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Generate impression based on findings. | Right lower lip adenoid cystic carcinoma. There is enhancement of the right lower lip with soft tissue defect from biopsy. There is no measurable mass. There is no evidence of significant cervical lymphadenopathy. The thyroid and major salivary glands are unremarkable. The major cervical vessels are patent. There is mi... | 1. Asymmetric enhancement of the right lower lip without measurable mass. 2. No evidence of significant cervical lymphadenopathy. |
Generate impression based on findings. | Wound posterior right hand No fracture, dislocation or radiopaque foreign body | No acute abnormality |
Generate impression based on findings. | Kidney stone. Following observations are made given limitations of an unenhanced study.ABDOMEN:LUNG BASES: Moderate coronary artery calcifications.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: Splenic granulomas.PANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKI... | No evidence of renal calculi. No CT findings to explain left flank pain. |
Generate impression based on findings. | Anemia and tachycardia. Rule out intra-abdominal hemorrhage. The following observations are made given the limitations of an unenhanced study.ABDOMEN:LUNG BASES: Bilateral pleural effusions with overlying compressive-type atelectasis, larger compared to prior. Severe coronary artery calcifications. Moderate pericardial... | Intraperitoneal hemorrhage predominating in the left lower quadrant and pelvis. End-stage kidneys with findings compatible to renal osteodystrophy. Bilateral pleural effusions with overlying compressive atelectasis. Ascites. Moderate pericardial effusion. |
Generate impression based on findings. | Reason: intracranial bleed/ lesion History: AMS There is encephalomalacia present along the left temporal lobe involving left inferior temporal gyrus and adjacent fusiform gyrus associated with ex vacuo effect. There is redemonstration of a hypodensity in the left pons.Periventricular and subcortical white matter hypod... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.Encephalomalacia involving the left temporal lobe is suspected to be a result of prior vascular injury3.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 4.Opaci... |
Generate impression based on findings. | fall No evidence of acute ischemic or hemorrhagic lesion on this scan.Mild non specific small vessel ischemic disease, no change since prior exam.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. Th... | No evidence of acute ischemic or hemorrhagic lesion on this scan. |
Generate impression based on findings. | Abdominal pain. Rule-out intra-abdominal process. ABDOMEN:LUNG BASES: Minimal right subsegmental atelectasis.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: No signif... | No definite CT findings to explain abdominal pain. Nonobstructive ventral hernia containing colon. Small amount of fluid in the pelvic cul-de-sac. T11 vertebral body congenital segmentation defect. |
Generate impression based on findings. | left arm numbness No evidence of acute ischemic or hemorrhagic lesion on this scan.Left side craniotomy with surgical clip on the Acom area indicating prior aneurysm clipping, no change since prior exam.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, in... | No evidence of acute ischemic or hemorrhagic lesion on this scan.No change of prior surgical clipping on Acom aneurysm since prior exam. |
Generate impression based on findings. | 67 year old male with left groin pain and decreased range or motion. Two views of the left hip show no acute fracture or dislocation. There is mild osteoarthritis with osteophyte formation. | Mild osteoarthritis without evidence of fracture or dislocation. |
Generate impression based on findings. | Reason: r/o ICH, meningitis History: vomiting, HA, neck stiffness There is subarachnoid blood present along the suprasellar cistern and sylvian fissures as well as the prepontine cistern and intrapeduncular cistern with a thicker clocked centered in the intrahemispheric fissure in the anterior communicating artery regi... | 1.Subarachnoid hemorrhage with suspected clot at the region of the anterior communicating artery associated with mild ventriculomegaly. |
Generate impression based on findings. | 30 year old female felt a pop during therapy now with pain and swelling. Four views of the right knee show a comminuted fracture of the distal femur with approximately 1.2 cm of posterior displacement. There is extensive heterotopic bone formation, demineralization, degenerative changes and muscular atrophy compatible ... | Findings compatible with neuropathic joint of the knees bilaterally with multiple fractures. |
Generate impression based on findings. | altered mental status, left pupil bigger than that of the right side Evolving left thalamic ICH demonstrates smaller acute hemorrhagic portion since prior exam. The degree of midline shift appears to be stable (about 13mm) since prior exam.The amount of IVH has significantly reduced since prior exam.The location of the... | Left thalamic ICH with mass effects demonstrates interval normal evolution since prior exam.Stable degree of midline shift toward right side since previous exam.Significantly reduced the amount of IVH since prior exam. |
Generate impression based on findings. | Epigastric pain history of pancreatitis ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No pancreatic or peripancreatic inflammation identified there noted to pancreatic edema or pseudoaneurysm. Note that mild pa... | No CT findings to explain abdominal pain. No CT evidence of pancreatitis although mild pancreatitis may be occult on imaging. |
Generate impression based on findings. | Female, 33 years old. Obese s/p C-section. Time stamped 13:44 hours, 2/8/2015. Note the examination is limited by body habitus. Given this limitation, no radiopaque foreign objects are seen. Nonobstructive bowel gas pattern. An epidural catheter projects over the upper lumbar spine. | Limited examination without evidence of radiopaque foreign objects. Findings discussed with the attending surgeon, Dr. Boyle, via telephone by Dr. Bennet at 2:06 PM on 2/8/2015. |
Generate impression based on findings. | Reason: presence of aneurysm History: SAH on CT Neck CTA: There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is no significant stenosis... | 1.There is a posteriorly directed 3mm anterior communicating aneurysm present with associated subrachnoid hemorrhage and mild ventriculomegaly. There is an anterior directed 2mm ACOMA aneurysm. The fact that there are two aneurysms present along the anterior communicating artery suggests that the anterior communicating... |
Generate impression based on findings. | 85 years, Male. Reason: 85M s/p distal ureterectomy, now with distention and nausea; please assess for ileus History: as above Nephroureteroscopy tube overlies the right hemipelvis. Pelvic drain tip projects over the left hemipelvis. Aortic graft is present. Diffusely gas distended loops of small and large bowel.Degene... | Ileus type bowel gas pattern. |
Generate impression based on findings. | 70 year old male with right knee pain. Two views of the right knee show mild degenerative changes with osteophyte formation and sharpening of the tibial spines. No evidence of acute fracture or dislocation. | Mild osteoarthritis without evidence of fracture or dislocation. |
Generate impression based on findings. | 57 year old male with pain. Single stress view of the right ankle shows the aforementioned fracture of the distal fibula with slight lateral translation. Again seen is widening of the medial tibiotalar joint space indicating, deltoid ligamentous injury. Surrounding soft tissue swelling is again noted. | Distal spiral fibular fracture with extension into the joint and widening of the medial talotibial joint space indicating a deltoid ligament injury. |
Generate impression based on findings. | Mental cell lymphoma The following observations are made given the limitations of an unenhanced studyCHEST:LUNGS AND PLEURA: Biapical pleural-based nodules. For reference purposes, the nodule at the left apex measures 3.1 x 2.3 cm (image 11; series 3). Bilateral pulmonary micronodules should be followed.MEDIASTINUM AND... | Multiple lesions in the chest, abdomen, and pelvis with reference measurements given above. |
Generate impression based on findings. | 57 year old male with pain. Three views of the right ankle and right foot show a distal spiral fibular fracture with extension into the joint. There is overlying soft tissue swelling. There is widening of the medial tibiotalar joint indicating deltoid ligament injury. | Distal spiral fibular fracture with extension into the joint and widening of the medial talotibial joint space indicating a deltoid ligament injury. |
Generate impression based on findings. | altered mental status No evidence of acute ischemic or hemorrhagic lesion on this scan.There are evidence of encephalomalacia on the right frontal and temporal lobes as well as right insular cortex, basal ganglia and thalamus indicating chronic infarction with right ventricular ex vacuo change. No change since prior ex... | No evidence of acute ischemic or hemorrhagic lesion on this scan.Chronic infarction with encephalomalacia on the right frontal and temporal lobe as well as right insular, basal ganglia and thalamus, no change since prior exam. |
Generate impression based on findings. | 33-year-old female patient with history of abdominal distention. Evaluate for obstruction. Nonobstructive bowel gas pattern. Postsurgical changes again noted in the right upper quadrant. IVC filter noted. | No evidence of bowel obstruction. |
Generate impression based on findings. | Male 31 years old; Reason: evaluate for bowel obstruction vs. ileus History: nausea, emesis, distension sinus to gastric resection and recent umbilical hernia repair. ABDOMEN:LUNG BASES: Mild bibasilar atelectasis.LIVER, BILIARY TRACT: Hepatic steatosis.SPLEEN: Splenomegaly at 15.2 cm.PANCREAS: No significant abnormali... | 1. Postsurgical changes relating to recent umbilical hernia repair. Mildly distended small and large bowel loops raises the possibility of a mild postoperative ileus. No evidence of bowel obstruction.2. Diffuse hepatic steatosis with mild splenomegaly. |
Generate impression based on findings. | 59 year old female with right anterolateral foot swelling/redness s/p steroid injection. Three views of the right foot show mild swelling about the dorsum of the foot. There are degenerative changes about the first MTP joint without acute fracture or dislocation. Hallux valgus deformity is noted. | Soft tissue swelling about the dorsum of the foot but no fracture or dislocation. |
Generate impression based on findings. | 76-year-old female with stage IV melanoma. Reevaluate disease status following additional immunotherapy therapy. CHEST:LUNGS AND PLEURA: The reference right lower lobe solid pulmonary nodule (series 5, image 77) measures 1.4 x 0.9 cm, increased from 1.0 x 0.8 cm previously. The reference left lower lobe pulmonary nodul... | 1.Interval progression of disease including increase in size of right lower lobe nodule, increase in size of left lower abdominal wall soft tissue nodules, and increase in size of non-reference right gluteal nodule.2.Additional reference lesions including retroperitoneal lymphadenopathy are similar to prior. |
Generate impression based on findings. | 28 year old female who slammed her finger in the door. Three views of the left index finger show soft tissue swelling and subtle irregularity indicating probable laceration about the dorsal aspect of the distal phalanx. No evidence of foreign body, fracture or dislocation. | Likely laceration of the dorsal aspect of the distal phalanx of the index finger without evidence of foreign body, acute fracture or dislocation. |
Generate impression based on findings. | 57 years, Female. Reason: distension History: distension Percutaneous biliary drain projects over the right hemi-abdomen. Midline surgical staples are present. Air-fluid levels are seen within the stomach with otherwise relative paucity of bowel gas. | Presumed post-operative ileus. |
Generate impression based on findings. | 66-year-old female patient with history of poorly functioning G-tube. G-tube projects over the expected location of the stomach on AP and lateral views. There is enteric contrast in the duodenum and proximal jejunum. Nonobstructive bowel gas pattern.AICD is partially visualized. | Findings compatible with functioning G-tube without evidence of obstruction. |
Generate impression based on findings. | 55 year old female with pain to the mid-humerus Four views of the left shoulder and two views of the left humerus show hardware components of a total reverse shoulder arthroplasty device which is situated in near-anatomic alignment without evidence of complication or loosening. No evidence of fracture or dislocation. D... | Total reverse shoulder arthroplasty device in near-anatomic alignment without evidence of complication, fracture or dislocation. |
Generate impression based on findings. | 11-year-old male with right inferior knee pain.VIEWS: Right knee AP, oblique, lateral (3 views) 2/8/2015 at 1248 No acute fracture or dislocation. Alignment is anatomic. No joint effusion is present. Mild fragmentation of the tibial tuberosity, likely normal variant. | No acute fracture or dislocation. |
Generate impression based on findings. | Female 63 years old; Reason: fx? History: hip pain s/p fall Two views of the right hip show an impaction fracture about the right femoral neck. Single AP view of the pelvis shows no evidence of a pelvis fracture. The aforementioned right femoral neck fracture is again seen. The left hip appears without fracture or disl... | Mild impaction fracture about the right femur. |
Generate impression based on findings. | 61-year-old male patient with flank pain and constipation. Nonobstructive bowel gas pattern with average stool burden. Radiopaque object projects over the midthoracic spine, compatible with a bullet. Bilateral hip arthroplasties and vascular calcifications noted. | Nonobstructive bowel gas pattern with average stool burden. |
Generate impression based on findings. | 54 year old female with right knee pain. Mild osteoarthritis with medial osteophyte formation and osteophytes at the undersurface of the patella. No evidence of an acute fracture or dislocation. No joint effusion | Mild osteoarthritis without evidence of acute fracture or dislocation. |
Generate impression based on findings. | Ms. Cotten is a 62 year old female recalled from screening mammogram for a focal asymmetry in the far posterior central left breast. An ML view and two spot compression views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may ob... | High probability benign lesion in the posterior central left breast, likely representing a complicated cyst. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended in 6 months to confirm stability of these findings. Results and recommendation were discussed wit... |
Generate impression based on findings. | Reason: Pretransplant w/u. Please perform ILD protocol. History: Pretransplant w/u LUNGS AND PLEURA: Right lower lobe calcified granuloma. Minimal basal subsegmental atelectasis. No abnormal pulmonary nodules or masses. No focal airspace consolidation. No significant air trapping seen on expiratory images. No pneumotho... | No evidence of ILD. |
Generate impression based on findings. | 6-year-old female status post ingestion of penny.VIEW: Chest PA and lateral (two views), Abdomen AP (one view) 2/8/2015 at 1401 Chest: Normal cardiothymic silhouette. No focal pulmonary opacity, pleural effusion, or pneumothorax.Abdomen: Radiopaque foreign body representing swallowed penny overlies the right lower quad... | 1.Swallowed penny overlies the right lower quadrant. No further radiologic follow-up is recommended unless clinically indicated.2.Normal chest radiograph. |
Generate impression based on findings. | 36 year old female right heel pain Three views of the right ankle show soft tissue swelling about the plantar aspect of the heel without underlying osseous abnormality or radiopaque foreign body. | Soft tissue swelling without evidence of acute fracture or radiopaque foreign body of the right heel. |
Generate impression based on findings. | Respiratory failure. Tachypnea.VIEW: Chest AP (one view) 2/9/15 at 508 hours. ET tube tip is at the thoracic inlet. Spinal rods residual thoracolumbar dextroscoliosis unchanged. Right IJ venous access tip is likely at the SVC. Right upper extremity PICC tip is at the right atrium. A drain type catheter overlies the rig... | Persistent bibasilar opacities as described. |
Generate impression based on findings. | 19 year old male with elbow pain. Patient was hit by a car while riding a bike. Four views of the left elbow show no evidence of acute fracture or dislocation. No evidence of joint effusion.Two views of the left humerus show no evidence of fracture or dislocation of the shoulder or elbow.Four views of the left knee sho... | No evidence of a fracture or dislocation of the left elbow, left humerus or left knee. |
Generate impression based on findings. | Unspecified fallClinical question: eval for ICHSigns and Symptoms: fall 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 ... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction. |
Generate impression based on findings. | Female 22 years old; Reason: abdominal pain, eval shunt catheter History: abdominal pain, eval shunt catheter The absence of intravenous and oral contrast limits evaluation of the solid organs and of the bowels. Given these limitations, the following observations were made:ABDOMEN:LUNG BASES: Mild left basal atelectasi... | 1.Visualized portions of the shunt catheter are intact terminating in the pelvis. No specific cause for patient's abdominal pain is identified. |
Generate impression based on findings. | Female 30 years old; Reason: r/o stone History: RIght CVA tenderness The absence of intravenous and oral contrast limits evaluation of the solid organs and of the bowels. Given these limitations, the following observations were made:ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significa... | 1.Mild right hydronephrosis and hydroureter with associated perinephric stranding. No stone is identified within the collecting system. The appearance is suggestive of a passed stone. Pyelonephritis could have a similar appearance however this is felt less likely. |
Generate impression based on findings. | Knee pain status post fall RIGHT HIP: Mild osteoarthritis of the right hip. No fracture or malalignment.RIGHT KNEE: Severe osteoarthritis of the right knee. No fracture or malalignment. | Osteoarthritis, without fracture. |
Generate impression based on findings. | Coronary atherosclerosis. Previous head and neck radiation. Preop. Dr. Balky wants arch vessels and internal mammary artery looked at. Abnormal carotid ultrasound. CHEST:LUNGS AND PLEURA: New spiculated right apical nodule measuring 1.4 x 1.6 cm (image 17; series 4); primary lung carcinoma versus metastases. Nodule at ... | 1. New right lung pulmonary nodules; metastases versus primary lung carcinoma. Dr. Balky was notified of this finding at the time of dictation. Bilateral pleural effusions.2. New mediastinal lymphadenopathy.3. Moderate to severe left subclavian artery stenosis. Internal mammary arteries are widely patent although the l... |
Generate impression based on findings. | Reason: CVA History: HA; episode of dysarthria 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 portions of the paranasal... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction. |
Generate impression based on findings. | Pupils non reactive, Cheyne-Stoke breathing, and not responding to sternal rub. Evaluate for stroke. There is no evidence of intracranial hemorrhage. There are scattered punctate areas of abnormal low attenuation in the periventricular and subcortical white matter, consistent with mild chronic small vessel ischemic cha... | No acute intracranial abnormality. Please note that CT is insensitive for the detection of acute nonhemorrhagic ischemic event. If there is continued clinical concern, MRI of the brain is recommended. |
Generate impression based on findings. | Reason: iph History: as above There is a redemonstration of a hematoma centered in the left thalamus associated with intraventricular blood. Since the prior exam the density of the intraparenchymal hematoma has decreased as has the density of the intraventricular blood. Overall there is less blood in the lateral ventri... | 1.There is a right-sided subdural effusion which has developed since the prior exam .2.Continued evolution of a left thalamic and brainstem hematoma associated with intraventricular blood. |
Generate impression based on findings. | Cardiac dysfunction. Intubated.VIEW: Chest AP (one view) 02/09/15, 0516 Endotracheal tube tip is below thoracic inlet. Two feeding tubes are present. One has its tip in fundus and the other in body. Right internal jugular line tip is at junction of superior vena cava and right atrium.Cardiothymic silhouette is mildly e... | Persistent left lower lobe opacity. This may be atelectasis or pneumonia. |
Generate impression based on findings. | Status post fall with frontal hematoma. There is a small left frontal scalp hematoma. There is no evidence of intracranial hemorrhage or depressed calvarial fracture. The ventricles and sulci are prominent, consistent with mild age-related volume loss. There are scattered punctate areas of abnormal low attenuation in t... | 1. Small left frontal scalp hematoma. No evidence of intracranial hemorrhage or depressed calvarial fracture.2. Mild age-indeterminate small vessel ischemic changes. |
Generate impression based on findings. | There is a background of scattered patchy periventricular and subcortical white matter T2 hyperintensities with a more conspicuous pattern of gyriform T2 hyperintensity involving the superior frontal gyri and cingulate gyri. The bilateral medial temporal lobes are symmetric. There is a small cortical defect at the rig... | 1. Scattered patchy periventricular and subcortical white matter signal abnormalities with a more conspicuous pattern of gyriform T2 hyperintensities in the superior frontal and cingulate gyri. Findings are of uncertain etiology, but may reflect sequela of prior ischemic injury, vasculitis, or a PRES-like phenomenon. I... |
Generate impression based on findings. | 11-week-old former 27 week gestational age patient with atelectasis and history of pleural effusion.VIEW: Chest AP (one view) 02/09/15, 0608 Endotracheal tube tip is between thoracic inlet and carina. Feeding tube has its side port at GE junction.Soft tissue edema persists.A small to moderate left pleural effusion is p... | Increase in left pleural effusion. |
Generate impression based on findings. | 9-year-old male with development of hypoxemia. Please assess ET tube.VIEW: Chest AP (one view) 2/9/2015 0525 ET tube tip at the level of the carina. Feeding tube tip in gastric body. Left central venous catheter tip in superior vena cava. Right upper extremity PICC tip at the junction of the right brachiocephalic vein ... | 1.ET tube tip at the level of the carina.2.Persistent retrocardiac atelectasis and pulmonary edema pattern. |
Generate impression based on findings. | Exam is limited by patient motion. The ventricles and sulci are within normal limits. The basal cisterns remain patent. There is no midline shift or mass effect. There are no areas of abnormal signal. There is no diffusion abnormality. No extra-axial fluid collection is identified. Normal flow-voids are demonstrated i... | Exam is limited by patient motion. Given this caveat, unremarkable exam with no findings to explain the patient's symptoms. |
Generate impression based on findings. | 9-year-old male status post NG tube placement.VIEW: Chest AP (one view) 2/8/2015 1451 ET tube tip between the thoracic inlet and carina. Feeding tube tip in gastric body. Left central venous catheter tip in the superior vena cava. Right upper extremity PICC tip at the junction of the right brachiocephalic vein and supe... | 1.Feeding tube tip in gastric body.2.Persistent retrocardiac atelectasis and slightly worsened pulmonary edema pattern. |
Generate impression based on findings. | RSV bronchiolitis and right-sided atelectasis.VIEW: Chest AP (one view) 02/09/15, 0540 Feeding tube tip is in first portion of duodenum.Right middle lobe atelectasis is present. Right upper lobe has reexpanded. Subsegmental atelectasis continues in right lower lobe. Left lung herniates across the midline. Lung volumes ... | Wandering atelectasis on a background of bronchiolitis. |
Generate impression based on findings. | There is a small retention cyst in the left maxillary sinus, unchanged. There is mildly worsened opacification right sphenoid sinus and a small stable retention cyst in the left sphenoid sinus. There are no bubbly secretions or air-fluid levels in the paranasal sinuses. There is minimal left mastoid air cell opacifica... | Mild chronic sinus findings as detailed above with no evidence of acute sinusitis. There is complete opacification of the right sphenoid sinus which is worsened from prior exam. Resolved right mastoid air cell opacification. Other findings are grossly stable. |
Generate impression based on findings. | Female 87 years old; Reason: pain with ambulation. Acute onset. Assess for etiology. Mild osteoarthritis. No fracture or malalignment. Pellegrini-Stieda lesion noted, indicating prior MCL injury. | Osteoarthritis, without fracture. |
Generate impression based on findings. | Pericardial and pleural effusions.VIEW: Chest AP (one view) 2/9/15 at 535 hours. Central line terminates at the RA/SVC junction. Left-sided chest drain and pericardial catheter are again noted. Cardiac silhouette size is enlarged, likely due to residual pericardial effusion. Left lower lobe opacity on underlying poor e... | No change in residual pericardial effusion, and coronal opacity and underlying pleural effusion. |
Generate impression based on findings. | Reason: please compare to previous, specifically the subdural hygroma History: AMS, seizures, ICPH There is redemonstration of a 16 x 10 mm hematoma centered in the left superior frontal gyrus which appears stable when compared to the previous exam. There is redemonstration of bilateral subdural effusions measuring 11 ... | 1.Bilateral subdural effusions are mildly enlarged when compared to the prior exam 2.Stable intraparenchymal hemorrhage in the left temporal lobe with continued evolution.3.Evolution of subarachnoid blood products in the right temporal lobe4.Redemonstration of old lacunar infarcts in the thalami and basal ganglia5.Peri... |
Generate impression based on findings. | Left knee and hip pain LEFT HIP: Total hip arthroplasty device in anatomic alignment, without radiographic evidence of hardware complication. No fracture or malalignment.LEFT KNEE: Mild osteoarthritis. No fracture of malalignment. No joint effusion evident. | No fracture or malalignment. |
Generate impression based on findings. | 74-year-old female with right lower extremity weakness since yesterday. Evaluate for stroke or bleed. No CT evidence of acute large territorial ischemia. There is no evidence of intracranial hemorrhage, mass, or cerebral edema. There is mild cerebral volume loss evidenced by sulcal and ventricular system prominence. Th... | No acute intracranial hemorrhage or CT evidence of ischemia. If there is high clinical suspicion for ischemia, further evaluation with MRI is recommended. |
Generate impression based on findings. | 52 years, Male. Reason: Dobbhoff placement History: as above Bilateral percutaneous nephrostomy tubes are again noted. Dobbhoff tube tip projects over the gastric fundus with guidewire partially retracted.Nonspecific bowel gas pattern. Note that the pelvis is excluded from the field-of-view. | Dobbhoff tip projects over the gastric fundus. |
Generate impression based on findings. | Pain RIGHT HIP: No fracture or malalignment. RIGHT FEMUR: No fracture or malalignment. No osseous lesions evident.RIGHT KNEE: No fracture or malalignment. Subcentimeter tibial enostosis noted. No knee joint effusion evident. | No fracture or malalignment. |
Generate impression based on findings. | 65 years, Female. Reason: eval ng History: Dobbhoff placement Spinal fixation hardware and intervertebral disk spacers are again noted. Common bile duct stent is present. Dobbhoff tube tip projects over the gastric antrum. Bibasilar opacities better evaluated on prior radiograph.Nonobstructive bowel gas pattern. Note t... | Dobbhoff tip projects over the gastric antrum. |
Generate impression based on findings. | Status post fracture.VIEWS: Right first finger AP and lateral 2/9/15 (two views) No acute or healing fracture noted. Normal alignment. No soft tissue swelling or joint effusion. | Normal examination. |
Generate impression based on findings. | 2-year-old female with pain in left wrist.VIEWS: Left wrist AP, oblique, lateral (3 views) , Left elbow AP, oblique, lateral (3 views) 2/8/2015 at 1600 Elbow: No acute fracture or dislocation. No evidence of elbow joint effusion.Wrist: No acute fracture or dislocation. Alignment is anatomic. | Normal examination of the left wrist and elbow. |
Generate impression based on findings. | 23-year-old female status post gastric bypass surgery, Roux-en-Y (2007) with weight gain for the past year Scout radiograph of the abdomen showed a nonobstructive bowel gas pattern. Cholecystectomy clips are in the right upper quadrant.Single contrast evaluation of the esophagus and gastric cardia/fundus revealed posto... | Rapid transit of contrast from gastric pouch into small bowel. No evidence of gasto-gastric fistula. |
Generate impression based on findings. | Reason: r/o PE History: tachycardia, cough, hypoxia, h/o ILD PULMONARY ARTERIES: No evidence of an acute pulmonary embolus.LUNGS AND PLEURA: There is redemonstration of extensive diffuse peripheral honeycombing and traction bronchiectasis. Increasing multifocal subpleural areas of consolidation are suggestive of organi... | 1.No evidence of an acute pulmonary embolus.2.Extensive interstitial fibrotic changes in an atypical UIP pattern there is only related this patient's underlying scleroderma. These have progressed over the last two exams dated 5/1714 and 6/27/14.3.Increasing subpleural areas of consolidation suggestive of organizing pne... |
Generate impression based on findings. | Fracture partially seen on chest radiograph. Proximal humeral diaphyseal fracture with increased callus formation and unchanged deformity. No new fracture or malalignment. | Healed proximal humeral diaphyseal fracture. |
Generate impression based on findings. | Reason: Hx copd now for lung transplant evaluation History: sob LUNGS AND PLEURA: Severe emphysema is seen throughout the lungs. No consolidation or pleural effusion. No air trapping is seen on expiratory phase imaging. Debris is noted in the trachea.MEDIASTINUM AND HILA: Incidental note is made of a common origin of t... | Severe emphysema compatible with given diagnosis of COPD. |
Generate impression based on findings. | Reason: history of RCC with mets, complaining of shoulder pain History: right scapular pain LUNGS AND PLEURA: Stable to slightly increased size of diffuse pulmonary metastases, with the reference left upper lobe nodule measuring 1.5 x 1.3 cm (series 7, image 24), previously measuring 1.4 x 1.2 cm. No new lesions are de... | 1. No evidence of osseous metastases though there are two new 1-2 cm soft tissue nodules in the subcutaneous tissue superficial to the right scapula. These findings are compatible with progression of additional metastatic disease2. New and increased soft tissue nodules in the bilateral breasts.3. Stable to slightly inc... |
Generate impression based on findings. | Fusion A posterior stabilization device is in place with left pedicle screws entering the L3, L4, and L5 vertebrae and right pedicle screws entering the L3 and L4 vertebrae. A fractured right pedicle screw is present at L5, likely from prior hardware. Bone graft material is noted in the L3/4 disk space.Mild levoscolios... | Postoperative changes as described above. |
Generate impression based on findings. | Female; 84 years old. Reason: Gallstones, Gallbladder distention, evaluation for Cholecystostomy History: OSH transfer for septic shock GALLBLADDER, BILIARY TRACT: The gallbladder wall measures 3 intake my mm. There is no pericholecystic fluid. The common bile duct measures 4 mm. A small shadowing stone is redemonstrat... | Small shadowing stone in the gallbladder neck with no evidence of acute cholecystitis. Given the patient's persistent pain, MRI/MRCP is recommended. |
Generate impression based on findings. | Reason: h/o larynx cancer History: r/o chest mets LUNGS AND PLEURA: Tracheostomy tube is seen in place. Large right apical bullae and fibrosis is unchanged from the prior study. No consolidation or pleural effusion is present. Right middle lobe and right basilar lung scarring is unchanged. No suspicious pulmonary nodul... | No evidence of pulmonary metastases. No change in right apical bullae/scarring. |
Generate impression based on findings. | Ms. Vellender is a 54 year old female with a personal history of right breast lumpectomy in 2011 for IDC followed by radiation and tamoxifen therapy. Personal history of benign right breast MR-guided biopsy. She has no current breast related complaints. Three standard views of both breasts were performed digitally and ... | Postsurgical changes of 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 - Diagnostic Ma... |
Generate impression based on findings. | ORIF Interval plate and screw fixation of the fracture through the posterior aspect of the right mandibular body/right mandibular angle, in anatomic alignment. The fracture through the left mandibular body remains nondisplaced. The patient is edentulous. Temporomandibular joint alignment appears normal. | Mandibular fractures with right mandibular fracture fixation. |
Generate impression based on findings. | Headache. An intraspinal shunt device is seen, exiting at the C1/2 level. The shunt catheter coils over the right lateral aspect of the occiput and courses inferiorly off of the field of view. There is no kink or discontinuity in the radiopaque portions of the shunt catheter. A valve is noted, with setting to be interp... | Shunt catheter as described above. |
Generate impression based on findings. | PHARYNX/LARYNX: The left arytenoid cartilage is rotated and sclerotic which also includes sclerosis of the left thyroid cartilage, correlating with the location of the patient's known malignancy. There is fairly significant soft tissue asymmetry including the pyriform sinus, false cords, and true cords with loss of pa... | 1. Rotated and sclerotic left arytenoid cartilage involving the left thyroid cartilage correlates with the location of the patient's biopsy proven and resected malignancy. Soft tissue asymmetry of the pyriform sinus, false cords, and true cords likely reflects postoperative changes. 2. No discrete soft tissue mass, pat... |
Generate impression based on findings. | No CT evidence of acute large territorial ischemia. Very small region of hyperdensity in the region of the left MCA precentral branch (series 4, image 14). No evidence of acute intracranial hemorrhage. The ventricles and sulci are normal in size. There are no masses, mass effect or midline shift. There are no extraaxi... | No CT evidence of acute territorial ischemia with a nonspecific small hyperdense focus in left MCA precentral branch. An MRI exam has been obtained at the time of this dictation. Please refer to that report for further details. |
Generate impression based on findings. | Reason: evaluation for LVAD History: History of asthma and COPD LUNGS AND PLEURA: Mild bronchial/bronchiolar wall thickening with the diffuse centrilobular groundglass opacities compatible bronchiolitis.No focal areas of consolidation.No pleural effusions.Minimal scarring/discoid atelectasis at the lung bases.No suspic... | Mild bronchial/bronchiolar wall thickening and centrilobular groundglass opacities compatible with bronchiolitis and/or reactive airway disease.. No evidence of pulmonary edema or pleural effusions. |
Generate impression based on findings. | Fall, hip pain Surgical staples, drain, and skin staples noted in the upper right thigh, reflecting recent surgery.No fracture or malalignment of the right hip. | No fracture or malalignment. |
Generate impression based on findings. | There are unchanged postoperative findings related to left parotid resection with no locoregional tumor recurrence or significant cervical lymphadenopathy. The thyroid and remaining major salivary glands are unremarkable. The major cervical vessels are patent. The osseous structures are unchanged with cervical degener... | Stable postoperative findings with no locoregional tumor recurrence or significant cervical lymphadenopathy. |
Generate impression based on findings. | 88 year-old male with dizziness and right leg weakness. Evaluate for stenosis or occlusion. HEAD:There is hyperdense focus in the expected location of a small precentral branch of left MCA. No CT evidence of acute large territorial ischemia. Patchy periventricular hypodensities consistent with age indeterminate small v... | 1.Lack of opacification of left MCA pre-central M3 branch raises suspicion of complete or partial occlusion. Subsequent MRI examination demonstrates evidence of acute to subacute ischemic injury. Please refer to MRI examination report for further details.2.Extensive OPLL and DISH of the cervical spine resulting in mild... |
Generate impression based on findings. | fall 2 days, prior on aspirin There is focal low attenuation on the right putamen which indicate age indeterminate likely subacute or older ischemic infarction. On the posterior aspect of the lesion, there is focal subtle increased attenuation (series 5, image 14/27) which may indicate possible petechial hemorrhage. Fu... | 1. Low attenuation lesion on the right putamen suggest age indeterminate ischemic infarction. Focal increase attenuation posterior aspect of the lesion may indicate possible focal petechial hemorrhage. 2. Brain MRI can be considered for further evaluation if clinically indicated. The findings were discussed with ER att... |
Generate impression based on findings. | Reason: LUQ abdominal pain, Chest pain, History: as above CHEST:LUNGS AND PLEURA: Scattered nonspecific pulmonary micronodules are present. No consolidation or pleural effusion is noted.MEDIASTINUM AND HILA: Residual thymic tissue is present. No mediastinal hilar lymphadenopathy seen. The heart is normal in size and th... | No evidence of pneumonia. No findings to account for the patient's symptoms. |
Generate impression based on findings. | Intubated. Respiratory insufficiency.VIEW: Chest AP (one view) 02/09/15, 0447 Endotracheal tube tip is at carina. Lung volumes are large. Subsegmental atelectasis is present in left lower lobe. Cardiothymic silhouette is normal. | Subsegmental atelectasis in left lower lobe persists. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: Bilateral apical fibrotic changes related to prior radiation.The large amounts of mucus and debris within the right central and lower lobe bronchi.Increasing subpleural consolidation/atelectasis in tree in bud opacities and ... | 1.No evidence of metastatic disease.2.Increasing right bronchial debris with progression of right lower lobe aspiration bronchiolitis and subpleural areas of consolidation/atelectasis compatible with chronic aspiration pneumonia.3.New small right pleural effusion . |
Generate impression based on findings. | Female 16 years old Reason: pain VIEWS: Right wrist AP and lateral 2/9/15 (two views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | 66 years, Female. Reason: ro obstruction History: abd pain Spinal fixation hardware and intravertebral disk spacers are present.Mildly distended loops of small and large bowel in ileus type bowel gas pattern. | Ileus type bowel gas pattern. |
Generate impression based on findings. | History of smoking, lung cancer screening LUNGS AND PLEURA: Mild upper lobe predominant centrilobular emphysema is present. No suspicious pulmonary nodule or mass is identified.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy is seen. The heart is normal in size and there is no pericardial effusion. Mild c... | Mild upper lobe predominant emphysema without suspicious pulmonary nodule or mass. |
Generate impression based on findings. | 43 day old former twin 27 to 28 week gestational age patientVIEW: Chest AP (one view) 02/09/15, 0553 Feeding tube tip is distal to GE junction and not included on image.Cardiothymic silhouette is normal. Hazy lung opacities persist. Lung volumes are large. | Continued hazy lung opacities. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements. No suspicious masses, microcalcifications or areas of architectural distorti... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Female 38 years old; Reason: pelvic pain and fever History: pelvic pain and fever ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Liver is normal morphology. No suspicious hepatic lesions. Hepatic and portal veins are patent. Gallbladder and biliary tree are without diagnostic abnormality.SPL... | 1.Abnormal CT scan with tubular structure adjacent to the right adnexa which has a corpus luteal cyst. Differential considerations hydrosalpinx or pyosalpinx. Further evaluation of pelvic sonography may be useful. |
Generate impression based on findings. | Male; 55 years old. Reason: with attention to the carotids History: right carotid body tumor, assess and c/w CT from 2012 A solid, hypoechoic mass compatible with patient's known carotid body tumor is seen at the carotid bifurcation. There is vascular flow on color Doppler images. This measures 4.0 x 2.9 x 2.2 cm and p... | Stable size of patient's known right carotid body tumor. |
Generate impression based on findings. | Reason: h/o vocal cord cancer and CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Scattered nonspecific pulmonary micronodules, one of which is calcified, are unchanged from the prior study. No suspicious pulmonary nodule or mass is seen. No consolidation or pleural effusion.MEDIASTINUM... | No evidence of metastatic disease. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is heterogeneously dense. No suspicious masses, microcalcifications or areas of architectural distortion are present. | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Ms. Sopocy is a 62 year old female with a personal history of right breast lumpectomy in 2007 for IDC followed by chemo radiation therapy. Family history of breast cancer in maternal aunt. No current breast related complaints. Three standard views of both breasts and a laterally exaggerated right CC view were performed... | Stable postsurgical changes of 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 - Diagno... |
Generate impression based on findings. | History of small cell lung cancer, compare to previous exam. Within the limits of a non IV contrast enhanced examination which limits the ability to evaluate solid parenchymal organs and vascular structures, the following observations can be made: ABDOMEN:LUNG BASES: A new small right pleural effusion is present. Pleas... | 1.New small right pleural effusion. Please see accompanying chest CT from same day for full details.2.Stable exam with unchanged perigastric lymph node and vertebral body sclerotic lesions.3.Unchanged mildly dilated abdominal aorta to 3.9 cm.4.Mild anasarca and nonspecific scattered ascitic fluid. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. No suspicious masses, microcalcificat... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Male 4 months old; Reason: ex 29 wk male, hx pulm HTN, diaphoresis, tachycardia, desaturations, rule out pna vs atelectasis VIEW: Chest AP (one view) 12:50:24 ET tube with tip below the thoracic inlet and above the carina. NG tube with sideport above the gastroesophageal junction, tip extends beyond the inferior margin... | 1. Interval increase in right upper lobe and right lower opacity, which may represent either infection or atelectasis, on background of bronchopulmonary dysplasia and chronic lung disease suggestive of pulmonary interstitial emphysema.2. NG tube with sideport above the gastroesophageal junction. |
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