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Generate impression based on findings. | Female 44 years old Reason: R Buttock abscesss History: above UTERUS, ADNEXA: No significant abnormality notedBLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: There are inflammatory changes along the gluteal crea... | No evidence of drainable abscess. |
Generate impression based on findings. | Male 19 years old Reason: r/o obstruction, infection History: pain, s/p appy ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS... | Mid/distal small bowel obstruction with a transition point in the lower midabdomen. Significant dilatation of the proximal small bowel loops. |
Generate impression based on findings. | Female 64 years old Reason: Metastatic pancreas cancer please assess and provide index lesion measurements for RECIST History: As above CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Hypervascular nodule arising from the right thyroid lobe extending into the superior mediastinum measures... | Locally invasive large pancreatic body cancer with hepatic and mesenteric metastatic disease.Right axillary adenopathy of uncertain etiology and significance.Hypervascular thyroid nodule extending into the superior mediastinum. A thyroid malignancy cannot be excluded. |
Generate impression based on findings. | Male 61 years old Reason: Eval for intraabdominal abscess, infection History: 61 yo M with abd pain, n/v, constipation, leukocytosis to 26 This study is limited due to lack of intravenous contrastABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Splenomegaly. Cholelithiasis.SPLEEN: No significan... | Limited study due to lack of intravenous contrast. Within the limitations high density within the bilateral common iliac and external iliac veins likely suggest thrombus involving these veins. Pelvic adenopathy and fat stranding in the retroperitoneum and pelvis.Decompressed bladder with a Foley catheter is in place. B... |
Generate impression based on findings. | Clinical question: Metastases? Signs and symptoms: History of cancer, AMS Nonenhanced head CT:Examination demonstrate a high density mass measuring approximately 32 mm in the left frontal lobe and with extensive surrounding vasogenic edema. Additional high density mass measuring at 29-mm in the left anterior frontal lo... | 1.Multiple high density masses with extensive surrounding vasogenic edema consistent with metastatic disease.2.Rightward deviation of midline of approximately 7 mm.3.Age indeterminate small vessel ischemic strokes on a chronic right MCA territory ischemic stroke is also noted. |
Generate impression based on findings. | Clinical question: Rule out bleed. Signs and symptoms: Seizure. Nonenhanced head CT:Examination is partially degraded due to motion artifact. Within this limitation however there is no detectable acute intracranial process. Paucity of cortical sulci is within expected range for patient stated age of 23. Ventricular sys... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Rule out bleed. Signs and symptoms: seizure. Nonenhanced head CT:No detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and gray -- white matter diffe... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: ICH. Signs and symptoms: Altered mental status, fell yesterday. Nonenhanced head CT:Examination demonstrates a focus of low-attenuation in the right basal ganglia and including the and right caudate head with associated mass effect on the right frontal horn consistent with a subacute nonhemorrhagic l... | 1.Subacute nonhemorrhagic large lacunar infarct of right basal ganglia as detailed.2.Unremarkable exam otherwise for stated age of 89. |
Generate impression based on findings. | Male 60 years old Reason: Newly dx partially obstructing ascending colon cancer History: abdominal pain CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: Well-defined low-density round lesion in the anterior mediastinum measuring 2.4 by 1.9-cm image number 25, series number 3. Exact etiology... | No CT findings to explain patient's abdominal pain. Ascending colon mass consistent with nations known history of colon cancer.Well-defined, round hypodense lesion in the superior mediastinum. Exact etiology of this lesion is unknown. Although, cannot be entirely excluded, it's unlikely that this lesion could represent... |
Generate impression based on findings. | Clinical question: Pituitary hemorrhage, ICH. Signs and symptoms: Pituitary adenoma. Nonenhanced head CT:Examination redemonstrates a large pituitary adenoma with resultant expansion of the sella, extension into the left cavernous sinus and superior extension into the right subfrontal region. Compared to prior exam the... | 1.Interval increased size of patient's previously known microadenoma. It demonstrates higher density than prior exam which could represent internal hemorrhage however high density of pituitary macroadenoma could be within normal. With MRI is recommended.2.Unremarkable exam otherwise and without evidence parenchymal ede... |
Generate impression based on findings. | Female 20 years old Reason: eval for acute process, p/w 1 d h/o diffuse abd pain, pmt periumbilical History: abd pain ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS... | Mild wall thickening involving the colon and small bowel segments. MR enterography may be obtained for further evaluation. No evidence of bowel obstruction or bowel perforation. |
Generate impression based on findings. | Clinical question: Rule out intracranial hemorrhage. Signs and symptoms: AMS on anti-coagulation. Nonenhanced head CT:There is no detectable acute intracranial process, CT however is insensitive for early detection acute nonhemorrhagic ischemic strokes.Periventricular and subcortical patchy low attenuation of white mat... | 1.No acute intracranial process.2.Age indeterminate small vessel ischemic strokes. |
Generate impression based on findings. | Female 51 years old Reason: r/o renal mass History: R flank pain. blood in urine ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKID... | Simple appearing right renal cyst, otherwise unremarkable CT. |
Generate impression based on findings. | Clinical question: Rule out worsening stroke. Signs and symptoms: Facial droop. Nonenhanced head CT:There is no detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes. Findings suggestive of mild age indeterminate small vessel ischemic strokes is ag... | 1.No acute intracranial process.2.Age indeterminate small vessel ischemic strokes. |
Generate impression based on findings. | 30 years, Female. Reason: patient with NJ tube placement today, confirm placement in small bowel History: abdominal pain Enteric feeding tube tip is in the right quadrant and likely projects over the proximal jejunum, given history of malrotation. Nonobstructive bowel gas pattern with residual barium in the colon. | Enteric feeding tube tip likely in the proximal jejunum. |
Generate impression based on findings. | Male 60 years old Reason: r/o occult infection, no contrast due to acute kidney injury and CKD History: hypotension This study is limited due to lack of intravenous contrast. CHEST:LUNGS AND PLEURA: Bilateral large pleural effusions and dependent atelectasis. Superimposed infection cannot be excluded. Septal thickening... | Limited study due to lack of intravenous contrast. Large bilateral pleural effusions, cardiomegaly and atelectasis. Superimposed infections cannot be excluded with this noncontrast CT. |
Generate impression based on findings. | Male 30 years old; Reason: evaluate for torsion, clot History: acute scrotal pain/swelling RIGHT TESTIS: The right testis measures 4.5 x 2.8 x 2.4 cm and is of normal echotexture. Small right hydrocele noted.LEFT TESTIS: The left testis measures 3.9 x 2.6 x 2.1 cm and is of normal echotexture.RIGHT EPIDIDYMIS: The righ... | No evidence of testicular torsion. Bilateral varicoceles noted. Scrotal skin thickening, likely reflects edema. |
Generate impression based on findings. | 47 years, Male. Reason: Dobbhoff placement History: Dobbhoff Placement Support devices are unchanged. Dobbhoff tube tip projects over the pyloric area of the stomach. Nonobstructive bowel gas pattern.Note that the pelvis is excluded from the field-of-view. | Dobbhoff tube tip projects over the pyloric area. |
Generate impression based on findings. | 34 years, Female. Reason: bowel obstruction History: abd pain, distension Nonobstructive bowel gas pattern. Few dilated loops in the midabdomen are compatible with redundant colon. Note that the pelvis is excluded from the field-of-view.There is a large right pleural effusion with air-fluid level, compatible with cavit... | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Male 14 years old Reason: r/o fracture History: pain, swelling, traumaVIEWS: Left ankle AP, lateral and oblique 2/11/15 (3 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. Navicular spur is likely a normal variant or chronic degenerative changes | Normal examination. |
Generate impression based on findings. | 55 years, Male. Reason: evaluate abdominal distension History: abdominal distension Loop of air distended redundant colon is noted in the midabdomen. Nonobstructive bowel gas pattern. Prominent stool burden in the rectum is noted. | Nonobstructive bowel gas pattern with prominent stool burden in the rectum. |
Generate impression based on findings. | Female 11 years old Reason: trauma, r/o fracture History: knee pain, swellingVIEWS: Left knee AP, lateral and oblique 2/12/15 (3 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Reason: r/o PE History: tachycardia. History of thymic carcinoid. PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber. No evidence of right heart strain.LUNGS AND PLEURA: Left paramediastinal dense radiation fibrosis, unchanged.A nodule within the left major fissure mea... | 1. No evidence of pulmonary embolism. 2. Multiple pulmonary/pleural nodules and enlarged mediastinal/hilar lymph nodes, stable to slightly increased from the prior exam.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | 49 year old woman with rising lactate, recent liver bx, question of right lung infiltrate. 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: CHEST:LUNGS AND PLEURA: Diffuse patchy gro... | 1.Diffuse patchy pulmonary opacities and septal thickening likely pulmonary edema although infection or hemorrhage may appear similarly.2.Nonspecific mediastinal lymphadenopathy. 3.No perihepatic hematoma.4.Anasarca. |
Generate impression based on findings. | 73 years, Female. Reason: r/o constipation History: N/V Spinal fixation rod and screw device traversing L2 to S1 is noted. Cholecystectomy clips right upper quadrant and surgical clips in the mid pelvis. Partially visualized cardiac leads. Mild compression deformity of L1. Flowing syndesmophytes from L2 to S1.Nonobstru... | Greater than average stool burden. |
Generate impression based on findings. | 40 years, Female. Reason: r/o obstruction History: nausea, bilious emesis Nonobstructive bowel gas pattern. | Nonobstructive bowel gas pattern |
Generate impression based on findings. | 63 years, Female. Reason: evaluate dobhoff placement History: dobhoff placement Enteric feeding tube tip projects over the distal gastric body. Left lower extremity central venous catheter is partially visualized in the left hemipelvis. Note that the majority of the pelvis is excluded from the field-of-view. | Enteric feeding tube tip projects over the distal gastric body. |
Generate impression based on findings. | 14-year-old male with history of Crohn's disease presents with abdominal pain, emesis. Concerning abdominal x-ray. Rule out cecal volvulus. ABDOMEN:LUNG BASES: The lung bases are normal. No suspicious pulmonary nodules or masses. No pleural effusion.LIVER, BILIARY TRACT: Liver is normal. No intra-intrahepatic biliary d... | Findings are consistent with terminal ileitis likely related to known history of Crohn's disease. There is associated slight narrowing of the terminal ileum and partial proximal small bowel obstruction. |
Generate impression based on findings. | 66 years, Female. Reason: increasing lactate, ?free air History: increasing lactate, ?free air Surgical staples project over the pelvis. Drainage catheter tip projects over the right hemipelvis. Foley catheter with contrast within the bladder. Degenerative changes affect the lumbar spine with rightward curvature of the... | Dilated loops of small bowel favors ileus. Crosstable lateral or lateral decubitus views are recommended for evaluation of free air. |
Generate impression based on findings. | 80 years, Female. Reason: Eval for ileus History: Abdominal pain Nonobstructive bowel gas pattern. IVC filter and right up quadrant surgical clips are noted. Cardiac support devices and bibasilar opacities are unchanged. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 45 years, Female. Reason: 45F hx cervical CA s/p anterior exenteration c/b chronic constipation. Evaluate stool burden History: Constipation Nonobstructive bowel gas pattern with average stool burden in the colon. Bilateral retrograde nephroureterostomy catheters with distal tips projecting over the right hemiabdomen, ... | Nonobstructive bowel gas pattern with average stool burden in the colon. |
Generate impression based on findings. | Male 14 years old Reason: r/o SCFE v hip dislocation v. fracture History: limp, pain s/p minor "pop" traumaVIEWS: Pelvis AP and frog leg 2/11/15 (two views) Irregularity and fragmentation of the right anterior and inferior iliac spine is concerning for avulsion fracture. Both round, smooth and normally formed femoral h... | Findings concerning for avulsion fracture of the right anterior-inferior iliac spine |
Generate impression based on findings. | 51 years, Male. Reason: Dobbhoff placement History: Dobbhoff placement Multiple surgical clips, surgical drains, and an IVC filter is noted. Dobbhoff tube projects over the gastric antrum. Residual contrast within the small bowel and colon.Nonobstructive bowel gas pattern. Note that the pelvis is excluded from the fiel... | Dobbhoff tube projects over the gastric antrum. |
Generate impression based on findings. | 63 year-old female. Tachycardia, tachypnea, SOB. Concern for PE. PULMONARY ARTERIES: Examination is diagnostic for PE to the segmental level. Low attenuation in a right lower lobe subsegmental artery is likely due to poor opacification (series 7, image 153). No definite pulmonary embolus is identified.LUNGS AND PLEURA:... | 1. No evidence of pulmonary embolism to the segmental level.2. Lower lung zone predominant ground glass opacities with associated mild traction bronchiectasis is most suggestive of a chronic interstitial lung disease, particularly NSIP. Further evaluation with dedicated ILD CT imaging as clinically warranted.PULMONARY ... |
Generate impression based on findings. | 11-day-old male with increased FiO2 requirement.VIEW: Chest AP (one view) 2/12/15 Enteric tube tip in the stomach. Right PICC coiled in the right subclavian vein. Epidural catheter tip at T5. Soft tissue gas in the right lower chest wall is again noted from recent surgery. The cardiothymic silhouette is normal.Interval... | Status post diaphragmatic hernia repair with improvement in right basilar opacity and atelectasis as described above. |
Generate impression based on findings. | 64 years, Male. Reason: Evaluate NG position History: Evaluate NG position NG tube tip projects over the gastric body. IVC filter is noted. Lung bases are clear. Residual contrast is noted throughout the colon.Nonobstructive bowel gas pattern. Note that the pelvis is excluded from the field-of-view. | NG tube tip projects over the gastric body. |
Generate impression based on findings. | 35 years, Female. Reason: Abdominal discomfort History: Abdominal discomfort Metallic linear radiodensities project over the upper mid abdomen. Nonobstructive bowel gas pattern. Note that the pelvis is excluded from the field-of-view. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 11-day-old male status-post CDH repairVIEW: Chest AP, Abdomen AP (two views) 2/11/15 18:01 Right PICC tip coiled in the subclavian vein. Enteric tube and side-port in the stomach. Epidural catheter tip at T6. Interval repair of diaphragmatic hernia. Bi-basilar atelectasis and right lower lobe opacity as well as lucency... | Status post diaphragmatic hernia repair with right basilar opacity and questionable right subpulmonic pneumothorax. |
Generate impression based on findings. | Stability of subdural collections There is interval evolution and decrease in size of small intraparenchymal hematoma involving the left superior frontal gyrus. Bilateral subdural fluid collections measuring approximately 11 millimeters on the left and 9 mm on the right are unchanged. Unchanged mild associated mass eff... | Compared to 2/10/2015, slight evolution of small left frontal intraparenchymal hematoma and right temporal subarachnoid hemorrhage. No significant change in bilateral subdural effusions. Unchanged mild associated mass effect. No new hemorrhage or new mass effect. |
Generate impression based on findings. | Pain to 4th and 5th toes status post box falling on area Lateral soft tissue swelling. No fracture or malalignment. Os peroneus noted, a normal variant. | No fracture or malalignment. |
Generate impression based on findings. | 68 years, Male. Reason: NG tube position History: Evaluate NG position NG tube with tip projecting over the gastric fundus. Residual contrast within the colon. Nonobstructive bowel gas pattern. Note that the pelvis is excluded from the field-of-view. | NG tube with tip projecting over the gastric fundus. |
Generate impression based on findings. | 5-year-old male with irregular breathingVIEWS: Chest AP/lateral (two views) 2/11/15 17:15 The cardiothymic silhouette is normal. Mild bronchial wall thickening, flattening of the hemidiaphragms and large lung volumes suggesting reactive airway disease or bronchiolitis. | Bronchial wall thickening and large lung volumes suggesting bronchiolitis or reactive airway disease. |
Generate impression based on findings. | Swelling Soft tissue swelling about the ankle. Tibiotalar joint effusion noted. No fracture or malalignment. | No fracture or malalignment. |
Generate impression based on findings. | 63 years, Female. Reason: Dobbhoff History: na Dobbhoff tube tip projects over the expected location of the proximal gastric body/fundus. Splenic artery calcifications noted. Nonobstructive bowel gas pattern. Note that the pelvis is excluded from the field-of-view. | Dobbhoff tube projects over the proximal gastric body/fundus. |
Generate impression based on findings. | History of aortic stenosis, pre-operative TAVR evaluation. Note that the far lateral aspects of the abdomen and pelvis are not included in the field-of-view. ANGIOGRAM: Please see accompanying cardiac CT report for description of thoracic aorta. Moderate atherosclerotic affect the abdominal aorta and branches. There is... | 1.Moderate-severe atherosclerotic disease of the abdominal aorta. Severe narrowing of the origin of the SMA. Mild-moderate narrowing of the origins of the celiac artery, IMA, and right renal artery. 2.Infrarenal aortic aneurysm measuring 3.3 x 2.7 cm. 3.Significant tortuosity and atherosclerotic disease of the bilatera... |
Generate impression based on findings. | History of VSD status post repair, presents with new onset heart failure; found to have enlarged thyroid on exam, TSH 0.01, markedly elevated free T3, T4. The thyroid images demonstrate uniform activity in a gland of normal size and configuration. The 4-hour radioactive iodine uptake is 53.8% and the 24-hour uptake is ... | Abnormally diffusely increased thyroid uptake compatible with Graves' disease. |
Generate impression based on findings. | Pain. History of fracture. Soft tissue swelling about the wrist. No fracture or malalignment. No significant abnormality is otherwise evident. | No fracture or malalignment |
Generate impression based on findings. | Global aphasia, right-sided weakness There is continued evolution of the left middle cerebral artery territory infarct with hypoattenuation and local mass effect of the left insula, left middle and inferior frontal gyri, as well as small areas within the left putamen and left caudate head. There is no evidence of acute... | Continued evolution of subacute left middle cerebral artery territory infarct. There is mild local mass effect and minimal rightward midline shift which are not significantly changed since 2/10/2015. No evidence of hemorrhagic conversion. |
Generate impression based on findings. | 14-year-old male with history of Crohn's with abdominal pain, emesis. Evaluate for free air, obstruction, acute pathology.VIEWS: Abdomen AP erect and supine (two views) 2/11/2015 Prominence of dilated bowel in the midabdomen measuring up to 5.9 cm. Air is seen distally in the rectum. No evidence of pneumatosis intestin... | Prominently dilated bowel loop in the midabdomen may represent small bowel or cecum with no definite evidence of obstruction or free air. A follow-up CT scan has been obtained, please refer to CT scan report for additional findings. |
Generate impression based on findings. | Reason: r/o PE History: hx of DVT on Xarelto, tachy, hypoxemic PULMONARY ARTERIES: Suboptimal study due to motion and poor contrast opacification. No large central pulmonary embolism. The main pulmonary artery measures up to 33 mm in diameter (series 8, image 131), suggestive of pulmonary hypertension.LUNGS AND PLEURA:... | 1. Suboptimal study for pulmonary embolism. No large central pulmonary embolus. At the time of exam, repeat imaging was not obtained due to the patient's renal status.2. Large left diaphragmatic hernia containing colonic loops and stomach is increased in extent from the prior exam with additional increased eventration ... |
Generate impression based on findings. | Male 62 years old Reason: patient with HCV and thrombocytopenia evaluate for cirrhosis History: HCV with thrombocytopenia LIVER: The liver measures 15.8 cm in length and the hepatic parenchyma is coarsely echogenic. Multiple abnormal hyperechoic lesions are identified throughout the liver. A reference lesion in the lef... | Coarsely echogenic hepatic parenchyma consistent with chronic liver disease. Multiple echogenic lesions within the liver are nonspecific. Hepatocellular carcinoma can not be excluded.Further evaluation with triphasic liver MRI is recommended.Findings discussed by myself Dr. Ward with Dr. Adebajo # 3736 02/12/15I person... |
Generate impression based on findings. | Trauma to face. There is extensive left cheek stranding and swelling with a more focal globular area of hyperattenuation in the left nasolabial fold region that likely represents a hematoma. There is also a small amount of subcutaneous emphysema in the left cheek and swelling of several left muscles of facial expressio... | 1. Left face contusion and subcutaneous emphysema.2. Age-indeterminate slightly displaced left nasal bone fracture. |
Generate impression based on findings. | Vertebral artery dissection. Lateral neck pain, posterior headache. NONCONTRAST CT HEADNo evidence of acute ischemic or hemorrhagic lesion on this scan.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intr... | 1. No evidence of acute ischemic or hemorrhagic lesion.2. No evidence of arterial dissection, arterial luminal stenosis, or intracranial arterial aneurysm. |
Generate impression based on findings. | Female 56 years old Reason: hep c cirrhosis, screen for hcv History: same LIVER: The liver is coarsely echogenic with a nodular contour consistent with history of chronic liver disease with cirrhosis. No focal liver lesion. The main portal vein is patent and demonstrates normal directional flow with peak velocity of 0.... | Cirrhotic liver morphology. No focal mass lesion identified. |
Generate impression based on findings. | Male 69 years old Reason: RCC eval for interval change History: none ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: 1.7 x 1.6 cm hyperdense lesion in the tail of the pancreas is unchanged from CT dated 10/25/200... | Slight interval increase in the size of the left renal cystic lesion, otherwise no significant change from previous study. |
Generate impression based on findings. | Metastatic prostate cancer. Again visualized is a single focus of increased activity in the superior left scapula consistent with metastatic disease with suggestion of an interval slight increase in size along the superolateral margin of the lesion.No new suspicious osseous foci identified. Redemonstration of asymmetri... | Stable to slight increase in size of the single osseous metastasis in the left scapula. No new suspicious osseous lesion is identified. |
Generate impression based on findings. | Intracranial hemorrhage Portable technique slightly limits evaluation. Compared to 2/8/2015, there is no significant change size of left intraparenchymal hematoma measuring approximately 5.0 x 4.4 x 4.6 cm in the AP, transverse, and craniocaudal dimensions. There is surrounding vasogenic edema not significantly change ... | 1. Compared to 2/11/2015, no significant change in size of large left cerebral intraparenchymal hematoma and surrounding edema. No significant change in rightward midline shift. There is mild worsening in severe effacement of the lateral and third ventricles. Again seen is downward herniation with diffuse effacement of... |
Generate impression based on findings. | Female 27 years old Reason: r/o fx History: ankle pain There is limited view of the ankle. Within these limitations no acute fracture or malalignment is identified. There is no joint effusion.There is a comminuted, intra-articular fracture with multiple fragments extending into the diaphysis of the proximal tibia. Ther... | Comminuted intra-articular tibial fracture as described above. Minimally displaced of the fibular fracture as described above. |
Generate impression based on findings. | Female 27 years old Reason: r/o traumatic inj History: pain. This is a limited study of the shoulder. There is no acute fracture or dislocation. There is no soft tissue swelling. | No acute fracture or dislocation. Limited study of the shoulder. |
Generate impression based on findings. | Reason: Hx of inflammatory breast cancer, clinical evidence of recurrence, assess extent of disease History: R SCV fixed node CHEST:LUNGS AND PLEURA: Right greater than left apical pleural and parenchymal nodularity/scarring.No suspicious pulmonary nodules or masses.Anterolateral right lung fibrosis likely related to p... | 1. An enlarged conglomerate of right level Vb lymph nodes is only partially visualized on CT images of the chest. See same-day CT soft tissue neck for additional details on cervical lymphadenopathy. 2. No CT evidence of recurrent or metastatic disease within the chest or upper abdomen. |
Generate impression based on findings. | Male 78 years old Reason: s/p R hip hemiarthroplasty History: see above. Again seen are components of a right bipolar hemiarthroplasty device in anatomic alignment. There is no evidence of fracture or dislocation. Skin staples and drain in the soft tissues reflect recent surgery. There is heterotopic bone formation in ... | No evidence of fracture or dislocation. Right bipolar hemiarthroplasty device in anatomic alignment. |
Generate impression based on findings. | Female 47 days old Reason: follow up lung fields History: s/p cardiac surgeryVIEW: Chest AP (one view) 2/12/15 at 818 hours. Mediastinal clips, epicardial pacer leads and NG tube unchanged. Interval removal of right IJ central line. Cardiac silhouette size is enlarged but stable. Left upper and lower lobe opacities, li... | Multifocal opacities as described. |
Generate impression based on findings. | 5 year old female with left thumb pain. VIEWS: Left hand PA, Left thumb PA and lateral (three views) 2/12/2015 There is a Salter-Harris type II fracture of the left thumb proximal phalanx with dorsal and lateral angulation. | Salter-Harris type II fracture of the left thumb with dorsal and lateral angulation.Findings were discussed with patient's father in person on 2/12/2015 at 8:45 AM. Several attempts were made to contact Dr. Lauren Conti's office, unable to reach. However discussed with father to contact Dr. Conti or to see her in clini... |
Generate impression based on findings. | Female 5 months old Reason: follow up right lung atelectasis History: respiratory distressVIEW: Chest AP (one view) 2/12/15 at 836 hours. Feeding tube terminates at the antral pyloric region. Cardiac silhouette size is normal. Right medial upper lobe opacities, likely atelectasis or pneumonia on a background of large l... | Persistent multifocal opacities as described. |
Generate impression based on findings. | Male 78 years old Reason: r shoulder pain, r/o dislocation History: see above. Single Velpeau view does not show any acute fracture or dislocation. There is mild irregularity along the inferior margin of the glenoid, likely representing small osteophyte formation. | No acute fracture or dislocation. |
Generate impression based on findings. | cerebrovascular accident There is a mass like lesion on the right frontal lobe with significant surrounding edema and mass effect.The mass lesion is measured about 27mm x 20mm with irregular thick high attenuation rim.The midline shift toward left side at the level of foramen of Monroe is about 8 to 10mm.The right late... | 1. Right frontal lobe mass with surrounding edema and mass effects as described above.2. Chronic ischemic infarction with encephalomalacia on the left parietal lobe.The findings were discussed with Dr. Cheema of ER at the time of this dictation. |
Generate impression based on findings. | 60 year-old with right benign appearing mass presents for follow-up mammogram for the right breast and annual mammogram for the left breast. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is heterogeneously dense, unchanged in pattern and di... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. In view of patient's dense breasts, tomosynthesis will be useful. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMEND... |
Generate impression based on findings. | Male 18 years old Reason: fx History: pain. There is mild soft tissue swelling along the lateral ankle. However, there is no acute fracture or dislocation. There is no joint effusion. | No acute fracture or dislocation. |
Generate impression based on findings. | Elevated ICP, subarachnoid hemorrhage Compared to 2/10/2015, there is evolution of postsurgical changes related to right frontal craniotomy and clipping of anterior communicating artery aneurysm. There is mild increase in hypoattenuation involving the right anterior temporal lobe which may represent edema or cytotoxic ... | 1. Evolution of postsurgical changes of anterior communicating artery aneurysm clipping. 2. Slight increase in hypoattenuation involving the right anterior temporal lobe which may represent cytotoxic injury. 3. No hydrocephalus. |
Generate impression based on findings. | There is an unchanged right frontal calvarial defect with well corticated borders and stable subjacent right frontal parenchymal area of hypoattenuation/encephalomalacia. There is no evidence of intracranial hemorrhage, mass, or cerebral edema. The ventricles and basal cisterns are normal in size and configuration wit... | Stable sequela of prior gunshot wound involving the right frontal lobe without acute intracranial hemorrhage or mass-effect. |
Generate impression based on findings. | Drainage at drive line. Status post LVAD, drive line infection. Assess for fluid collection around the line. CHEST: Motion artifact in the lung bases somewhat limits evaluation.LUNGS AND PLEURA: Trace left pleural effusion.Intraluminal debris in the trachea. Small peripheral wedge-shaped groundglass opacity in the righ... | No fluid collection is seen around the LVAD drive line. Small peripheral wedge-shaped groundglass opacity in the right upper lobe may represent aspiration although infarct is also a consideration. Bibasilar aspiration and atelectasis. Trace left pleural effusion. |
Generate impression based on findings. | Male 63 years old Reason: History of metastatic renal cancer on sunitinib, assess for progression History: none CHEST:LUNGS AND PLEURA: Multiple bilateral pulmonary nodules in all lobes are redemonstrated and again are highly suspicious for metastatic disease. The nodules are grossly unchanged.Reference left upper lobe... | Stable examination in a patient status post left nephrectomy with multiple bilateral pulmonary metastases. |
Generate impression based on findings. | Female 85 years old Reason: bilateral knee pain after fall 10/2014 History: bilateral knee pain after fall 10/2014 Right knee: Bone mineralization is reduced. Alignment is near-anatomic. Moderate osteoarthritis affects the right knee with tricompartmental osteophytes and joint space narrowing. There is chondrocalcinosi... | Osteoarthritis without definite fracture. |
Generate impression based on findings. | No evidence of acute intracranial hemorrhage. No new mass effect, midline shift or downward herniation. The ventricle size does not show any significant interval change since prior exam. There is no change of ventricular shunt position, right frontal approach and the tip location near the foramen of Monro. Bilateral s... | 1. No evidence of acute intracranial hemorrhage or mass effect. 2. Unchanged size of the ventricles which appear dysmorphic and without evidence of hydrocephalus.3. Unchanged small chronic bilateral subdural collections, dysgenesis of the corpus callosum, left occipital encephalomalacia, diminished periventricular whit... |
Generate impression based on findings. | Reason: Tonsil cancer surveillance exam History: Tonsil cancer surveillance exam CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.Multiple small basilar subpleural scar-like opacities. No focal air space consolidation.No pleural effusions.MEDIASTINUM AND HILA: The heart is normal in size without perica... | No evidence of metastatic disease. |
Generate impression based on findings. | Male 52 years old Reason: History of hep C/ETOH cirrhosis with significant volume overload, AKI not consistent with hepatorenal syndrome, please evaluate for thrombosis History: As above LIVER: The liver measures 17.8 cm in length and demonstrates cirrhotic morphology. There is no focal liver lesion. The main portal ve... | Cirrhotic liver morphology. No focal hepatic lesion. Abdominal ascites. |
Generate impression based on findings. | pT1N2b right tonsil squamous cell carcinoma status post chemoradiotherapy completed in January 2014. There are postoperative findings in the right neck related to right tonsillar tumor resection and neck dissection with persistent mild asymmetric thickening of the right palatine tonsillar fossa mucosa. However, there i... | Post-treatment findings in the neck without evidence of measurable tumor recurrence or significant lymphadenopathy.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Male 61 years old; Left ankle pain x 5 years. Questionable trauma. Comes and goes but more regularly x 2 years now. Prominent bone spur at the posterior aspect of the talus, likely representing a Stieda process. 3mm ossicle adjacent to the medial malleolus likely reflects prior deltoid ligament injury.No joint effusion... | 1. Suspected Stieda process. Correlation for posterior impingement syndrome is recommended.2. 3mm ossicle adjacent to the medial malleolus likely reflects prior deltoid ligament injury. |
Generate impression based on findings. | 49 year old female with history of recurrent left breast abscess presents for annual mammogram. 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 elements, unchanged in pattern and distribution. Mild skin... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Reason: eval pulmonary nodule seen on last CT History: none LUNGS AND PLEURA: A small irregular subpleural nodule in the right lower lobe (series 5/244) measures 14 mm in maximum transverse diameter, unchanged from the previous scan. Review of multiple earlier scans dating back to 2012 do not show any consistent increa... | Stable right lower lobe nodule, unchanged since 2012 and most likely benign. Continued annual surveillance scans are recommended in this high risk patient. |
Generate impression based on findings. | Female 63 years old Reason: abnormality to explain LUE radiculopathy History: LUE pain Bone mineralization is normal. Alignment is anatomic. There is minimal glenohumeral joint space narrowing. No acute fracture or malalignment.Enthesopathic changes are noted at the supraspinatus footprint suggesting underlying rotator... | Mild left shoulder osteoarthritis and other findings as detailed above. |
Generate impression based on findings. | Female 67 years old Reason: cholecystitis History: CT evidence of cholecystitis, febrile LIVER: The liver measures 16.7 cm in length. The hepatic parenchyma demonstrates increased echogenicity consistent with fatty infiltration. No focal liver lesion is identified. The main portal vein is patent and demonstrates normal... | 1. Acute cholecystitis. Dilatation of the common bile duct without filling defect identified.2. Increased echogenicity of the liver suggestive of fatty infiltration.Findings discussed by myself Dr. Ward with Dr. Berg 02/12/15 at 9:20 a.m. |
Generate impression based on findings. | Call back from screening mammogram for focal asymmetry in the right breast. 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. Ill-defined focal asymmetry measuring approximately 25 mm at 5-6 o'clock position is again seen and persists with s... | Focal asymmetry in the right breast at the 5-6 o'clock position, with sonographic correlation. Ultrasound-guided biopsy is recommended for definitive diagnosis. Results and recommendations were discussed with the patient.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: H - Percutaneous Biopsy/Aspiration. |
Generate impression based on findings. | Intramedullary rod Interval removal of the cast and tibial fracture fixation with an intramedullary rod with screw device. The distal tibial and fibular fractures are in near-anatomic alignment. No significant callus formation is evident. There is no radiographic evidence of hardware complication. Note is made of an os... | Post operative changes, as above. |
Generate impression based on findings. | Metastatic renal cell cancer, evaluate for progression of disease. Status post 24 weeks investigational immunotherapy. The previously seen, multiple subtle lesions in the ribs and spine, most compatible with metastatic foci are stable in appearance. However, there is one small and one medium focus of new increased acti... | Slight progression of osseous metastases with two new lesions in the superior medial left iliac wing. |
Generate impression based on findings. | 44 year old male with history of Crohn's disease with large resection 3 months ago. Symptoms of diarrhea, severe abdominal pain and bloating. Evaluate for recurrence of Crohn's disease. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Several subcentimeter low-attenuation hepatic lesions are to... | 1.Postsurgical changes of prior ileocecectomy. 2.Active inflammation of an approximately 14 cm segment of distal small bowel. 3.Active inflammation of the distal-most sigmoid colon/proximal rectum with associated mild distention of the colon. 4.Additional sequela of Crohn's disease including mesenteric fibrofatty proli... |
Generate impression based on findings. | Metastatic prostate cancer. No abnormal osseous foci are identified to indicate metastatic disease.Low signal with distortion seen in the lower pole of the right kidney is consistent with a large cyst seen on CT. Faint diffuse activity in the soft tissues of the heart is nonspecific but pericarditis, hypercalcemia or a... | No evidence of bone metastases. |
Generate impression based on findings. | Right eyebrow trauma with deep laceration. There is an irregular defect in the skin and subcutaneous tissues overlying the right superior orbital rim with surrounding fat stranding. There is no evidence of maxillofacial fractures or radioattenuating foreign bodies. The orbital contents appear to be intact, without evid... | Right supraorbital skin laceration and contusion without evidence of maxillofacial fractures or radioattenuating foreign bodies. |
Generate impression based on findings. | Male 75 years old Reason: EUS noted sludge in gallbladder History: as above LIVER: The liver measures 16.1 cm in length. The hepatic parenchyma is hyperechoic suggestive of diffuse fatty infiltration. No focal liver lesion is identified. The main portal vein is patent and demonstrates normal directional flow with peak ... | 1. Gallstones. 0.6-cm non-mobile focus adherent to the gallbladder wall suggestive of a gallbladder polyp.2. Medical renal disease.3. Hyperechoic hepatic parenchyma which likely represents fatty infiltration. |
Generate impression based on findings. | 85-year-old female with history of forgetfulness and urinary incontinence. There is no evidence of acute intracranial hemorrhage. There is mild periventricular white matter hypoattenuation compatible with age indeterminate ischemic small vessel disease. The gray-white differentiation is preserved. There is enlargement ... | 1. Mild periventricular white matter hypoattenuation compatible with age indeterminate ischemic small vessel disease. 2. No evidence of hydrocephalus or acute intracranial hemorrhage.3. Enlargement of the pituitary gland, measuring up to 14 mm in the craniocaudal dimension, may represent an underlying adenoma. A dedica... |
Generate impression based on findings. | 39-year-old with history of benign biopsy in the right breast presents for annual mammography. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. Percutaneously placed clip at ante... | No mammographic or sonographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Increasing ICP, evaluate intracerebral hemorrhage Portable technique somewhat limits evaluation. Right thalamic intraparenchymal hemorrhage is again seen with slight interval evolution compared to 2/7/2015 measuring approximately 2.3 x 4.0 x 4.0 cm in the AP, transverse, and craniocaudal dimensions. There is mild decre... | 1. Evolution of right thalamic intraparenchymal hematoma with intraventricular extension. No new hemorrhage or new mass-effect. Shunted ventricular system remains dilated with slight decrease in size of the left lateral ventricle compared to 2/7/2015.2. Diffuse sulcal and partial suprasellar cistern effacement are agai... |
Generate impression based on findings. | Female 16 years old knee painVIEWS: Left knee AP, lateral and oblique 2/12/15 (3 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Male 11 years old Reason: evaluate healing of fracture History: left knee fractureVIEWS: Left knee AP, lateral and oblique 2/12/15 (two views) There is no evidence of acute or healing fracture, malalignment or soft tissue swelling. No joint effusion. | Normal examination. |
Generate impression based on findings. | Female 63 years old Reason: Nerve compression? History: LUE radiculopathy The lower cervical vertebra from C6 through T1 are obscured on the lateral view. The odontoid is unremarkable. Mild degenerative changes affect the mid cervical spine with small disk osteophytes. | Suboptimal evaluation of the lower cervical spine due to overlying anatomy. Mild osteoarthritis affects the mid cervical spine. |
Generate impression based on findings. | Metastatic breast cancer.RADIOPHARMACEUTICAL: 12.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 85 mg/dL. Today's CT portion grossly demonstrates left lung lower lobe atelectasis or scarring. Again identified are calcified splenic granulomas and calcified uterine fibroids. Innumerable sclerotic lesions th... | No FDG avid tumor currently. |
Generate impression based on findings. | Female 0 days old Reason: Evaluate bowel gas pattern History: no lines - increasing respiratory distress; increasing O2 requirementVIEW: Abdomen and chest AP (two views) 2/12/15 Dilation of the after esophagus noted. Aortic arch, cardiac apex and stomach are left-sided. Cardiac silhouette is normal in size and shape. B... | Findings consistent with RDS or TTN.Upper esophageal dilatation and bowel distention are concerning for esophageal atresia with TEF. Obstruction is also a concern.Findings were communicated to acknowledged by Dr. MULLER, AARON on 2/12/15 at 949 hours. |
Generate impression based on findings. | Female 66 years old Reason: pain History: pain Postsurgical changes in the first metatarsal head. There is valgus angulation at the first IP joint.Mild to moderate osteoarthritis affects the first metatarsophalangeal joint and first IP joint. Mild osteoarthritis affects the midfoot. | Postsurgical changes and osteoarthritis as detailed above. |
Generate impression based on findings. | Male 55 years old Reason: eval for dorsal bone protrusion and spur near 3rd Metacarpal History: dorsal hand pain. Lateral view of the right wrist shows mild degenerative arthritic changes at the base of the third metacarpal joint. Otherwise, there are no acute fractures or dislocation. | Degenerative arthritic changes of the third metacarpal joint as described above. |
Generate impression based on findings. | Male 60 years old Reason: evaluate left knee pain History: left knee pain. Three views of the left knee demonstrates tricompartmental osteophytes, joint space narrowing, and near bone to bone apposition of medial tibiofemoral compartment. Degenerative arthritic changes affect the patella. Frontal view of the right knee... | Severe osteoarthritis of the left knee as described above. |
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