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Generate impression based on findings. | Male 84 years old Reason: Ng tube placement History: ng tube placement The tip of the enteric tube is in the antrum. Nonobstructive bowel gas pattern. No free air. | The tip of the enteric tube is in the antrum. |
Generate impression based on findings. | Female 29 years old Reason: eval stool burden, ileus History: abd pain, obstipation Rectal tube is coiled in the rectum with its tip in the distal descending colon. Mild to moderate interval distention of the small bowel loops within the interval. This may be secondary to ileus, however, bowel obstruction cannot be exc... | Interval increase in the distention of small bowel loops. CT may be helpful to exclude bowel obstruction. |
Generate impression based on findings. | 57 years old, Male, Reason: Progressive right arm swelling, evaluate for fasciatis History: Right arm swelling Interval increase in subcutaneous edema throughout the right forearm. There is fluid tracking within the subcutaneous tissues extending from the level of the elbow to the wrist. There are no foci of subcutaneo... | Significant interval increase in subcutaneous edema with fluid tracking along the fascial planes of the forearm. No CT evidence of osteomyelitis. |
Generate impression based on findings. | There is no evidence of intracranial hemorrhage, mass, or cerebral edema. There is mild nonspecific periventricular and subcortical white matter hypoattenuation with an old small infarct in the right basal ganglia again seen. The ventricles and basal cisterns are unchanged. There is no midline shift or herniation. The... | No acute intracranial hemorrhage or mass effect. CT is insensitive for detection of early nonhemorrhagic stroke. |
Generate impression based on findings. | Female 54 years old Reason: placemennt of NGT History: NGT placement The tip of the enteric tube is in the antrum. Nonobstructive bowel gas pattern. No free air. Calcification in the midline pelvis may represent a calcified fibroid. | No free air. |
Generate impression based on findings. | Female 22 years old Reason: abdominal pain, decreased bowel sounds History: abdominal pain Nonobstructive bowel gas pattern. No free air. The tip of the enteric tube is in the jejunal segments. Ventriculoperitoneal shunt with its tip in the pelvis. A pacemaker is superimposed over the right lower quadrant. G-tube in th... | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | There is a 22 x 27-mm homogeneously hypoattenuating structure centered in the left sublingual space/floor of the mouth with extension to the right paramedian aspect of the floor of the mouth. However, it does not extend to involve the left lingual tonsil as was seen on prior exam. There is an asymmetrically prominent ... | 22 x 27 mm homogeneously hypoattenuating cystic lesion in the left sublingual space/floor of the mouth crossing the midline, showing smaller size and a different morphology than on the prior examination. Differential considerations include cystic hygroma, atypical thyroglossal duct cyst, or even ranula. Please correlat... |
Generate impression based on findings. | Male 63 years old Reason: evaluation for NGT History: NGT placement The tip of the NG tube is in the antrum. Nonobstructive bowel gas pattern. No free air. | The tip of the NG tube is in the gastric antrum. |
Generate impression based on findings. | Female 96 years old Reason: check ngt History: see above The tip of the NG tube is in the antrum. No free air. Nonobstructive bowel gas pattern. | No free air. |
Generate impression based on findings. | 50 years old, Female, Reason: is there a fracture History: fall onto knee, +pain anterior, small abrasion below knee area No acute fracture or malalignment is evident. No evidence of joint effusion. Extensor mechanism is intact. | No fracture or malalignment. |
Generate impression based on findings. | Male 69 years old Reason: Follow up Feeding Tube Placement 2/14/15 History: Follow up Feeding Tube Placement 2/14/15 Distal end of the feeding tube is coiled in the stomach. No bowel obstruction. | Distal end of feeding tube within stomach. No bowel obstruction. |
Generate impression based on findings. | 77 years old, Male, Reason: r/o fx History: very ttp along 1st metacarpal. Basilar joint osteoarthritis without evidence of acute fracture or malalignment. Osteoarthritis of the distal interphalangeal joints. | Osteoarthritis without evidence of acute fracture or malalignment. |
Generate impression based on findings. | 77 years old, Male, Reason: assess for fracture History: fall Single view of the forearm shows no evidence of acute fracture or malalignment. Degenerative changes of the carpal joints, specifically the basilar joint is noted.Shoulder and humerus: No acute fracture is present. Chronic degenerative changes of left should... | No acute fracture or dislocation. |
Generate impression based on findings. | There is no evidence of intracranial hemorrhage, mass, or cerebral edema. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. There are air-fluid levels in the bilateral maxillary sinuses and in the right sphenoid sinus suggesting acute sinusitis. The skull ... | 1.No acute intracranial hemorrhage or mass-effect. 2.Bilateral maxillary and right sphenoid sinus air-fluid levels suggest acute sinusitis in the proper clinical setting. |
Generate impression based on findings. | There is encephalomalacia along the left superior paramedian cerebellar hemisphere/vermis. There is widened right cerebellopontine angle cistern consistent with arachnoid cyst seen on prior MRI. There is no evidence of intracranial hemorrhage, mass, or cerebral edema. The ventricles and basal cisterns are otherwise no... | No acute intracranial hemorrhage or mass-effect. |
Generate impression based on findings. | 38 years old, Male, Reason: is there a rib fracture History: left lower rib pain sp fall No displaced rib fractures are seen. No evidence of pneumothorax. | No displaced rib fractures. |
Generate impression based on findings. | There is streak artifact from dental amalgam limiting evaluation. There is significant soft tissue edema surrounding the left orbit and left face with hematoma along the lateral aspect of the left orbit measuring 1.8 cm. The globes are intact. There is a chronic right nasal bone fracture again seen. There are no other... | 1.No definite acute facial bone fracture.2.Extensive superficial left facial and periorbital soft tissue swelling with discrete superficial soft tissue hematoma along the lateral aspect of the orbit. 3.Extra-axial calcified lesion posterior to the clivus at the level of the foramen magnum with mass effect on the medull... |
Generate impression based on findings. | 23 years old, Female, Reason: reduction of R 5th digit dislocation History: R 5th digit dislocation, now reduced Interval reduction of fifth PIP joint dislocation without evidence of fracture. The finger is now in anatomic alignment. | Interval reduction of the PIP joint dislocation without evidence of fracture. |
Generate impression based on findings. | 23 years old, Female, Reason: r/o fracture History: deformity Volar dislocation of the middle phalanx of the fifth digit without evidence of acute fracture. | Volar dislocation of the middle phalanx of the fifth digit without evidence of acute fracture. |
Generate impression based on findings. | There is a small amount of hyperattenuating subarachnoid hemorrhage in the right sylvian fissure. There is minimal intra-ventricular hemorrhage layering in the right occipital horn on series 80476 image 23. There is mild asymmetric effacement of the right temporal/parietal sulci which may reflect isodense subarachnoid... | Small focus of acute subarachnoid hemorrhage in the right sylvian fissure with minimal interventricular hemorrhage layering in the right occipital horn. No significant mass effect or midline shift. |
Generate impression based on findings. | Small focus of subarachnoid hemorrhage in the right sylvian fissure is unchanged. There is persistent effacement of the right temporal and parietal sulci which is asymmetric to the left. There is persistent small focus of intraventricular hemorrhage suspected layering in the right occipital horn. There are no definite... | Stable small focus of subarachnoid hemorrhage in the right sylvian fissure with persistent effacement of the right temporal and parietal sulci, asymmetric to the left. |
Generate impression based on findings. | Left-sided pneumothoraxVIEW: Chest AP (one view) 2/15/15 at 957 hours. ET tube tip is above the thoracic inlet. NG tube is present. Cardiac silhouette size is normal. Bibasilar streaky opacities likely subsegmental atelectases on a background of diffuse lung haziness. Slight improvement in left-sided pneumothorax. No e... | Interval improvement in left sided pneumothorax with development of bibasilar streaky opacity. |
Generate impression based on findings. | 51 years old, Female, Reason: r/o fracture, loosened hardware History: s/p fall, unable to flex or stand on knee Evidence of a right knee arthroplasty device in anatomic alignment without evidence of fracture or loosening. No malalignment. There is a small joint effusion present. | No evidence of fracture, malalignment or loosening. |
Generate impression based on findings. | There are unchanged postoperative findings related to right parietal craniotomy with encephalomalacia in the right temporal, occipital and posterior parietal lobes with ex vacuo dilatation of the right lateral ventricle atrium, unchanged. The ventricles and sulci are unchanged. There is no acute intracranial hemorrhag... | No acute intracranial hemorrhage or mass-effect. Encephalomalacia in the right cerebral hemisphere and postoperative findings without change. |
Generate impression based on findings. | 65 years old, Female, Reason: evaluate for fracture or dislocation History: s/p injury Right hip: No acute fracture or malalignment. Pelvis: No acute fracture or malalignment.Right knee: Hardware components of total knee arthroplasty device is situated in near-anatomic alignment without evidence of hardware complicatio... | No evidence of acute fracture or malalignment. Ossicle the dorsal aspect of the DIP joint likely represents old injury. |
Generate impression based on findings. | 47 years old, Male, Reason: fx History: swelling Comminuted fracture through the level of the neck of the fifth metacarpal with volar angulation. The fracture does not appear to involve the joint space. No other fractures are noted. | Comminuted fracture of the neck of the fifth metacarpal with volar angulation. |
Generate impression based on findings. | 63 years old, Female, Reason: fracture History: knee pain Right Knee: Significant vascular calcifications are present within the soft tissues. No evidence of fracture or malalignment. There is no evidence joint effusion. Extensor mechanism appears intact.Right foot: Patient status post amputation through the mid metata... | 1.No evidence of fracture or malalignment.2.Vascular calcifications within the soft tissues suggests vasculopathy.3.Soft tissue irregularity of the right foot suggest possible ulcerations without definite evidence of osteomyelitis. If there is clinical concern for osteomyelitis MRI may be considered. |
Generate impression based on findings. | There is no evidence of intracranial hemorrhage, mass, or cerebral edema. There are multiple areas of nonspecific white matter periventricular and subcortical hypoattenuation better visualized on the MRI dated 2/8/2015, which may be slightly less prominent as compared to the prior exam. The ventricles and basal cister... | 1.No acute intracranial hemorrhage or mass effect. Please note, CT is insensitive for detection of early nonhemorrhagic stroke.2.Scattered areas of nonspecific white matter hypoattenuation again seen, appearing slightly less prominent as compared to prior exam. |
Generate impression based on findings. | Male, 55 years old, left lower extremity radicular symptoms. Unilateral left pedicle screws are in place at L5 and S1 affixed to a posterior stabilization rod. Up to 6 mm of lucency is seen along the anterior aspect of the S1 screw. Laminectomy has been performed at L5 and probably at S1 as well.A grade 2 anterolisthes... | 1. Postoperative findings compatible with unilateral left posterior spinal fusion at L5 and S1. Lucency of up to 6 mm is seen along the anterior aspect of the S1 screw which suggests the possibility of hardware loosening.2. Severe disk and endplate degeneration is seen at L5-S1 with a grade 2 anterolisthesis. The spina... |
Generate impression based on findings. | Male, 64 years old, with altered mental status, thrombocytopenic, confused and hypertensive. Assess for hemorrhage. Small areas of encephalomalacia are again seen within the right middle frontal gyrus and the left parietal lobe without significant interval change. Patchy periventricular hypoattenuation is nonspecific b... | Small bilateral subdural collections are seen, questionably present on the prior recent MRI but definitely new when compared to older studies. The attenuation of these collections is low, but in the setting of coagulopathy, low-attenuation is unreliable as a distinguishing feature between new hemorrhage, old hemorrhage... |
Generate impression based on findings. | Male, 60 years old, history of atrial fibrillation with weakness. Assess for stroke. Mild nonspecific periventricular hypoattenuation is seen. The gray-white differentiation is preserved. No evidence of parenchymal edema or mass effect is detected. No acute intracranial hemorrhage or any abnormal extra axial fluid coll... | Nonspecific periventricular hypoattenuation may reflect age indeterminate microvascular ischemic disease. No definite acute intracranial abnormality is seen including no evidence of intracranial hemorrhage or acute ischemia. Please note, however, that CT is insensitive for the detection of small or early ischemic lesio... |
Generate impression based on findings. | Male, 51 years old, history of laryngeal cancer. The supraglottic mucosa is diffusely thickened similar to prior. However, superimposed upon this thickening is new patchy ill-defined enhancement affecting the base of the epiglottis, aryepiglottic folds, the left greater than right piriform sinuses and the mucosa of the... | On a background of stable thickened supraglottic mucosa, there is new superimposed ill-defined and patchy enhancement. This could be reactive or inflammatory in nature, however it is somewhat more striking than what is typically seen in the post therapy period. Direct visual inspection and/or close interval follow-up i... |
Generate impression based on findings. | Female, 46 years old, struck with iron rod in the right temporal and zygomatic region. No acute intra-cranial hemorrhage, loss of gray-white distinction, parenchymal edema or mass effect is detected. No abnormal extra-axial collections are seen. The ventricles are normal in size and morphology.No clear fracture of the ... | 1. No acute intracranial abnormality.2. No clear acute fracture of the skull or facial bones. |
Generate impression based on findings. | 81 years, Female, Reason: r/o abdominal obstruction History: persistent n/v, bilious. Ovarian cancer. ABDOMEN:LUNG BASES: Moderate bilateral pleural effusions, increased from the prior exam. Associated compressive atelectasis.LIVER, BILIARY TRACT: Multiple hepatic metastases are increased in size. Right hepatic lobe le... | 1.Increased hepatic metastases.2.Slightly increased peritoneal metastases with increased abdominal ascites and a pseudomyxoma peritonei appearance.3.Stable tumor encasing the gastric antrum with resolution of gastric outlet obstruction. No evidence of abdominal obstruction.4.Increased moderate pleural effusions. |
Generate impression based on findings. | Reason: SDH stability History: sdh stabilty There is redemonstration of a right parafalcine hematoma measuring 14 mm in width on the current exam and measuring the same on the prior exam. Sagittal dimensions are currently 47 x 26 mm and previously were approximately the same. There is redemonstration of a subgaleal hem... | 1.Since the prior exam a right parafalcine hematoma has not changed 2.Foci of encephalomalacia in the right temporal lobe and left cerebellar hemisphere . |
Generate impression based on findings. | The ventricles and sulci are normal in size. There are no masses, mass effect or midline shift. There is no evidence for intracranial hemorrhage or acute cerebral or cerebellar cortical infarction. There are no extraaxial fluid collections or subdural hematomas. The visualized portions of the paranasal sinuses and mas... | Negative unenhanced brain CT. |
Generate impression based on findings. | Reason: F/u compared to previous History: F/u compared to previous. Subarachnoid hemorrhage The patient is status post right-sided craniotomy for anterior communicating artery aneurysm clip placement. In addition, a ventriculostomy tube has been placed which courses to the right frontal lobe into the frontal horn of th... | 1.Status post ventriculostomy tube placement. The lateral ventricles are stable.2.Status-post a recent craniotomy for anterior communicating artery aneurysm clip placement.3.Hypodensities along the anterior aspect of the right temporal lobe as well as the inferomedial aspects of the frontal lobes, right caudate nucleus... |
Generate impression based on findings. | 46 year old female with firm, tender mass along periumbilical left upper quadrant,rule out strangulated periumbilical hernia. ABDOMEN:LUNG BASES: No consolidation or pleural effusions.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality noted... | 1.Periumbilical small bowel containing ventral hernia causing small bowel obstruction. Herniated bowel with findings raising the question of ischemia. 2.Separate small abdominal wall fluid collection inferior to the hernia sac of uncertain etiology, abscess not excluded.3.Enlarged uterus with multiple heterogenous lesi... |
Generate impression based on findings. | 58-year-old male with altered mental status and lethargy There is no acute intracranial hemorrhage, edema, mass-effect, midline shift or hydrocephalus. CT however it is insensitive for early detection of acute nonhemorrhagic ischemic strokes. Mild ex-vacuo dilatation of left frontal horn of lateral ventricle secondary ... | No acute intracranial abnormality. CT is insensitive for early detection of acute nonhemorrhagic ischemic stroke. |
Generate impression based on findings. | 29 years, Female. Reason: eval ileus, colonic distension History: colonic distension Rectal tube is unchanged in position, coiled in the rectum with tip in the distal descending colon. Persistent colonic dilatation, proximal to the surgical anastomosis diminished compared to prior . Central venous catheter is incomplet... | Persistent colonic distention, proximal to the anastomosis, diminished compared to prior. |
Generate impression based on findings. | 19 year old man with sudden onset left flank pain with associated nausea, vomiting, and microscopic hematuria. 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: No... | 1.4 millimeter calculus in the bladder -- if recently passed into bladder may explain patient's current clinical symptoms..2.Currently, no hydronephrosis or nephrolithiasis, and no other significant abnormalities. |
Generate impression based on findings. | 34 year old female with abdominal pain, assess for acute process. 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: No significant abnormality notedLIVER, BILIARY ... | 1.Uncomplicated diverticulitis of the descending colon in similar location to prior exam without perforation or abscess. Amount of inflammation is greater than on prior exam which may represent an acute worsening, although without interval imaging it is not possible to exclude the possiblity that these changes are resi... |
Generate impression based on findings. | Reason: F/u to previous, ventriculomegaly History: ventriculomegaly There are foci of encephalomalacia present involving the left inferior frontal gyrus and part of the left superior temporal gyrus extending into the left supramarginal gyrus. There is associated enlargement of the left lateral ventricle. Foci of enceph... | 1.Subarachnoid hemorrhage is collected predominantly in the posterior fossa in the pre-medullary cistern and surrounding the medulla. 2.Status post ventriculostomy tube placement. Ventriculomegaly is stable compared to previous day's exam.3.Multiple foci of encephalomalacia are present in the left frontal lobes and to ... |
Generate impression based on findings. | 9 year old male intubated. Follow up examVIEW: Chest AP (one view) 2/16/2015 4:05 Central venous catheter tip in the SVC. ET tube tip below the thoracic inlet and above the carina. NG tube tip in the stomach. Cardiac silhouette is normal. Interval near complete collapse of the right lung with mediastinal shift to the ... | Interval near complete collapse of the right lung likely a combination of atelectasis and a small pleural effusion. Interval improved aeration of the left lung with a small left pleural effusion. |
Generate impression based on findings. | 56 years, Female. Reason: eval for stool impaction History: malaise, appears to be excess stool in CXR Nonobstructive bowel gas pattern. Less than average stool burden. Left lower lung opacity is better evaluated on prior chest radiograph. | Nonobstructive bowel gas pattern with less than average stool burden. |
Generate impression based on findings. | Male 26 years old Reason: Appendicitis vs. diverticulitis History: abdominal pain The exam is limited secondary to motion artifact.ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality noted... | Limited examination due to patient's inability to hold his breath. No CT findings to explain patient's acute abdominal pain. |
Generate impression based on findings. | Foci of encephalomalacia with gliosis are noted involving the left frontal, left frontotemporal and left parieto-occipital regions most likely representing chronic infarcts given morphology and locations. The ventricles are normal in size. There are no masses, mass effect or midline shift. There is no evidence for acu... | Foci of encephalomalacia with gliosis are noted involving the left frontal, left frontotemporal and left parieto-occipital regions most likely representing chronic infarcts given morphology and locations. If there is continued clinical concern for acute ischemia, MRI would be recommended. |
Generate impression based on findings. | 78 year-old female with left lower quadrant pain and rectal bleeding, evaluate for diverticulitis vs other abdominal pathology. ABDOMEN:LUNG BASES: Mild basilar atelectasis. Partially visualized coronary artery calcifications. Cardiomegaly. LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant ab... | 1.Postoperative changes of abdominal aortic aneurysm repair, unchanged.2.Mild left hydroureteronephrosis which may be related to compression by abdominal aortic aneurysm. No obstructing calculi on the left.3.Findings compatible with right mid ureteral stone versus wall calcification, unchanged since 2009, and without p... |
Generate impression based on findings. | 58 year old female with history of HTN, DM, HLD, OSA, DVT, SLE, RA, COPD presenting with new onset abdominal pain, evaluate for obstruction. Evaluation of the solid organs is somewhat limited due to contrast bolus timing (exam was combined with a chest CT PE protocol). ABDOMEN:LUNG BASES: Mild basilar atelectasis. Part... | 1.Pneumoperitoneum suggesting perforation of a hollow viscus, however, no clear source is identified on this examination.2.No evidence of bowel obstruction.3.The cecum is displaced toward the midline suggesting that it is freely mobile. Findings discussed by on call resident with Dr. Patel at 10:58 p.m. on 2/15/2015. |
Generate impression based on findings. | 51 years, Female. Reason: eval for megacolon History: cdiff, continued fevers, abd pain The lung bases are clear.Nonobstructive bowel gas pattern. No intramural or free intraperitoneal free air. No evidence of bowel wall thickening. Average stool burden. No evidence of toxic megacolon. | No evidence of bowel wall thickening or colonic dilatation to suggest toxic megacolon. |
Generate impression based on findings. | Reason: PE or infection? History: low O2 sats Respiratory motion artifact and expiratory phase imaging moderately limit evaluation of the lungs.PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber.LUNGS AND PLEURA: New bilateral small pleural effusions, right slightly gr... | 1. No pulmonary embolism.2. Bilateral pleural effusions and mild pulmonary edema, likely related to CHF.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | 47 years, Male. Reason: DHT placement History: DHT pulled and readvanced Note that the pelvis is excluded from the field of view and patient motion artifact limits evaluation. LVAD and AICD unchanged. Enteric feeding tube tip appears to project over the proximal stomach. | Enteric feeding tube tip appears to project over the proximal stomach. |
Generate impression based on findings. | 74 year old female with abdominal pain, evaluate for small bowel obstruction or fluid collection. 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: Mild basilar at... | 1.Interval ventral hernia repair with diffuse fluid/edema in the anterior abdominal wall surrounding the surgical mesh. Though the fluid is incompletely characterized on CT and infection cannot be excluded, there are no specific signs of infection such as air or loculation. 2.No evidence of bowel obstruction. 3.Mild to... |
Generate impression based on findings. | The ventricles and sulci are normal in size. There are no masses, mass effect or midline shift. There is no evidence for intracranial hemorrhage or acute cerebral or cerebellar cortical infarction. There are no extraaxial fluid collections or subdural hematomas. The visualized portions of the paranasal sinuses and mas... | Negative unenhanced brain CT. |
Generate impression based on findings. | 56 year old male with acute onset right flank pain, evaluate for renal stone. 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: No significant abnormality notedLIV... | 1.Bilateral punctate renal stones with mild right caliectasis and dilated right ureter of uncertain etiology. This may be secondary to a recently passed stone. No evidence of ureteral stones.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 47 years, Male. Reason: eval dobhoff placement History: above Enteric feeding tube tip projects over the gastric fundus.Support devices unchanged. Pelvis excluded from the field of view. | Enteric feeding tube tip projects over the gastric fundus. |
Generate impression based on findings. | For purposes of numbering, the lowermost level containing a well formed disc is presumed to be L5/S1. Alignment is anatomic. There are no fractures or subluxations. The marrow signal is benign. The conus is normal in signal and morphology and terminates at an appropriate level. The visualized intra-abdominal and paras... | 1.T12/L1: There is a small left paracentral disc protrusion causing mild left lateral recess stenosis, unchanged.2.L2/3: A previously demonstrated tiny right paramedian annular fissure of diffuse disc bulge now has an appearance of a right paracentral shallow disc protrusion causing new mild right lateral recess stenos... |
Generate impression based on findings. | 33 -year-old female with history of diabetes now with epigastric pain and abdominal distention. ABDOMEN:LUNG BASES: Small right pleural effusion with associated atelectasis, similar to prior. Trace left pleural effusion with associated atelectasis, improved from prior. Cardiomegaly. LIVER, BILIARY TRACT: The liver is e... | 1.Increasing hepatomegaly.2.Heterogenous hepatic enhancement and multiple small avidly enhancing nodules in pattern most consistent with benign regenerative nodules in setting of chronic passive hepatic congestion.3.Approximately 5 cm mass in the right lobe of the liver most likely represents an FNH or a additional ben... |
Generate impression based on findings. | 47 years, Male. Reason: re eval dobhoff reposition History: above Enteric feeding tube tip projects over the gastric body.Support devices unchanged. Pelvis is excluded from the field of view. | Enteric feeding tube tip projects over the gastric body. |
Generate impression based on findings. | cerebrovascular accident No evidence of acute ischemic or hemorrhagic lesion.Underlying brain shows non specific small vessel disease, no change since prior exam.Diffuse minimal brain atrophy which is age appropriate.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, mid... | No evidence of acute ischemic or hemorrhagic lesion.Non specific small vessel disease, mild. |
Generate impression based on findings. | Sternal wound drainage and minor instability after MV repair. Evaluate for sternal dehiscence. LUNGS AND PLEURA: Very small bilateral pleural effusions.Dependent subsegmental atelectasis and/or basilar scarring.MEDIASTINUM AND HILA: Cardiomegaly with a mitral valve prosthesis. Epicardial pacer wire terminates along the... | 1. Postsurgical findings of recent median sternotomy for mitral valve replacement without evidence of dehiscence. 2. Very small bilateral pleural effusions and bibasilar subsegmental atelectasis/scarring. |
Generate impression based on findings. | 65 years, Female. Reason: eval abdominal pain History: RLQ abd pain, Lung bases clear.Nonobstructive bowel gas pattern. Average stool burden. No intramural or free intraperitoneal air. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 69 years, Male. Reason: Repeat Abdominal Xray per Radiology to assess Dobhoff line placement History: Dysphagia Enteric feeding tube tip projects over the gastric body and is questionably kinked distally. Mildly dilated loops of small bowel in the left hemi abdomen. Right sided pulmonary opacities are better evaluated ... | Enteric feeding tube tip projects over the gastric body. |
Generate impression based on findings. | altered mental status No evidence of acute ischemic or hemorrhagic lesion.Minimal non specific small vessel disease.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/a... | No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | 9-year-old male with worsening desaturation. Evaluate for interval change.VIEW: Chest AP (one view) 2/15/2015 15:07 Central venous catheter tip in the SVC. ET tube tip below the thoracic inlet and above the carina. NG tube tip in the stomach. Interval near complete collapse of the left lung likely a combination of ate... | Interval near complete collapse of the left lung likely a combination of atelectasis and small pleural effusion. Interval improved aeration of the right lung with a small pleural effusion. |
Generate impression based on findings. | Male 77 years old Reason: r/op acute fracture/abnormalities History: pain, swelling s/p fall. There is no acute fracture or dislocation. There is demineralization of bones. There are osteophytes and severe joint space narrowing of the basilar joint. | Severe osteoarthritis of the basilar joint without evidence of acute fracture or dislocation. |
Generate impression based on findings. | Pain and swelling of the left upper jaw No fracture or malalignment. No temporomandibular joint subluxation. The paranasal sinuses are unopacified. Dental amalgam noted. | No fracture or malalignment. |
Generate impression based on findings. | Female 33 years old Reason: r/o bile leak, retained cbd stone History: s.p lap chole on 2/3, epigastric and RUQ persistent pain ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Status post cholecystectomy with surgical clips in the gallbladder fossa.Hypodense, nonenhancing fluid collection in t... | Small fluid collection in the gallbladder fossa which is likely postsurgical in nature. |
Generate impression based on findings. | Assess for cholecystitis. Abdominal pain. Angiographic images are unremarkable. Prompt clearance of radiotracer from the blood pool and uniform accumulation of the tracer by the liver is present. There is normal excretion of tracer into the intrahepatic ducts, common bile duct, and duodenum, indicating patent common bi... | Non-filling of the gallbladder without specific secondary signs of inflammation is non-specific. Findings discussed with the surgery resident at pager 1616 prior to dictation. |
Generate impression based on findings. | Right ankle fracture The medial gutter of the tibiotalar joint is minimally prominent, though within normal limits. Moderate soft tissue swelling is present at the lateral aspect of the ankle. The distal fibular fracture is again noted, in anatomic alignment. | Fibular fracture, as above. |
Generate impression based on findings. | Male 52 years old Reason: r/o fx History: decreased ROM, injury, pain, swelling. There is no soft tissue swelling surrounding the fifth digit. No acute fracture or dislocation. | No acute fracture or dislocation. |
Generate impression based on findings. | Ileus and collapse, intubatedVIEW: Chest AP (one view) 2/16/2015 0647 Thoracolumbar dextroscoliosis is again noted. Cholecystectomy clips are seen. Patchy opacities throughout the left lung are unchanged. No pneumothorax or new air space opacity is identified. The cardiothymic silhouette is within normal limits.Bilater... | No change in patchy left lung opacities. |
Generate impression based on findings. | Female 22 years old Reason: r/o fracture History: pain, swelling. There is a nondisplaced fracture of the radial head with a large elbow joint effusion. | Radial head fracture as described above. |
Generate impression based on findings. | Ms. Costella is a 46 year old female with a personal history of left breast lumpectomy in 2005 for IDC/DCIS followed by chemotherapy, radiation and hormonal therapy. Family history of breast cancer in maternal grandmother, diagnosed at the age of 40. No current breast related complaints. Three standard views of both br... | Stable postsurgical changes of the left 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 - Diagnos... |
Generate impression based on findings. | Male 25 years old Reason: dislocation History: pain. There is no acute fracture or dislocation of the elbow. No joint effusion is identified. | No acute fracture or dislocation of the right elbow. |
Generate impression based on findings. | Reason: eval for PE History: chest pain, elevated ddimer PULMONARY ARTERIES: No evidence of pulmonary embolism. Main pulmonary artery is normal in caliber.LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.Mild basilar subsegmental atelectasis/scarring. Scattered subtle groundglass likely related to expiratory... | 1. No evidence of pulmonary embolism. Mild basilar subsegmental atelectasis/scarring. Scattered subtle groundglass likely related to expiratory phase imaging. No focal air space consolidations. No pleural effusions.2. Approximately 2-cm solid left breast nodule. Correlate with physical exam.PULMONARY EMBOLISM: PE: Nega... |
Generate impression based on findings. | 61-year-old male. Relapsed AML. E coli bacteremia, cough with blood-tinged mucous. Evaluate for infection. LUNGS AND PLEURA: Significant motion artifact, most severe in the bases. Patchy ground-glass opacities bilaterally suggestive of atelectasis and mild pulmonary edema. No reliable evidence of infection.Right apical... | 1. Mild groundglass opacities suggestive of pulmonary edema with small pleural effusions.2. No reliable evidence of infection.3. Nonspecific moderately enlarged mediastinal lymph nodes. Small amount of perihepatic ascites.Findings communicated to Dr. Rich over the phone at time of dictation. |
Generate impression based on findings. | Pain and swelling status post fall Moderate soft tissue swelling is present at the lateral aspect of the ankle. An oblique nondisplaced fracture is seen in the distal fibula, at the level of the tibiotalar joint. | Fibular fracture, as above. |
Generate impression based on findings. | 8-year-old male with intermittent severe abdominal pain and emesis. Rule out obstruction.VIEWS: Abdomen AP upright and supine (two views) 2/15/2015 Large colonic stool burden. Nonobstructive bowel gas pattern. No focal pulmonary opacities in the visualized lung bases. | Large colonic stool burden with no evidence of obstruction. |
Generate impression based on findings. | Pleural effusion status post chest tubeVIEW: Chest AP (one view) 2/16/2015 0355 Bilateral pleural effusions, left greater than right, are again seen. A pigtail catheter projects over the left lower hemithorax. No pneumothorax is present. Nonspecific retrocardiac consolidation/atelectasis is unchanged.Right upper extrem... | No change in bilateral pleural effusions with left chest tube in place. |
Generate impression based on findings. | Male 62 years old Reason: fx History: pain, swelling. Limited study of the ribs is unremarkable for left rib fracture. Visualized thoracic vertebral bodies heights and intervertebral spaces are preserved. | No definite left rib fracture, however the study is limited. |
Generate impression based on findings. | Podagra Chronic deformities of the 1st, 2nd, and 4th metatarsals likely reflect prior injury. No acute fracture evident. No specific evidence of gout. Scattered degenerative changes are noted, particularly at the 1st MTP joint. | No specific evidence of gout. |
Generate impression based on findings. | 76-year-old female with history of fall. Head: No evidence of acute intracranial hemorrhage. There is minimal confluent periventricular white matter hypoattenuation. The gray-white differentiation is preserved. There is an empty sella with expanded margins likely secondary to CSF pulsation. The basal cisterns are intac... | 1. No evidence of acute intracranial hemorrhage or cervical spine fracture. There is mild subluxation at C4-5 which is suspected to be a result of degenerative change.2. Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 3. Asymmetri... |
Generate impression based on findings. | Female 76 years old Reason: r/o fx History: fall, pain. There is no acute fracture or dislocation. Osteophytes affect the glenohumeral joint. There is a high riding humeral head consistent with a chronic rotator cuff tear. Humeral head deformities consistent with prior trauma. A well corticated ossicle in the axillary ... | 1.No acute fracture or dislocation of the left shoulder joint.2.High riding humeral head consistent with chronic rotator cuff tear and deformity of the humeral head consistent with prior trauma. |
Generate impression based on findings. | Female, 48 years old, with mucoepidermoid cancer of the buccal and parotid area. Compared to last CT and measured the left infratemporal fossa mass in the coronal and axial plane, and the nodule deep to the left zygomatic arch. Head:No mass effect, focal edema or suspicious enhancement is seen to suggest brain parenchy... | 1.Stable bulky mass in the left infratemporal fossa with stable additional nodules deep to the zygomatic arch and along the anterior aspect of the masseter muscle.2.No pathologic adenopathy is detected in the neck and no significant change of any reference nodes is seen.3.Erosion of the skull base and infiltration of t... |
Generate impression based on findings. | Term infant status post congenital diaphragmatic hernia repair. Please assess right pleural effusion and multiple opacities noted on previous chest radiographVIEW: Chest AP (one view) 2/16/2015 0430 Right pleural effusion has increased in size and now appears moderate to large in size. Diffuse haziness of the right lun... | Increase in right pleural effusion. No change in patchy left lung opacities. |
Generate impression based on findings. | Swelling and ecchymosis, particularly at the medial right knee status post fall RIGHT KNEE: No fracture or malalignment. No joint effusion. Vascular calcifications noted.LEFT FOOT: No fracture or malalignment. Mild hallux valgus deformity noted. Extensive vascular calcifications. | No fracture or malalignment. |
Generate impression based on findings. | 3 day old female status post line adjustment. Evaluate tip of PCVC.VIEW: Chest AP (one view) 2/15/2015 16:23 Left upper extremity PICC tip has been retracted and now terminates at the confluence of the brachiocephalic veins. NG tube tip in the gastric body.Cardiothymic silhouette is normal. No focal pulmonary opacities... | Left upper extremity PICC tip terminates at the confluence of the brachiocephalic veins. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views and tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is extremely dense, which lowers the sensitivity of mammography. No suspicious masses, microcalcifications or areas o... | No mammographic evidence of malignancy. Early arterial calcifications can be an indicator of cardiovascular disease. Recommend correlation with clinical history. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.Mammography is optimally performed when prio... |
Generate impression based on findings. | Status post left varus derotational osteotomy and Spica placementVIEWS: Pelvis AP (one view) 2/16/2015 0755 Overlying spica cast obscures fine bone detail.Status post left varus derotational osteotomy. Left proximal femur plate and screw device is seen in place without complication. The osteotomy margins are indistinct... | Postoperative changes. |
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 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. Scattered benign calcifications are pr... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | L4-5 fusion Spinal fusion of L4-5 with bipedicular screws and bone graft. No radiographic evidence of hardware complication. Grade 1 anterolisthesis of L4 on L5, unchanged. Vertebral body heights are preserved. | Postoperative changes, as above. |
Generate impression based on findings. | SOB, palpitations. Evaluate for PE, history of PE in 2012. PULMONARY ARTERIES: Suboptimal examination due to poor opacification of the pulmonary arteries. No evidence of pulmonary embolism to the lobar level.LUNGS AND PLEURA: Scattered micronodules, most-likely postinflammatory.No pleural effusion or focal airspace con... | No evidence of pulmonary embolism to the lobar level or other significant abnormality.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Ms. King is a 52 year old female with a history of bilateral breast calcifications. She has no current breast related complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pat... | Bilateral benign calcifications. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Reason: r/o PE History: oxygen desaturations PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber.LUNGS AND PLEURA: Basilar subsegmental atelectasis, increased from the prior exam. No new focal air space consolidation. No pleural effusions.Left upper lobe round, heteroge... | 1. No evidence of pulmonary embolism.2. Mildly increased size of a left upper lobe subpleural nodule. Indolent primary cancer and hamartoma remain on the differential. PET imaging may be useful for further evaluation. PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal... |
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 9.3. The breast parenchyma is composed of scattered fibroglandular density. There are microcalcifications in the right upper inner breast at approximately 14 cm d... | Microcalcifications in the right upper inner breast for which comparison with prior examinations is recommended.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: OB - OLD FILM FOR COMPARISON |
Generate impression based on findings. | Reason: concern for subacute stroke History: aphasia, ataxia The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a 15 x 10 millimeter extra-axial calcified lesion adjacent to the right parietal bone. There is a 11 x 23 mm coronal dimension calcified extra-axial lesion adjacent to... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction.3.Findings suggest calcified meningiomas at adjacent to the right and left parietal bones |
Generate impression based on findings. | 14-year-old female with abdominal pain. Evaluate stool burden.VIEW: Abdomen supine AP (one view) 2/15/2015 Average stool burden. Nonobstructive bowel gas pattern. | Average stool burden. |
Generate impression based on findings. | 13-month-old male with cough and streaks of blood. Evaluate for pneumonia.VIEWS: Chest AP/lateral (two views) 2/15/2015 Left-sided aortic arch, cardiac apex and stomach. Cardiothymic silhouette is normal. Mild peribronchial thickening and subsegmental atelectasis in the right lower lobe. No pleural effusion or pneumoth... | Bronchiolitis or reactive airway disease. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurments History: none CHEST:LUNGS AND PLEURA: Emphysema. Scattered punctate micronodules, including the previously reference subpleural nodule in the left lower lobe (image 69/123) are stable and presumably benign. No new pulmonary nodules.MEDIASTINUM AND HILA: No signif... | No evidence of metastatic disease. |
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