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Generate impression based on findings. | Seven week old male with a history of left UPJ obstruction status post left pyeloplasty. BLADDER Wall Thickness: Normal Contents: Distended and normal. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: Not observedKIDNEYS Cortical Echogenicity: Normal Medullary Echogenicity... | Grade 3 left hydronephrosis and grade 1 right hydronephrosis, not significantly changed.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4... |
Generate impression based on findings. | 13-year-old female, evaluate for gastric outlet obstructionVIEW: Abdomen AP (one view) 2/20/15 9:53 Contrast is noted in the ascending and transverse colon from recent esophagram, precluding a diagnostic upper GI exam from being performed. The bowel gas pattern is nonobstructive. | Contrast in the colon from recent esophagram. Upper GI exam will be deferred until this contrast clears. |
Generate impression based on findings. | 58 year-old female with a history of carcinoid and chronic diarrhea. Patient was unable to tolerate the full prescribed amount of oral contrast. The small bowel is suboptimally distended which somewhat limits evaluation.ABDOMEN:LUNG BASES: Calcified nodule in the right lower lobe likely from prior granulomatous disease... | 1.Postsurgical changes of right hemicolectomy.2.Several punctate hepatic segment 7/6 hypervascular lesions are nonspecific but given history of carcinoid may represent carcinoid metastases. Recommend MRI for further evaluation. 3.Evaluation of small bowel mildly limited by suboptimal distention of the proximal small bo... |
Generate impression based on findings. | Four-year-old male with right femoral fracture status post orthopedic fixation.VIEWS: Right femur AP and lateral (two views) 2/20/2015 at 1036 Evaluation of bony detail is limited by overlying casting material. Oblique fracture of the mid femoral diaphysis is in near-anatomic alignment status post orthopedic fixation w... | Healing mid femoral fracture as described above. |
Generate impression based on findings. | 65 years, Male, Reason: recommended f/u imaging for US significant for "Questionable right lower pole complex mass lesion versus partial duplication" History: as above. CHEST:LUNGS AND PLEURA: Left basilar subsegmental atelectasis. Scattered nonspecific micronodules. No suspicious nodule.MEDIASTINUM AND HILA: Trace per... | 1.Well-circumscribed heterogeneous mass in the right kidney, appearance suspicious for primary renal neoplasm. Recommend contrast enhanced MRI or CT for further evaluation.2.Additional subcentimeter right lower pole lesion of higher than fluid attenuation is incompletely characterized. |
Generate impression based on findings. | Reason: R/o sinusitis History: R facial pain, fever The ostiomeatal complex units are patent bilaterally. Within the nasal cavity no obstructive lesions are appreciated. There is partially opacified right-sided concha bullosa present. The nasal septum is deviated towards the left side and there is an osteophyte off the... | 1.There are scattered opacities present in the right frontal sinus, anterior ethmoid air cells and right maxillary sinus with inspissated secretions which suggests obstruction at the right hiatus semilunaris. Of note there is a Haller cell in this region. |
Generate impression based on findings. | 61 year old man with chest pain. He is referred to exclude obstructive coronary disease. Patient was referred as part of a clinical study.CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of Valsalva and bifurcates into the left anterior descending and left circumf... | 1. There are no significant coronary artery stenoses present. 2. There is minimal coronary atherosclerosis. 3. Moderate RV dilation with mild RA and main pulmonary artery dilation. This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and upper abdomen will be... |
Generate impression based on findings. | 15-year-old male with history of trauma to 4th digit two weeks ago. VIEWS: Left hand PA, left fourth finger oblique and lateral (3 views) 2/20/2015 at 1103 There is a faint lucency through the dorsal epiphysis of the 4th middle phalanx adjacent to the PIP joint. Minimal sclerosis is noted about this fracture line. Mild... | Healing Salter Harris 3 fracture of the fourth middle phalanx as described above. |
Generate impression based on findings. | Reason: h/o left carcinoma ex-pleomorphic adenoma History: r/o lung mets LUNGS AND PLEURA: Scattered punctate benign appearing micronodules without evidence of pulmonary or pleural metastases.Stable foci of linear scarring.MEDIASTINUM AND HILA: Unchanged upper normal sized left paratracheal lymph node, likely benign gi... | No sign of metastases, or other significant abnormality. While several mediastinal lymph nodes are visible, they are not abnormally enlarged. |
Generate impression based on findings. | Known type B aortic dissection being medically managed now with SOB and hemoglobin drop. Evaluate for hemothorax or other bleeding. LUNGS AND PLEURA: Mild centrilobular emphysema.Lobular areas of groundglass opacity diffusely, greater on the right, increased from prior exam. This is suspicious for pulmonary hemorrhage,... | 1. Type B aortic dissection without significant change in aorta caliber or evidence of rupture.2. No hemothorax as clinically questioned. 3. Increased bilateral groundglass opacities suspicious for pulmonary hemorrhage or aspirated blood given history; alternative possibility would be other types of aspirated fluid. |
Generate impression based on findings. | Ms. Barnes is a 77 year old female with a personal history of left breast mastectomy in the 1970s for breast cancer. Personal history of stable right breast mass for 60 years corresponding to a known fibroadenoma. Family history of ovarian cancer in her mother. Three standard views of the right breast were performed di... | Stable hyalinized fibroadenoma in the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: N... |
Generate impression based on findings. | Ms. Alitto is a 75 year old female with a personal history of right breast lumpectomy in 1997 for cancer followed by radiation, chemotherapy, and tamoxifen therapy. 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 br... | Stable postsurgical changes of the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagno... |
Generate impression based on findings. | Again seen are postsurgical changes of next dissection including resection of inferior right level 5 mass. There is interval decrease in previously seen residual lesion with no discrete measurable mass apparent on the current study. There is ill-defined soft tissue which may represent scar. Multiple surgical clips are... | Continued evolution of postsurgical changes of right inferior level 5 neck dissection and tumor resection. There is interval decrease in previously seen residual lesion with no discrete measurable mass apparent on the current study. There is ill-defined soft tissue in the surgical bed which may represent scar. No recur... |
Generate impression based on findings. | Male, 56 years old, history of T2 N2b base of tongue cancer. Head:No mass effect, focal edema or suspicious enhancement is seen to suggest brain parenchymal metastatic disease. The bones of the calvarium and skull base are intact. Neck:The aerodigestive mucosa is unremarkable with no evidence suggesting recurrent tumor... | 1. No evidence of local disease recurrence or pathologic adenopathy is seen.2. No intracranial metastases. |
Generate impression based on findings. | 14 year old male with recent diagnosis of SMA syndrome. Limited double contrast visualization of the esophagus showed no large morphologic abnormalities of the mucosal surfaces or mural contours. The stomach was significantly enlarged in size with a J-shape extending inferior to the pelvis. In the right side down later... | 1.Findings compatible with patients diagnosis of SMA syndrome. 2.Significantly enlarged stomach suggestive of chronic gastric outlet obstruction. |
Generate impression based on findings. | Male 54 years old; Reason: History of AML, s/p stem cell transplant patient with progressive ascending LE weakness. Weakness at level of diaphragm. Diffuse infiltrative process seen on recent CT. History: LE weakness, numbness, heaviness, sensation changes, ataxia, dysmetria, hyperreflexia.RADIOPHARMACEUTICAL: 11.6 mCi... | 1.No FDG avid activity to indicate tumor.2.Minimal stranding and activity in the retroperitoneum indicates residual inflammatory process. |
Generate impression based on findings. | PMH of ectopic atrial beats presents with palpitations. Question of PE. The comparison chest radiograph performed on 2/20/2015 demonstrates no focal pulmonary opacities or pleural fluid. The ventilation images show a uniform distribution of activity on single-breath and wash-in images. There is abnormal Xe-133 retentio... | Low probability for pulmonary embolus. |
Generate impression based on findings. | DesaturationVIEW: Chest AP Tracheostomy tube in place. NG tube tip in the stomach. Cardiothymic silhouette cannot be evaluated. Near complete collapse of the right lung with atelectasis new from prior study. Patchy atelectasis left lower lobe. | Near complete collapse of the right lung with atelectasis new from prior study. |
Generate impression based on findings. | FractureVIEWS: Left clavicle AP and axial Healing fracture involving the distal left clavicle with bony remodeling. The alignment is near anatomic. | Healing left clavicular fracture as described above. |
Generate impression based on findings. | 57 year old male with history of pancreatic cancer s/p duodenal stent placement with symptoms of obstruction. Scout image demonstrates a duodenal stent in the first and second portion of the duodenum. Water soluble contrast swallow demonstrated spontaneous emptying into the duodenum. There is narrowing of the second po... | Narrowing of the lumen at the second portion of the duodenum measuring up to 6 mm in maximum distention. |
Generate impression based on findings. | Female 38 years old Reason: 38F s/p ex lap for metastatic colon cancer with ileus vs obstruction History: N/V ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No focal liver lesions. Cholelithiasis. No biliary dilatation.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormali... | Concern for high grade mechanical obstruction near the anastomosis in the left lower quadrant. Small amount of intraperitoneal fluid may be postoperative in nature or related to obstruction.Cholelithiasis. Findings discussed with Dr. Martin Coronel pager 3163. |
Generate impression based on findings. | CVA, muscle weakness. The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portions of the paranasal sinuses demonstrate a mi... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction. |
Generate impression based on findings. | Male 59 years old; Reason: esophageal cancer, monitoring History: cachectic CHEST: Interval improvement in previously seen thin walled cavity in the right lower lobe. Biapical bleb formation and centrilobular emphysema.LUNGS AND PLEURA: Improved aeration in right upper lobe. Sequela of aspiration, including small debri... | 1. Interval improvement in right lower lobe cavitary lesion and improved aeration as described.2. Accounting for differences in technique, no significant change in stented gastroesophageal mass. |
Generate impression based on findings. | Male 64 years old; Reason: bladder stones, prostate cancer History: bladder stones The exam is not sensitive detecting lesions in the bowel to the lack of oral contrast in the solid organs and vasculature due to the lack of intravenous contrast. Given those limitations, the following observations are made:ABDOMEN:LUNGS... | 1.Single punctate focus of nephrolithiasis right lower pole. Presumed renal cysts bilaterally. No hydronephrosis. 2.A few bladder calculi, but decreased compared to the prior exam. |
Generate impression based on findings. | Follow-up Evaluation of the hindfoot is limited by an overlying external fixation device. The patient has presumably undergone resection of the distal fibula and medial malleolus. The distal fibular osteotomy margin is better defined on the current study than the prior study, suggesting healing. The medial malleolar ma... | Postoperative changes and osteoarthritis as described above. |
Generate impression based on findings. | Medial knee pain Four views of the left knee are provided. Moderate osteoarthritis affects the patellofemoral joint, with a prominent subchondral cyst seen in the medial facet of the patella. Mild osteoarthritis affects the tibiofemoral compartments.Similar osteoarthritic changes affect the right knee as seen on the fr... | Osteoarthritis. |
Generate impression based on findings. | Pain, swelling, decreased range of motion at base of distal phalanx. Evaluate for fracture. There is a comminuted fracture of the distal phalanx involving the tuft and base of the phalanx; fracture fragments are in near-anatomic alignment. There is surrounding soft tissue swelling. | Third toe fracture as above. This was text paged to 4480 at the time of dictation. |
Generate impression based on findings. | Left lower extremity pain. Evaluate for lumbar spine pathology. Severe degenerative disk disease affects L5/S1. The remaining intervertebral disk spaces are relatively well-preserved. Vertebral body heights are maintained. Mild facet joint osteoarthritis affects the lower lumbar spine. Alignment is within normal limits... | Degenerative disk disease and other findings as above. |
Generate impression based on findings. | Male 72 years old ; Surgical Case Information | Procedure(s): Procedure(s) with comments: | LAPAROSCOPIC /THORACOSCOPIC ESOPHAGECTOMY W/ THORACIC ANASTOMOSIS | LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT | OPEN ESOPHAGECTOMY WITH THORACOTOMY | JEJUNOSTOMY TUBE PLACEMENT | IVC FILTER - Procedure performed: IVC Filter Placem... | No unexpected radiopaque foreign body.These findings were discussed by telephone with Dr. Patti, the attending surgeon, on 2/20/2015 at 12:30 p.m.. |
Generate impression based on findings. | Reason: intracranial hemorrhage? History: altered mental status The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portions... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction. |
Generate impression based on findings. | Right knee pain Four views of the right knee are provided. There is mild narrowing of the medial tibiofemoral compartment and tiny patellar osteophytes indicating minimal osteoarthritis. Poorly defined mineralization along the medial facet of the patella likely simply represent additional osteophyte formation; however ... | Osteophytes and other findings as described above. If there is clinical concern for fracture or soft tissue derangement of the knee, then MRI may be considered. |
Generate impression based on findings. | Female, 67 years old, history of supraglottic cancer, radiotherapy follow-up examination. Treatment related findings are seen including infiltration of the fascial planes and supraglottic mucosal edema. No evidence of any mucosal space mass lesion is seen.No pathologic adenopathy in the neck by size criteria. The saliv... | Treatment related findings with no evidence of mucosal tumor or pathologic adenopathy. |
Generate impression based on findings. | Right knee pain and swelling. Assess degree of osteoarthritis. Four views of the right knee are provided. Small osteophytes indicate mild osteoarthritis. There is a small joint effusion.Mild osteoarthritis affects the left knee as seen on the frontal view. | Mild osteoarthritis. |
Generate impression based on findings. | 65 years old male. Reason: primary origin of metastatic squamous cell carcinoma. History: squamous cell carcinoma of the skin suggestive of internal malignancy. RADIOPHARMACEUTICAL: 9.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 103 mg/dL. Today's CT portion grossly demonstrates curvilinear densities in... | 1.Focal abnormal FDG uptake in the right lower quadrant of the abdomen, corresponding to an apparent wall thickening/mass seen in the cecum. The differential diagnoses including colon cancer, inflammatory change or normal variation. Suggest further evaluation with colonoscopy. No evidence of regional lymph node or dist... |
Generate impression based on findings. | Reason: h/o met medullary thyroid cancer, compare to previous, measurements. CT neck:Within the suprahyoid neck on the basis of size criteria for lymphadenopathy no lymphadenopathy is appreciated. Within the infrahyoid neck on the basis of size criteria for lymphadenopathy no lymphadenopathy is appreciated.There is a 1... | 1.Lymphadenopathy in the neck has mildly regressed in size when compared to the December 2014 exam.2.Mediastinal adenopathy. Please refer to chest CT of the same date for additional information.3.No evidence for brain metastases. |
Generate impression based on findings. | Fracture The bones are demineralized suggesting osteopenia/osteoporosis. Again seen is a predominantly transverse impacted fracture of the distal radius with fracture fragments in near anatomic alignment. There has been maturation of callus along the fracture indicating some interval healing. There is a slight positive... | Healing distal radius fracture as above. |
Generate impression based on findings. | 67-year-old with abscess on right base of big toe. Rule-out osteo-. There is swelling of the soft tissues along the medial and inferior aspects of the first metatarsophalangeal joint. Small foci of gas density within the swollen soft tissues plantar to the first MTP joint presumably represent the known abscess. I see n... | Findings compatible with the stated diagnosis of soft tissue abscess without radiographic evidence of osteomyelitis. If further imaging evaluation is clinically warranted, MRI may be considered. |
Generate impression based on findings. | There is no evidence of intracranial hemorrhage, mass, or cerebral edema. The ventricles and basal cisterns are prominent but unchanged. There is no midline shift or herniation. The imaged paranasal sinuses and mastoid air cells are clear. There are bilateral concha bullosa. The skull and extracranial soft tissues are... | No acute intracranial hemorrhage or skull fracture. |
Generate impression based on findings. | Metastatic lung cancer evaluate response to erlotinib. CHEST:LUNGS AND PLEURA: Nodule near in the left apex abutting the major fissure measures 4 x 9 mm, previously 6 x 9 mm (4/18). Left lower lobe paramediastinal opacities (4/37-45) are associated with adjacent focal pleural fluid and retraction, the pattern is sugges... | Minimal increase in pericardial fluid volume which remains small. Skeletal metastases with the reference lesion measurement not significantly changed. Left apical nodule and mediastinal lymph node measure smaller. |
Generate impression based on findings. | Lumbar spine pain status post lower speed MVC. Fracture? There is perhaps a slight leftward curvature of the thoracolumbar spine, but alignment is otherwise within normal limits and I see no fracture. Tiny osteophytes project from the anterior aspects of the lumbar vertebrae. There is perhaps minimal degenerative disk ... | No fracture evident. Minimal degenerative changes and other findings as above. |
Generate impression based on findings. | Elbow pain There is a linear lucency seen on the external oblique view traversing the medial condyle which I suspect is artifactual, perhaps due to an overlying skinfold. I see no definite fracture, malalignment, or joint effusion. | No specific findings to account for the patient's elbow pain. If further imaging evaluation is clinically warranted, MRI may be considered. |
Generate impression based on findings. | Status post ORIF A plate and screw device affixes a fracture of the distal fibular diaphysis in near anatomic alignment. I see no hardware complications. A pin and screw affix a fracture of the medial malleolus in near anatomic alignment. The fracture line is less distinct on the current study than on the prior study, ... | Orthopedic fixation of distal fibular and tibial fractures as above. |
Generate impression based on findings. | Severe pain in right second toe. Rule out fracture. Evaluation of the second toe is limited as the PIP joint is held in flexion. Seen on the lateral view is a linear lucency traversing a dorsal osteophyte projecting from the base of the distal phalanx, suggesting a nondisplaced fracture. Severe osteoarthritis affects t... | Findings suggestive of a nondisplaced fracture through an osteophyte projecting from the dorsal aspect of the base of the distal phalanx. This was text paged to Dr. Schwartz at the time of dictation. |
Generate impression based on findings. | Cervical spondylosis with myelopathy Again seen are postoperative changes of multilevel laminoplasty appearing similar to those seen on the prior study. Degenerative disk disease affecting the mid and lower cervical spine also appears similar to the prior study. | Postoperative changes of multilevel laminoplasty and degenerative disk disease appearing similar to the prior study. |
Generate impression based on findings. | Back pain There is a slight leftward curvature of the thoracolumbar spine. There is also a slight pelvic tilt with the superior border of the right iliac wing projecting approximately 8 mm above that of the left iliac wing. Severe degenerative disk disease affects L1/2, with relatively mild degenerative disk disease af... | Degenerative disk disease and other findings as above. |
Generate impression based on findings. | Lung cancer on chemotherapy. CHEST:LUNGS AND PLEURA: Thick walled necrotic nodule with internal air and fluid significantly increased in size compared to the prior study, 2.5 x 2.1 cm (5/34), previously 6 x 5-mm.The originally measured necrotic mass just below the level the fiducial markers at the left interlobar level... | Interval increase in size of reference lesions, with suspicious lesions in the left kidney and right adrenal gland. The spacing device between L3 and L4 vertebral bodies has migrated to the left of the spine, protruding beyond the margins of the vertebral column by approximately 2-cm. |
Generate impression based on findings. | Pain in the left knee with pain posteriorly Four views of the left knee are provided. There is narrowing of the medial compartment and small tri-compartmental osteophytes indicating mild to moderate osteoarthritis.Moderate osteoarthritis affects the right knee as seen on the frontal view. | Osteoarthritis. |
Generate impression based on findings. | Cough feverVIEWS: Chest AP and lateral Cardiothymic silhouette normal. Cardiac apex and stomach left-sided. Peribronchial wall thickening with subsegmental atelectasis in the right lower lobe and left lower lobe. No pleural effusion or pneumothorax. | Bronchiolitis or reactive airway disease. |
Generate impression based on findings. | 52-year-old male, evaluate transplant kidney mass. 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 coronary artery calcifications are present. Cardiomegaly.... | Outside exam read:1.Severe hydronephrosis of transplant kidney in the right iliac fossa with associated cortical thinning.2.Dense material within the transplant kidney collecting system and ureter may represent blood products or neoplasm. Correlation with patient's clinical history for any recent intervention recommend... |
Generate impression based on findings. | 15-year-old male with respiratory distress, rule out pneumoniaVIEW: Chest AP (one view) 2/20/15 1:11 Severe scoliosis appears similar to the prior exam. The cardiothymic silhouette is unchanged. Right middle and lower lobe atelectasis without evidence of pneumonia or pleural effusions. | No evidence of pneumonia. |
Generate impression based on findings. | Retained food/bezor on EGD. RUQ pain. Visually there was significant and progressive gastric emptying. Using anterior and posterior geometric means, residual gastric activity at the following postprandial intervals was calculated as follows:30 mins: 71 % of peak activity (normal >70 %)1 hour: 58 % of peak activity (nor... | Gastric emptying within normal limits. |
Generate impression based on findings. | Pain, limping. Left total hip replacement November 2014. Four views of the right knee are provided. There is mild medial compartment narrowing and small tricompartmental osteophytes indicating mild to moderate osteoarthritis. I see no joint effusion.Mild osteoarthritis affects the left knee as seen on the frontal view. | Osteoarthritis. |
Generate impression based on findings. | Cough feverVIEWS: Chest AP and lateral Cardiothymic silhouette normal. Minimal peribronchial wall thickening with subsegmental atelectasis in the left lower lobe. No pleural effusion or pneumothorax. | Bronchiolitis or reactive airway disease. |
Generate impression based on findings. | Six months postop Again seen is a posterior stabilization device with screws entering L4, S1, and both iliac wings. Also again seen are spacer devices at L4/5 and L5/S1 with screws entering L5 and S1 anteriorly. A small amount of cement is again seen within the L4 vertebral body. Overall, these findings are similar to ... | Postoperative and degenerative changes appearing similar to those seen on the prior study. |
Generate impression based on findings. | 9-year-old male with desaturationVIEW: Chest AP (one view) 2/20/15 13:04 Interval placement of left pleural catheter with tip directed medially. Right pleural catheters are unchanged in position. ETT is above the carina. Left central venous catheter tip extends to cavoatrial junction.New moderate to large right pneumot... | Moderate to large right pneumothorax. Interval decrease in left pleural effusion. |
Generate impression based on findings. | Patient with metastatic lung cancer with bone metastases. There are multiple new osseous lesions involving the ribs, thoracic and lumbar spine, pelvis, distal right femur, and distal right tibia. There is also worsening and increased uptake of several calvarial, a left scapular, a left 7th rib, a proximal right tibial,... | Progression of osseous metastatic disease. |
Generate impression based on findings. | UC evaluate toxic megacolonVIEW: Abdomen AP Disorganized nonobstructive bowel gas pattern. There is no abnormal bowel dilation. No pneumatosis or pneumoperitoneum. An IUD device is present in the lower pelvis new from prior study. | Normal examination. |
Generate impression based on findings. | Male 58 years old Reason: septic shock, possible sources aspiration PNA, parapneumonic effusion, peri-pancreatic fluid collection, recent diarrhea History: acute on chronic alcoholic pancreatitis, severe alcohol withdrawal Exam is suboptimal secondary to motion artifact. Limited study due to absence of intravenous cont... | 1.Global small bowel and colonic wall thickening with severe wall thickening of a segment of proximal jejunum. Bowel ischemia cannot be excluded. 2.Large peripancreatic and perisplenic loculated low-density fluid collections causing significant compression of the stomach and likely secondary to patient's known pancreat... |
Generate impression based on findings. | History of rheumatoid arthritis. Patient is participating in research study. Evaluate for lung disease. LUNGS AND PLEURA: Calcified nodules consistent with healed granulomatous disease.Scattered noncalcified micronodules are most likely also post-inflammatory.No evidence of interstitial lung disease.Mild bronchial wall... | No evidence of interstitial lung disease. Mild bronchial wall thickening. 1 cm fat-containing hepatic lesion, which is likely benign. |
Generate impression based on findings. | Status post ORIF of left wrist. Left wrist pain. There is a volar plate with screws affixing a fracture of the distal radius in near-anatomic alignment. I see no hardware complications. Portions of the fracture remain visible, but there is adjacent callus suggesting an attempt at healing. Severe osteoarthritis affects ... | Orthopedic fixation of distal radius fracture as above. |
Generate impression based on findings. | Female 68 years old Reason: rule out perforation - cervical, mid and distal esophagus History: cervical web s/p dilation, Schatzki ring distally, s/p biopsy interruption Scout radiograph of the chest shows air space opacity in the right upper lung. A right chest terminates at the cavoatrial junction. There is atelectas... | No evidence of esophageal leak.Pulmonary opacity in the right upper lobe. |
Generate impression based on findings. | Male 23 years old Reason: left foot pain in sole, assess for foreign body History: as above. Three views of the left foot demonstrate perhaps soft tissue swelling, but we see no fracture, malalignment, or radiopaque foreign body. | No acute fracture, malalignment, or radiopaque foreign body. |
Generate impression based on findings. | Primary hyperparathyroidism. Please evaluate for parathyroid adenoma. There is physiologic distribution of the radiopharmaceutical. An abnormal focus of increased uptake is noted posterior to the mid to upper pole of the left thyroid lobe.The right thyroid lobe appears to measure 4.1 cm and the left lobe 4.1 cm in leng... | Abnormal focus of uptake posterior to the mid to upper pole of the left thyroid pole is highly suspicious for a parathyroid adenoma. |
Generate impression based on findings. | 47 years, Male. Reason: Dobbhoff placement History: Dobbhoff placement Note that the pelvis is excluded from the field-of-view. Enteric feeding tube tip projects over the gastric body. Support devices and pleural effusions are unchanged. | Enteric feeding tube tip projects over the gastric body. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: No evidence of pulmonary or pleural metastases, or other significant abnormalities.Stable basilar linear scarring.MEDIASTINUM AND HILA: There is no mediastinal or hilar lymphadenopathy.A large amount of thrombus in the left ... | 1. No evidence of metastases, or other significant abnormality.2. Large right renal cyst decreased in size, for which annual ultrasound has been previously recommended. |
Generate impression based on findings. | 82-year-old male with abdominal pain, evaluate for small bowel obstruction. ABDOMEN:LUNG BASES: Left basilar subsegmental atelectasis, slightly increased from prior. There is chronic elevation of the left hemidiaphragm.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREA... | 1.Postsurgical changes of right partial colectomy.2.Small bowel obstruction with transition point in the right lower quadrant.3.Two segments of colitis involving the colon just distal to the ileo-colonic anastomosis which may be due to infectious, inflammatory, or less likely ischemic etiologies.4.Prostatomegaly.Findin... |
Generate impression based on findings. | Inflammatory myeloradiculopathy. The etiology could be CMV, tuberculosis, inflammation, infection or cancer. Please evaluate. RADIOPHARMACEUTICAL: 7.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 79 mg/dL. Today's CT portion grossly demonstrates opacification of the right sphenoid sinus and an air-fluid l... | Increased activity within the endplates of L2-L3; degenerative change is favored over the possibility of infection. This appearance is not consistent with tumor. No other evidence of an FDG avid lesion. |
Generate impression based on findings. | Liver lesion. Question of metastases. Patient also reports fall on left side a few weeks ago. No abnormal osseous foci are identified to indicate metastatic disease. Increased areas of uptake along several anterolateral lower left ribs is compatible with likely healing fractures from prior trauma. There is slightly abn... | 1. No evidence of bone metastases.2. Slightly abnormal renal radiotracer retention; this may be due to dehydration or parenchymal dysfunction, clinical correlation is suggested. |
Generate impression based on findings. | Cirrhosis. Liver lesion. Evaluate for metastases. History of sarcoidosis. LUNGS AND PLEURA: Upper and mid zone predominately perilymphatic distribution of numerous micronodules and right upper lobe conglomerate mass with coarse calcifications, consistent with sarcoidosis, not significantly changed.Calcified nodules con... | Extensive sarcoidosis related lung disease, unchanged. No specific evidence of metastatic disease. Large left pleural effusion, new from prior. |
Generate impression based on findings. | Male 60 years old Reason: ETOH cirrhosis, please evaluate for presence of PVT clot and HCC History: ETOH cirrhosis PORTAL VENOUS: Flow in the main portal vein is very slow near the hepatic hilum and could not be demonstrated as the main portal vein courses in the liver. This may represent either very slow, sluggish flo... | Possible thrombosis of the main portal vein. Further evaluation with contrast enhanced CT or MRI is recommended to differentiate between very slow flow versus thrombosis.Cirrhotic liver. |
Generate impression based on findings. | Reason: h/o recurrent met HNC, s/p chemotherapy. compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: 9 x 13 mm right upper lobe nodule image 29 series 5, present as far back as 10/29/2010 and relatively stable in size and likely benign.Severe centrilobular emphysema unchanged.MEDIASTINUM AND HIL... | 1. No evidence of metastases.2. Right upper lobe nodule unchanged since 2010 and likely benign or a very indolent primary lung cancer.3. Severe emphysema.4. Infrarenal abdominal aortic aneurysm, unchanged following repair. |
Generate impression based on findings. | Female 50 years old Reason: r/o recurrence History: h/o thyroid cancer. S/p surgery. No RAI RIGHT LOBE: Status post thyroidectomy.LEFT LOBE: Status post thyroidectomy. Previously noted hyperechoic focus in the left thyroid bed is unchanged measuring 1.2 x 0 .8 cm.ISTHMUS: No significant abnormality noted.PARATHYROID GL... | No significant change from previous study. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. Tomosynthesis images are also obtained. The breast parenchyma is composed of scattered fibroglandular elements. No suspicious masses, microcalcifica... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Rheumatoid arthritis Right hand: Increased continued demineralization limits sensitivity, however the appearance remains essentially unchanged with diffuse rheumatoid changes including pronounced swan-neck and boutonniere deformities. Pencil in cup erosion with questionable complete dislocation of third, fourth and fif... | Essentially stable extensive severe rheumatologic changes involving both hands |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is mostly fatty replaced, unchanged in pattern and distribution. No suspicious masses, microcalcifications or areas of archite... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | 64 years, Male. Reason: ng tube location History: dec ng output Enteric feeding tube tip is past the ligament of Treitz. Multiple pigtail drains project over the left upper quadrant. A pancreatic stent is noted. Left sided pleural effusion. Nonobstructive bowel gas pattern. | Enteric feeding tube tip is past the ligament of Treitz. |
Generate impression based on findings. | 44-year-old with metastatic breast cancer recurrent malignant pleural effusion with pleurex catheter and fevers. LUNGS AND PLEURA: Diffuse pulmonary metastases. Large multiloculated right pleural fluid collection with layering in dependent debris, likely blood or cellular products. The largest area of loculation occurs... | Large complex loculated fluid collection in the right hemithorax with development of internal layering of fluid consistent with blood or cellular products. Thickening of both of the visceral and parietal pleural surfaces is more pronounced compared to previous examinations and is now compatible with superimposed empyem... |
Generate impression based on findings. | No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are within normal limits for age without evidence of hydrocephalus. No extra-axial collections. There are scattered areas of hy... | 1. 7 x 6 mm aneurysm involving the right middle cerebral artery bifurcation. There is 2.5 mm aneurysm at the left middle cerebral artery bifurcation. 2. Right vertebral artery is occluded from its origin with flow within the right V4 segment and right posterior inferior cerebellar artery, which may be retrograde. Mild ... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. Tomosynthesis images are also obtained. The breast parenchyma is composed of scattered fibroglandular elements. A small circumscribed mass is presen... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Right hemiparesthesia Head:No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No abnormal parenchymal or meningeal enhancement. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without ... | . 1. No intracranial mass or mass-effect. No abnormal enhancement. 2. Prominent enhancement of the epidural venous plexus, which may be related to increased central venous pressure. There are mild degenerative changes including mild to moderate right neural foraminal narrowing at right C3-C4 level. |
Generate impression based on findings. | Patient fell. Pain, check for fracture Hand and wrist: No radiographic abnormality. Specifically no findings to suggest a fracture or malalignment. Soft tissues are unremarkable. | Normal |
Generate impression based on findings. | Ms. Jackson is a 68 year old female presenting for a short-term followup for calcifications in the left breast. She has no current breast related complaints. Three standard views of the left breast, additional left MLO view and three left spot magnification views were performed digitally and reviewed with the aid of R2... | High probability benign calcifications in the left breast. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months to confirm stability of these findings. Results and recommendation were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMM... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. Tomosynthesis images are also obtained. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. Scattered benign calc... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | 45 years, Female. Reason: evaluate for progression of ileus History: abd pain Enteric feeding tube tip projects over the gastric fundus. Ileus type bowel gas pattern is mildly improved compared to prior examination. | Ileus type bowel gas pattern is mildly improved compared to prior examination. |
Generate impression based on findings. | Female 72 years old Reason: gi bleeding History: anemia, gi bleeding ABDOMEN:LUNGS BASES: Emphysematous changes with mild bibasilar atelectasis.LIVER, BILIARY TRACT: Hypodense lesion in the dome of the liver likely representing hepatic cyst. SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality ... | No CT evidence of gastrointestinal bleeding. |
Generate impression based on findings. | Male 43 years old Reason: evaluate vasculature to support kidney transplant History: weak distal pulses The study is limited due to lack of oral and IV contrast. Evaluation of the visceral organs and bowel loops is extremely limited.ABDOMEN:LUNG BASES: New small pleural effusion. Cardiomegaly.LIVER, BILIARY TRACT: No s... | No significant atherosclerotic calcifications. Extremely limited study due to lack of oral and intravenous contrast. Generalized anasarca, cardiomegaly and right-sided pleural effusion. |
Generate impression based on findings. | Check fracture Indistinct margins to the distal fibular fracture without change in overall near anatomic alignment. Appearance is compatible with mild interval continued healing. Soft tissue swelling persists greater laterally | Interval partial healing of the distal fibular fracture |
Generate impression based on findings. | 82 years, Male. Reason: pt with diarrhea, rule out overflow diarrhea related to partial obstruction History: diarrhea Nonobstructive bowel gas pattern with average stool burden in the colon. Surgical coils project over the left hemipelvis. | Nonobstructive bowel gas pattern with average stool burden in the colon. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. Circumscribed masses in both breasts ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 85 years, Female. Reason: distension History: sepsis Nonobstructive bowel gas pattern. Less than average stool burden in the colon. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. No suspicious masses, microcalcificat... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Male 57 years old Reason: Patient with stage IVA Waldenstrom's Macroglobulinemia now s/p 6 cycles of CRD in need of reimaging History: Waldenstrom's Macroglobulinemia CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: Index anterior mediastinal lymph nodes measure 4.6 by 1.3 cm on image numbe... | Limited study due to lack of intravenous contrast. No significant change from previous study. |
Generate impression based on findings. | 71 year-old woman with history of right breast-cancer status post lumpectomy and radiation 19 years ago, recently with a right axillary recurrence that is status post excision. Evaluate for recurrent breast tumor. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The... | 1. Post-operative findings of right lumpectomy without mammographic evidence of malignancy. Continued followup with surgery and oncology are recommended for treatment planning. Results and recommendation were discussed with the patient. MRI could be considered if further evaluation of the breast is needed. 2. Large pos... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. No suspicious masses, microcalcificat... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. Tomosynthesis images are also obtained. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. Arterial calcificatio... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. There are a few arterial and other be... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Medulloblastoma status post craniotomy and induction chemotherapy History: Infectious work up pre-transplant. The images are degraded by patient motion. There is moderate mucosal thickening in the right maxillary sinus. There is also patchy opacification of the ethmoid and sphenoid sinuses. The nasal cavity is also cle... | Scattered paranasal sinus opacification may represent sinusitis. |
Generate impression based on findings. | Female 56 years old Reason: new lung nodule, response to chemotherapy? History: new lung nodule, response to chemotherapy? CHEST:LUNGS AND PLEURA: Severe emphysema again noted. Index opacity in the left lower lobe is no longer visualized. However, there is new right lower lobe consolidation which represents pneumonia. ... | Interval resolution of the left lower lobe nodule. Interval development of right lower lobe also location which may represent pneumonia.Slight interval decrease in the size of the right adrenal nodule.Sclerotic pelvic bone lesions are stable. |
Generate impression based on findings. | Female 69 years old Reason: mets lung cancer. s/p 14 cycles of MPDL3280A. Pls c/w previous study and evaluate tx response. History: lung ca ABDOMEN:LUNG BASES: Chest CT will be dictated separately.LIVER, BILIARY TRACT: Multiple cystic hepatic lesions are unchanged.SPLEEN: No significant abnormality notedPANCREAS: No si... | No significant change from previous study. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. No suspicious masses, microcalcifications or areas of archite... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
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