate impression based on findings. | Postop Again seen is a plate and screw device affixing a fracture of the distal fibular diaphysis in near anatomic alignment. There has been progression of callus formation along the fracture, indicating some interval healing. There is also a transsyndesmotic screw affixing the distal tibia and fibula in near-anatomic ... | Orthopedic fixation of ankle fractures as above. |
Generate impression based on findings. | 10-year-old male with pain after fall. Rule out fracture.VIEWS: Left ankle AP/lateral/oblique (3 views) 1/6/2015, 1130 hrs. No joint effusion, fracture, or malalignment is evident. | No evidence of fracture or malalignment. |
Generate impression based on findings. | ALL for intrathecal chemotherapy. The procedure, indications, benefits, risks/complications and alternatives were described to the patient and informed consent was obtained. The patient was placed in the prone position and the inferior back was prepped with Betadine, draped and anesthetized with 1% lidocaine subcutaneo... | Successful fluoroscopically guided lumbar puncture and intrathecal chemotherapy injection without immediate complication. |
Generate impression based on findings. | Three months status post C7 -- T1 ACDF. Assess implants. Again seen is an anterior fixation device with screws entering the C7 and T1 vertebrae. There is also an intervertebral spacer at C7 -- T1. I see no frank bony bridging at this level at this time. There is also an anterior plate with screws entering the C6 and C7... | Postoperative changes of ACDF appearing similar to those seen on the prior study. |
Generate impression based on findings. | Female, 67 years old. Reason: s/p Dobbhoff tube please eval placement History: - Dobbhoff tube with tip overlying the proximal gastric body.Nonobstructive bowel gas pattern. | Dobbhoff tube with tip overlying the proximal gastric body. Recommend to advance 3-4 cm. |
Generate impression based on findings. | Left wrist pain Three views of left wrist are provided. The bones appear slightly demineralized, and there is perhaps mild soft tissue swelling along the ulnar aspect of the wrist, but otherwise I see no specific findings to account for the patient's pain.Three views of the left hand are provided. The bones are perhaps... | Possible mild soft tissue swelling along the ulnar aspect of the wrist. I otherwise see no findings to account for the patient's pain. |
Generate impression based on findings. | Reason: R sided weakness, AMS History: coumadin The CSF spaces are appropriate for the patient's stated age with no midline shift. Periventricular and subcortical white matter hypodensities of a moderate degree are present. Is also present on the prior examPunctate hypodense foci are present in the thalami and right ca... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of nonhemorrhagic CVA.3.Punctate lesions in the thalami and right caudate nucleus could represent lacunar infarcts of indeterminate age.4.Periventricular and subcortical white matter changes of a mild degree... |
Generate impression based on findings. | There is levoscoliosis of the thoracolumbar spine with apex at the at the T10-T11 level as seen on prior radiographs. The most inferior well-defined disc space is L5-S1.There is a butterfly vertebral body involving the T12 vertebral body. There is associated focal convexity involving the inferior and superior endplate... | 1. Butterfly vertebra at T12. There is associated mild focal convexities of inferior T11 and superior L1 endplates. 2. Low-lying conus at the mid L3 level, which does not demonstrate anterior displacement on the prone sequence. Imaging findings are suggestive of tethered cord and can be correlated with clinical finding... |
Generate impression based on findings. | Reason: h/o oropharyngeal ca and CRT, compare to previous, measurements pls History: none There continues to be effacement of fat planes adjacent to left carotid space. This is suspected to be related to posttreatment change.Within the suprahyoid neck on the basis of size criteria for lymphadenopathy no lymphadenopathy... | 1.No convincing evidence for local recurrence or neck lymphadenopathy on the basis of CT size criteria for lymphadenopathy. Please note, however, that a contrast-enhanced CT soft tissues neck study is more sensitive in the detection of lymphadenopathy and than a noncontrast study.2.Deviation of the vocal cord may imply... |
Generate impression based on findings. | Postoperative changes from prior total thyroidectomy, neck dissection, and tracheostomy are again noted. There remains irregular soft tissue in the subcutaneous fat just adjacent to the left inferolateral aspect of the tracheotomy stoma. This has a somewhat persistent rounded appearance on 6/63 but has not changed sig... | 1. Stable post treatment changes without evidence of locoregional tumor recurrence or cervical lymphadenopathy.2. Chronic deformity and irregularity of the residual medial left clavicle which is felt to be due to a combination of postsurgical and posttreatment changes as well as healed fracture, with progressive change... |
Generate impression based on findings. | Female 30 years old; Reason: eval for stone History: abdominal pain ABDOMEN:LUNG BASES: Micronodule in the right lung base.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, ... | 1.Nonobstructive right renal calculi.2.Punctate calcification adjacent to the right wall of the bladder may represent either a small distal ureter calculus or small phlebolith. |
Generate impression based on findings. | Male 49 years old; Reason: Stage IV pancreas cancer, please compare to previous scan and provide index lesion as required per RECIST CHEST:LUNGS AND PLEURA: Visualized lung fields without significant change. Scattered calcified and noncalcified pulmonary micronodules stable.MEDIASTINUM AND HILA: Small residual soft tis... | 1. Mild interval increase in prominence of pancreatic duct at level of head, measuring 8 mm, previously measured 4 mm. Accounting for differences in technique, no significant change with respect to ill-defined hypoattenuating pancreatic head mass. 2. Reference portacaval lymph node mildly increased in size, additional ... |
Generate impression based on findings. | Ms. Rodriguez is a 56 year old female recalled from screening mammogram for an asymmetry in the right breast. Family history of breast cancer in maternal aunt. An ML view and two spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is compose... | Simple benign right breast cyst. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 12 months. If that exam is stable, she could then probably return to routine screening in subsequent years. All results and recommendati... |
Generate impression based on findings. | Male 58 years old; Reason: GIST please assess and evaluate and compare to previous scan for RECIST as required per study History: As above ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Hypodense lesion at the dome of the liver measures 0.9 x 0.9 cm (image 16/series 3) previously, 1.1 x 0.9 ... | 1.Stable exam with near stable size measurements of the reference liver lesion. |
Generate impression based on findings. | Status post left total knee arthroplasty Components of a left total knee arthroplasty device are situated in near anatomic alignment without radiographic evidence of hardware complication. Skin staples, a drain, and foci of gas density in the anterior soft tissues reflect recent surgery. | Postoperative changes of total knee arthroplasty as above. |
Generate impression based on findings. | PHARYNX/LARYNX: There are again post treatment changes in the neck, including mild supraglottic mucosal edema with slightly improved mild narrowing of the airway. There is improved aeration of the piriform sinuses. The nasopharynx, oropharynx, hypopharynx, and larynx are otherwise unremarkable. The upper trachea and e... | Continued stable post treatment appearance of the neck without evidence of tumor recurrence or cervical lymphadenopathy. |
Generate impression based on findings. | Follow-up Two views of the left knee are provided. Again seen are sideplates and screws affixing a proximal tibial fracture in near-anatomic alignment. The fracture lines are less distinct on the current study than on the prior study, with callous formation noted along the posterior aspect of the fracture, indicating s... | Orthopedic fixation of healing proximal tibial fracture as above. |
Generate impression based on findings. | 48-year-old with history of left lumpectomy for breast cancer in 2011. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No dominant mass, suspicious microca... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Female 56 years old; Reason: restating for colon cancer s/p hemi colectomy; prior to starting treatment History: none CHEST:LUNGS AND PLEURA: Few scattered pulmonary micronodules. No dominant lung lesion. The pleural spaces are clear.MEDIASTINUM AND HILA: Heart size is enlarged. No pericardial effusion. No mediastinal ... | 1.Status post partial colectomy without evident metastatic disease. |
Generate impression based on findings. | Pain, swelling status post fall. Rule out dislocation/fracture. There is dorsal dislocation of the middle phalanx with respect to the proximal phalanx. There is also slight ulnar angulation of the middle phalanx with respect to the proximal phalanx. I see no fracture on this study, although postreduction radiographs ma... | PIP joint dislocation as above. |
Generate impression based on findings. | Redemonstrated is a left lateral occipital lobe enhancing lesion measuring 6 x 7 mm, previously 6 x 7 mm, consistent with known metastatic lesion. Apparent curvilinear high signal in the left cerebellar hemisphere on series 1701, not reproduced on sagittal images, is likely artifactual. There are no new lesions detect... | No significant interval change in left lateral occipital lobe lesion. No new lesions are detected. |
Generate impression based on findings. | 60 year-old male with a history of pancreatic cancer. Presents for restaging. CHEST:LUNGS AND PLEURA: No significant pulmonary parenchymal or pleural abnormality. Minimal right basilar subsegmental atelectasis. No pleural effusions.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Normal cardiac size witho... | No significant interval change in the post-operative findings, hepatic lesions and right adrenal nodule. No new sites of disease are identified. |
Generate impression based on findings. | Male 42 years old; Reason: metastatic colon cancer off chemotherapy since June 2014 History: colon cancer CHEST:LUNGS AND PLEURA: There are multiple bilateral pulmonary nodules compatible with metastatic disease. Index lesion in the right lower lobe measures 10 millimeters (image 79/series 5) previously, 6 millimetersR... | 1.Multiple new pulmonary lesions and increase in the size of existing lesions.2.New liver lesions and increase in size of existing lesions.3.Retroperitoneal/mesenteric nodal mass that partially occludes the right ureter. |
Generate impression based on findings. | 44 years old, Male, Reason: hematuria ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: At least 3 liver hypodensities which peripherally fill with discontinuous nodular enhancement and appears to fill in on delayed imaging, consistent with multiple hemangiomas. The largest of these lesions, in ... | 1. Multiple hemangiomas in the liver.2. No specific findings to explain patient's hematuria. |
Generate impression based on findings. | Testicular carcinoma CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: Stable subcentimeter right hepatic lobe low attenuation foci.SPLEEN: No significant abnormality notedPANCREAS: No s... | Stable negative examination. No evidence for acute, inflammatory, or metastatic process. |
Generate impression based on findings. | Male 6 years old Reason: fracture VIEWS: Left forearm AP and lateral 1/6/15 (two views) Cast material obscures fine bone details. Healing fractures of both forearm bones are in anatomic alignment. | Healing fractures , in anatomic alignment. |
Generate impression based on findings. | Right upper extremity lymphedema.RADIOPHARMACEUTICAL: The right upper extremity was prepared in a sterile manner. A total of 0.5 mCi Tc-99m filtered sulfur colloid was injected subcutaneously. Following injection, intraoperative probe localization was performed. No images were acquired. | Successful injection for intraoperative identification of lymph nodes for lymph node transfer. |
Generate impression based on findings. | 68-year-old female, follow-up exam Again seen is a transverse fracture of the base of the fifth metacarpal with fragments in near anatomic alignment. Increased callus formation along the fracture suggests some interval healing. | Healing fifth metacarpal fracture. |
Generate impression based on findings. | 75-year-old male status post fall, evaluate for shoulder dislocation The bones are demineralized. Small glenohumeral osteophytes indicate mild osteoarthritis. Glenohumeral alignment is within normal limits. No fracture is evident. Mild degenerative arthritic changes affect the visualized spine. | Mild degenerative arthritic changes without fracture or dislocation. |
Generate impression based on findings. | 57-year-old male with shortness of breath and a history of cystic fibrosis. Evaluate for gastric emptying for lung transplant evaluation. Visually there was significant and progressive gastric emptying. Using anterior and posterior geometric means, residual gastric activity at the following postprandial intervals was c... | Gastric emptying within normal limits. |
Generate impression based on findings. | Female; 68 years old. Reason: pre-op for MAKO stryker protocol / left tha History: pain Marked osteoarthritis affects the left hip. Right total hip arthroplasty situated in near-anatomic alignment without evidence of complication. Degenerative arthritic changes of the partially visualized lumbar spine. Mild osteoarthri... | Marked osteoarthritis of the left hip and other findings as described above. |
Generate impression based on findings. | Female 67 years old Reason: Pt is a 67 y/o female with urothelial cancer, s/p radical cystectomy, evaluate for recurrence, CT urogram, delayed views, 3D reconstruction History: urothelial cancer CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: There is no evidence of mediastinal or hilar l... | Postoperative changes related to cystectomy and ileal conduit formation, without evidence of locoregional recurrence or metastatic disease. |
Generate impression based on findings. | Status post fracture.VIEWS: Left wrist AP and lateral 1/6/15 (two views) Cast material obscures fine bone details. Healing fracture of the distal metaphyses of the left radius is in anatomic alignment. | Healing fracture in anatomic alignment. |
Generate impression based on findings. | 28-year-old male with a growing right sided groin mass which recently "popped" and is bleeding. RIGHT TESTIS: The right testicle is normal in morphology, echogenicity and size, measuring 3.1 x 2.0 x 3.9 cm. Spectral Doppler evaluation demonstrates arterial blood flow.LEFT TESTIS: The left testicle is normal in morpholo... | 1. Inflammatory/phlegmonous collection corresponding to the patient's palpable abnormality and bleeding in the right scrotal area without a drainable fluid collection.2. Normal testes.3. Small bilateral varicoceles. |
Generate impression based on findings. | 65-year-old female with hip and groin pain Hip: Severe osteoarthritis affects the left hip.Pelvis: There is also severe osteoarthritis affecting the right hip although to a lesser degree than the left. The remainder of the pelvis is unremarkable. Degenerative arthritic changes affect the lumbar spine. | Osteoarthritis. |
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