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Generate impression based on findings. | 38 year old woman with history of diabetic mastopathy. Patient gives history of waxing and waning palpable mass in the lateral left breast. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is extremely dense, which lowers the sensitivity of mam... | Decrease in size of mixed echogenicity area in the left breast, benign in appearance. 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 - Benig... |
Generate impression based on findings. | Lung cancer metastatic to bone status post chemotherapy, last given February 2015. Restaging exam.RADIOPHARMACEUTICAL: 9.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 200 mg/dL. Today's CT portion grossly demonstrates left frontal craniotomy defect. Air-fluid levels in both maxillary sinuses suggestive o... | 1.Left ischial osseous metastasis remains significantly metabolically active although slightly improved from previous.2.No new or additional FDG avid metastasis.3.Bilateral upper lobe ground glass pulmonary nodules are again not FDG avid but remain suspicious for indolent synchronous lung cancer.4.Acute appearing bilat... |
Generate impression based on findings. | Total elbow arthroplasty LEFT WRIST: The bones are demineralized. Three views of the left wrist demonstrate a plate and screw device affixing a healed distal radius fracture in near-anatomic alignment. We see no radiographic evidence of hardware complication. Deformity of the distal ulnar diaphysis indicates an old hea... | Healed wrist and shoulder fractures and total elbow arthroplasty device, as described above. |
Generate impression based on findings. | Male; 38 years old. Reason: PE History: tachypnea, hypoxia. PULMONARY ARTERIES: No evidence of acute pulmonary embolism. Normal main pulmonary trunk diameter.LUNGS AND PLEURA: New moderate bilateral pleural effusions with overlying compressive atelectasis. Multiple ill-defined solid nodules in both lungs with surroundi... | 1.No evidence of acute pulmonary embolism.2.Interval increase in size of multifocal solid lung nodules, consistent with worsening fungal infection.3.New bilateral pleural effusions and increased pericardial effusion and ascites.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Mos... |
Generate impression based on findings. | 40-day-old male with hypoxia, continued O2 requirements. Evaluate for interstitial and/or parenchymal lung disease. LUNGS AND PLEURA: Diffuse bilateral ground-glass opacities are present. Multiple very small round lucencies are noted. No air trapping is seen. No pleural effusion or pneumothorax. MEDIASTINUM AND HILA: N... | Diffuse bilateral ground-glass opacities which may represent congenital surfactant deficiency or pulmonary interstitial glycogenosis. Neuroendocrine cell hyperplasia in infancy is less likely given that there is no air trapping. |
Generate impression based on findings. | Restaging marginal zone lymphoma status post chemotherapy, last January 2015.RADIOPHARMACEUTICAL: 11.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 108 mg/dL. Today's CT portion of the neck demonstrates no significant pathology. Please see diagnostic CT reports for details of the chest, abdomen, and pelvi... | 1.Complete interval resolution of previous extensive hypermetabolic tumor without FDG avid tumor currently in the neck, chest, abdomen or pelvis.Diagnostic CTs of the chest, abdomen, and pelvis also performed at today's visit will be reported separately. |
Generate impression based on findings. | Male 43 years old; Reason: acute pancreatitis, pseudocyst with drain in place, not draining, evaluate fluid collections and pancreas History: Acute pancreatitis, pseudocyst ABDOMEN:LUNGS BASES: Small left pleural effusion with underlying atelectasis.LIVER, BILIARY TRACT, PANCREAS: Intra/peripancreatic fluid collections... | Pancreatic fluid collections as above. |
Generate impression based on findings. | Female 66 years old; Reason: Evaluate left 4th toe fracture There is a nondisplaced fracture through the proximal phalanx of the fourth toe, seen only on the oblique view.Deformity at the neck of the proximal phalanx of the second toe presumably represents a chronic fracture as this appears similar to the prior study. | Nondisplaced fracture of the fourth toe, as described above. |
Generate impression based on findings. | No CT evidence of acute large territorial ischemia. Moderate to severe subcortical and periventricular hypoattenuation consistent with small vessel ischemic disease of indeterminate age. Scattered prior cortical strokes are noted. Moderate prominence of the ventricles and sulci consistent with age-related volume loss.... | 1.No CT evidence of large acute territorial ischemia. If there is high clinical concern for acute ischemia, further evaluation with MR is recommended.2.Severe small vessel ischemic disease of indeterminate age and evidence of prior remote scattered cortical strokes. |
Generate impression based on findings. | Reason: s/p LVAD, wound debridement for chest infection w/ ecoli , Now ecoli bacteremia. Eval for fluid collection History: ecoli bacteremia and fever CHEST:LUNGS AND PLEURA: Persistent bilateral pleural effusions. Stable ground glass, interstitial and airspace opacity in the lingula which may be due to aspirate or inf... | Persistent bilateral pleural effusions. Stable ground glass, interstitial and airspace opacity in the lingula which may be due to aspirate or infection. Similar but less severe findings in the right middle lobe are also stable. No evidence of abscess as clinically queried. |
Generate impression based on findings. | One day old male full-term neonate with chest tube in place, history of pneumothorax now with hypocarbia. No interval change pneumothorax or other acute intrapulmonary process.VIEW: Chest AP (one view) 2/23/20151 5:50 Right-sided chest tube has been retracted with tip outside the lung in the subcutaneous soft tissues o... | 1. Persistent small right pneumothorax not significantly changed.2. Right chest wall tube tip has been retracted and is located outside the lung. |
Generate impression based on findings. | 70-year-old female with history of foreign body in colon, assess for passage. 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: Dependent atelectasis and new bilat... | 1.New bilateral small pleural effusions.2.There is a 1.3-cm nonspecific density within the lumen of the sigmoid colon which may represent interval transit of previously seen nonspecific density in the transverse colon.3.Cholelithiasis. 4.Small foci of gas within the bladder which may be related to instrumentation, corr... |
Generate impression based on findings. | Male 14 years old Reason: post-operative s/p K-wire placement History: post-op s/p K wire placement. The K wires seen on the previous study affixing a fracture of the first metacarpal and proximal phalanx have been removed. The fracture lines remain visible, although are less distinct on the current study than on the p... | Healing fractures and postoperative changes as described above. |
Generate impression based on findings. | 18-month-old female with history of trauma. Evaluate for intracranial hemorrhage or fracture. There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. The image... | No evidence of acute intracranial hemorrhage or calvarial fracture. |
Generate impression based on findings. | Male, 50 years old, history of dentigerous cyst with maxillary sinus fistula. A periapical cyst is again seen associated with the left second maxillary molar projecting superiorly into the left maxillary sinus. This lesion demonstrates a thickened sclerotic wall which is irregular and discontinuous in areas, particular... | A periapical cyst associated with the left second maxillary molar has not significantly changed in size. While on the prior examination, the cyst contained an air fluid level, it is completely opacified on the present study. There remain some areas of discontinuity of the lateral aspect of the cyst wall which imply fis... |
Generate impression based on findings. | 76 years, Female, Reason: Assess for treatment response for small cell ung cancer History: None. ABDOMEN:LUNG BASES: Pleural-based right lower lobe nodule is unchanged in size measuring 1.7 x 1.0 cm (3/9), previously 1.7 x 1.2 cm.LIVER, BILIARY TRACT: Cholelithiasis without evidence of cholecystitis.SPLEEN: No signific... | 1.Evolving hematoma abutting the pancreatic tail is decreased in size. Adjacent enhancing tissue is unchanged.2.Right lower lobe nodule is stable.3.Resolution of bowel wall thickening in the descending colon.4.Stable right adrenal nodule. |
Generate impression based on findings. | Rule out FAI, CAM The patient initially underwent CT scanning of the hip on February 13. However, due to technologist error, the knees and pelvis were not scanned. The patient therefore was asked to return for additional scanning on February 23.MEASUREMENTS: CAM location : Three o'clock anteriorAlpha angle : 55 degrees... | Cranial acetabular retroversion, borderline CAM deformity and other measurements as described above. |
Generate impression based on findings. | Baseline pre-transplant. Status post chemotherapy. The patient’s weight of 91 kg and height of 193 cm were used for all calculations.Raw GFR = 206 mL/minBSA = 2.219 m2Estimated GFR/m2 = 93 mL/min/m2Estimated GFR/m2 * 1.73 m2 (average adult BSA) = 160 mL/min (adult GFR equivalent) | GFR measurements as above. |
Generate impression based on findings. | Male 72 years old Reason: renal cancer History: renal cancer. Per surgical pathology from outside hospital, FNA of left lower lobe mass positive for renal cell carcinoma, clear-cell type. CHEST:LUNGS AND PLEURA: Lobulated, slightly heterogeneous lesion in the superior segment of the left lower lobe measuring 2.8 x 2.6 ... | 1.Multifocal renal cell carcinoma with biopsy proven metastatic left lower lobe pulmonary mass. 2.Left adrenal lesion suspicious for metastasis.3.Findings suspicious for right renal vein thrombus. |
Generate impression based on findings. | Pain radiating from back down to posterior thigh. LUMBAR SPINE: The vertebral body heights and disk spaces are preserved. There may be mild narrowing of the L5/S1 neural foramina bilaterally as a result of mild facet joint hypertrophy, however this is equivocal and would be better assessed with cross-sectional imaging.... | 1. Possible mild narrowing of the L5/S1 neural foramina, which may be better assessed with cross-sectional imaging.2. Minimal bilateral hip osteoarthritis.3. Lucent lesion with sclerotic margins in the right iliac wing. This lesion has a benign appearance and may be postsurgical in etiology, such as a bone graft harves... |
Generate impression based on findings. | Pain. Skiing injury. Four views of the left knee demonstrate no fracture, malalignment, or other findings to account for the patient's pain.The right knee is normal in appearance as seen on frontal views. | No findings to account for the patient's pain. |
Generate impression based on findings. | Pain. Swelling. Three views of the right foot demonstrate no fracture, malalignment, or specific findings to account for the patient's pain. | No findings to account for the patient's pain. |
Generate impression based on findings. | Metastatic breast cancer. Evaluate for progression. One view of the pelvis demonstrates hardware components of a left total hip arthroplasty device situated in near-anatomic alignment. The inferior margin of this device is not included in the field-of-view.Lucent lesions seen on the prior radiograph are again noted on ... | Metastatic lesions and other findings, appearing similar to prior. |
Generate impression based on findings. | Female 88 years old Reason: right femur fracture s/p nail History: fracture. Pelvis: Sensitivity of the study is limited by overlying bowel gas and stool. The bones are diffusely demineralized. There is mild osteoarthritis of the hips. Again seen is an intramedullary rod and screw device with the attempt affixation of ... | Attempt orthopedic fixation of a comminuted intertrochanteric fracture unchanged in position. |
Generate impression based on findings. | Reason: 78 year old female patient diagnosed with HCC is here foradministration of THERASPHERES in addition to a nuclear medicine study Please refer to interventional radiology study for description of procedure andimages. | Successful Y90 Therasphere administration to liver tumor via the right hepaticartery. Please refer to interventional radiology exam for description of procedure andimages. |
Generate impression based on findings. | 14-year-old male, evaluate for C-spine bullet fragmentsVIEWS: Cervical spine, AP and lateral (two views) 2/23/15 16:52 Unchanged bullet fragments project over the right pedicle of C7. Cervical spine alignment is within normal limits. The prevertebral soft tissues are normal. | Unchanged bullet fragments. |
Generate impression based on findings. | A 48 years old female with hypertension, dyslipidemia and non compliance to medications, referred to cardiac CT because of chest pain to rule out coronary artery disease. CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of Valsalva and bifurcates into the left ant... | 1.There are no significant coronary artery stenoses present; however, the distal vessels and branches are small and not well visualized. 2. The patient has several non-obstructive atherosclerotic plaques through out the coronary tree. 3. The overall burden of atherosclerosis is high for a 48 year old woman. 4. Mild le... |
Generate impression based on findings. | Pain and swelling. Abnormality? There is mild soft tissue swelling, particularly at the fingertip. There is a punctate density seen only on the lateral view dorsal to the head of the middle phalanx which could conceivably represent old trauma, but I see no donor site to confirm an acute fracture fragment. | Soft tissue swelling and punctate density dorsal to the head of the middle phalanx, but I see no definite acute fracture or radiographic features of osteomyelitis. |
Generate impression based on findings. | Post reduction Evaluation of fine detail is limited by overlying cast material. Again seen is an oblique fracture of the distal fibula with approximately 2 mm lateral displacement of the distal fracture fragment. There is also a transverse fracture of the medial malleolus with fracture fragments in near anatomic alignm... | Ankle fracture status post reduction as above. |
Generate impression based on findings. | Status post fall one week ago. Left hip pain. Left knee pain. Fracture? Four non-weight-bearing views of the left knee are provided. I see no fracture. There is perhaps a small joint effusion. Alignment is within normal limits. Small osteophytes indicate mild osteoarthritis. Arterial calcifications are noted in the pos... | Mild osteoarthritis of the hips and left knee without fracture evident. |
Generate impression based on findings. | History of sciatica and degenerative disk disease, worsening "fx", lost to follow-up secondary to insurance. Vertebral body heights and intervertebral disk spaces are within normal limits. There is perhaps mild facet joint osteoarthritis at L4/5, with a minimal (grade 1) anterolisthesis of L4. Alignment is otherwise wi... | Mild facet joint osteoarthritis as above. I see no fracture. |
Generate impression based on findings. | 72 year old man being considered for robotic mitral and tricuspid valve repair. Referred to evaluate cardiovascular anatomy to guide procedure.CPT: 75572 Aortic and Aortic Root. There is a left sided aortic arch with normal brachiocephalic branching pattern. No thoracic aortic dissection is noted; however, the thoracic... | 1. Thoracic aorta mildly dilated with mild to moderate burden of atheroslcerosis. 2. Severe left atrial dilation 3. Mild overall burden of coronary calcification. 4. Mild mitral annular calcification.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and up... |
Generate impression based on findings. | Two weeks ago with injury after falling on Christmas tree. Mild osteoarthritis affects the knee and there may be a joint effusion; however, I see no fracture or malalignment. | Mild osteoarthritis and joint effusion without fracture evident. |
Generate impression based on findings. | Pain. Rule out fracture. Three views of the left hand are provided. The bones appear slightly demineralized. There is dorsal soft tissue swelling, but I see no underlying fracture. There is widening of the scapholunate interval suggesting scapholunate ligamentous disruption that may be chronic in etiology; there appear... | Findings suggestive of scapholunate ligamentous disruption bilaterally that I suspect is chronic in etiology as there are associated arthritic changes of the wrists. I see no acute fracture. |
Generate impression based on findings. | Clinical question: Fall. Signs and symptoms: Trauma after fall Nonenhanced head CT:Examination demonstrate a thin band of hyperdensity along the right falx measuring approximately 3.5 mm in thickness. Finding is suspicious for a small subdural collection. Recommend follow-up exams.Left posterior temporal -- occipital s... | 1.Small 3.5-mm right-sided falcine subdural hematoma is suspected.2.Unremarkable intracranial contents otherwise.3.Left posterior temporal -- occipital scalp/subgaleal small hematoma. |
Generate impression based on findings. | Clinical question:? Intracranial hemorrhage. Signs and symptoms: Assault with bat and read last of consciousness. Nonenhanced head CT:There is no detectable acute posttraumatic intracranial, calvarial or soft tissues of the scalp findings.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and ... | Negative nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Evaluate status-post right temporal craniotomy for resection of tumor. Signs and symptoms: As above. Unenhanced head CT:Examination demonstrates post operative changes are right anterior temporal and frontal large craniotomy. Surgical cavity containing fluid and air fluid level in the anterior right ... | 1.Extensive postoperative changes are large right temporal -- frontal craniotomy as detailed.2.Focus of high density suspected of hemorrhage in the dependent portion of surgical cavity posteriorly is noted, however possibility of adjacent parenchymal hemorrhage cannot be entirely excluded.3.Dilated supratentorial ventr... |
Generate impression based on findings. | Clinical question: Out subdural hematoma. Signs and symptoms: Headache. Nonenhanced head CT:There is no detectable acute intracranial process. EG however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and gray -- w... | 1.Unremarkable nonenhanced head CT.2.Left-sided otitis media. |
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, unchanged in pattern and distribution. Scattered benign calcifications and right later... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.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 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. No suspicious masses, microcalcifications or areas of architectural di... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | altered mental status No evidence of acute ischemic or hemorrhagic lesion.Diffuse moderate to severe non specific small vessel ischemic disease.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The ... | No evidence of acute ischemic or hemorrhagic lesion.Moderate to severe small vessel ischemic disease. |
Generate impression based on findings. | 73 old female with history of small cell carcinoma now with abdominal pain and delirium. ABDOMEN:LUNG BASES: Please see chest CT report from the same day for full evaluation of the thorax. LIVER, BILIARY TRACT: The left hepatic lobe abuts and is slightly superiorly displaced by the extensive retroperitoneal lymphadenop... | 1.Large retroperitoneal mass which appears to be a conglomerate of necrotic retroperitoneal lymph nodes compatible with metastatic disease, similar to prior. Mass results in encasement of the mesenteric and retroperitoneal vasculature causing narrowing of the portal vein, renal vasculature, and IVC. Splenic vein and ar... |
Generate impression based on findings. | Reason: transient numbness/weakness, eval for intracranial process s/p crani for tumor resection History: transient numbness/weakness, eval for intracranial process s/p crani for tumor resection The patient is status post right-sided craniotomy right parafalcine meningioma. Compared there is an additional extra axial m... | 1.No evidence for acute intracranial hemorrhage.2.Redemonstration of vasogenic edema adjacent to the prior tumor bed.3.small right parafalcine meningioma adjacent to the precuneus is stable. |
Generate impression based on findings. | 48-year-old male with history of Crohn's disease status post completion proctocolectomy now with increasing pain. CHEST:LUNGS AND PLEURA: Mild basilar atelectasis. No pleural effusions. Scattered nonspecific pulmonary micronodules.MEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormal... | 1.Expected postoperative changes of recent proctocolectomy and end ileostomy.2.No evidence of bowel obstruction or abscess. 3.Hepatic steatosis. |
Generate impression based on findings. | 12 year old female felt shoulder pop out of place. Evaluate for dislocation.VIEWS: Right shoulder AP external and internal rotation (two views) 2/23/2015 No evidence of fracture or dislocation. No soft tissue swelling or joint effusion. | Normal examination. |
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. No suspicious masses, microcalcifications or areas of architectural distortion are pre... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually. Mammography is optimally performed when prior studies are available to detect changes. If the patient's prior mammograms can be submitted, then an addendum to this r... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of bilateral benign biopsies. Two standard digital views of both breasts with repeat right MLO view 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... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | 45-year-old female with history pancreatitis with peripancreatic fluid collections, evaluate for bleeding prior to possible embolization. Evaluation of the lower abdomen and pelvis in portal venous phase limited by suboptimal contrast phase timing. ABDOMEN:CT Angiography: There is no evidence of aortic aneurysm, dissec... | 1.Peripancreatic and additional lower mediastinal and retroperitoneal fluid collections appearing similar to prior, given patient's diagnosis of ongoing pancreatitis, suspicious for pseudocyst formation.2.No evidence of active bleeding.3.Large right pleural effusion with underlying compressive atelectasis and mediastin... |
Generate impression based on findings. | 63 years, Male. Reason: s/p Dobbhoff placement, check line History: s/p Dobbhoff placement Dobbhoff tube tip projects over the proximal gastric body. Nonobstructive bowel gas pattern. Note that the pelvis is excluded from the field-of-view. | Dobbhoff tube tip projects over the proximal gastric body. |
Generate impression based on findings. | 58 years, Male. Reason: NJ placement, h/o acute on chronic pancreatitis c/b large cystic fluid collections, recent stent placed for cyst stent gastrostomy History: as above Bibasal atelectasis. Enteric feeding tube is projected over the stomach and proximal jejunum with tip projected far past the ligament of Treitz, ov... | Enteric feeding tube is projected over the stomach and proximal jejunum with tip projected far past the ligament of Treitz. |
Generate impression based on findings. | 61-year-old male status post prostatectomy on 1/29/2015 now with right groin swelling, redness, and pain rule out abscess or mass. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedA... | 1.Multiple post-operative fluid collections in the pelvis and extending into the right inguinal canal and scrotum as described above which may represent postoperative lymphocele/seroma. Superimposed infection cannot be excluded. One of the fluid collections abuts the bladder with associated bladder wall thickening and ... |
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 almost entirely fatty, unchanged in pattern and distribution. No suspicious masses, microcalcifications or areas of architectural di... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | 82 years, Female. Reason: NGT position History: feels that it is falling out Nasogastric tube tip projects over the gastric body. Residual contrast is noted within the ascending colon. Calcified diverticula pelvis. Surgical clips noted in the right upper quadrant and in the pelvis. Dilated small bowel loops measuring u... | Resolving small bowel obstruction. NG tube tip projects over the gastric body. |
Generate impression based on findings. | 27 years, Female. Reason: eval for stool burden History: abd pain Nonobstructive bowel gas pattern. Below average stool burden. Vascular calcifications noted. | Nonobstructive bowel gas pattern. Below average stool burden. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microca... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Female 58 years old Reason: r/o acute process History: abd pain, recently post-op. Per Epic note, patient had recent surgery for peptic ulcer disease. Patient did not complain of diarrhea. CHEST:LUNGS AND PLEURA: Moderate left and small right pleural effusions with overlying atelectasis.MEDIASTINUM AND HILA: No signifi... | 1.Wall thickening of the cecum to the transverse colon which is suspicious for colitis. Differential diagnosis favors portal colopathy given lack of history of diarrhea, with infectious, inflammatory, and ischemic etiology less likely. 2.New right upper pole high attenuation renal lesion. Without precontrast CT it cann... |
Generate impression based on findings. | 32 year old female with upper abdominal pain. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Status post cholecystectomy.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: No significant abnormali... | 1.No specific findings to account for patient's symptoms. |
Generate impression based on findings. | 23 years, Male. Reason: fevers w/ ureteral stent placement a few weeks ago History: fevers Nephroureterostomy tube is noted on the left. Calcified stone is noted within the left collecting system. Bullet fragment projects over the right paraspinal area; noted to be in the soft tissues of the back on prior CT. Greater t... | Nephroureterostomy tube and calcified stone within the left collecting system. |
Generate impression based on findings. | 32 years, Female, Reason: to evaluate soft tissue infection of the R buttock near groin, r/o gas gangrene or perirectal abscess History: soft tissue infxn of R buttock. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: Small splenule's.PANCREAS: No signifi... | Soft tissue stranding in the right gluteal fold and upper thigh compatible with cellulitis. A few foci of subcutaneous gas are present, which may be seen in necrotizing fasciitis. |
Generate impression based on findings. | 61 years, Male. Reason: right sided abdominal pain History: right sided abdominal pain Enteric contrast opacifies portions of small and large bowel. Displacement of bowel gas from the right upper quadrant. Right lower zone consolidation and pleural thickening consistent with patient's known lung mass. This is better ev... | Displacement of bowel gas from the right upper quadrant, may be secondary to known lung mass and hepatomegaly. Right lower zone consolidation and pleural thickening is better evaluated on recent chest CT. |
Generate impression based on findings. | Clinical question: Hemorrhage in moyamoya/hemoglobin SS patient. Signs and symptoms: Headache. Nonenhanced head CT:There is no detectable acute intracranial hemorrhage, mass, mass effect, midline shift or hydrocephalus. CT however is insensitive for early detection of acute non-hemorrhagic ischemic strokes.There are il... | 1.No acute intracranial process. 2.Subtle patchy periventricular and subcortical hypoattenuation of white matter in the left hemisphere and with evidence of left sided craniotomy as detailed. |
Generate impression based on findings. | 74 year old female with left lower quadrant pain, evaluate for diverticulitis. ABDOMEN:LUNG BASES: Cardiomegaly. Moderate coronary artery calcifications. Basilar pulmonary nodules measuring up to 8 mm which are not definitively present on prior exams. No consolidation or pleural effusions.LIVER, BILIARY TRACT: Status p... | 1.No acute findings to account for patient's symptoms.2.Umbilical hernia containing transverse colon without evidence of complication.3.Diverticulosis without diverticulitis. 4.Bibasilar pulmonary nodules measuring up to 8 mm. Follow up recommended.5.Complex right renal upper pole lesion. Increased attenuation within t... |
Generate impression based on findings. | 14-year-old male status post patella reductionVIEWS: Left knee, AP, oblique, and lateral (3 views) 2/24/15 3:46 Large joint effusion. The patella is slightly laterally subluxed. Small fracture fragment anterior to the lateral femoral condyle is again visualized. | Large joint effusion and small fracture fragment anterior to the lateral femoral condyle. MRI is recommended for further evaluation if clinically warranted. |
Generate impression based on findings. | 39 year old male with abdominal pain, rule out acute process. ABDOMEN:LUNG BASES: Left basilar consolidation/ground glass opacities and right basilar groundglass opacities suspicious for pneumonia. No pleural effusions.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: Status post splenectomy.PANCREAS: Evalu... | 1.Basilar pneumonia.2.No acute abnormalities in the abdomen or pelvis.3.Mild age indeterminate compression deformity of T11.4.Evaluation of the pancreas is somewhat limited by metallic streak artifact, within this limitation previously described pancreatic body lesion is no longer visualized and low attenuation pancrea... |
Generate impression based on findings. | 65 years, Male. Reason: Dobbhoff placement History: same Enteric feeding tube is partially obscured with tip projecting over the gastric body. Support devices are unchanged. Again seen are multiple surgical clips and 8mm radiodensity projected over the pelvis. Nonobstructive bowel gas pattern. Cardiomegaly and bibasila... | Enteric feeding tube tip projects over the gastric body. |
Generate impression based on findings. | 14-year-old male with left knee painVIEWS: Pelvis, AP and frog leg (two views) 2/24/15 2:31 Both femoral heads are well directed with respect to the well formed acetabula. No fracture or malalignment. The osseous structures of the pelvis are normal for the patient's age. | Normal examination. |
Generate impression based on findings. | Male 66 years old Reason: ileus? History: pseudomonal bacteremia with dilated loops of bowel Limited exam secondary to lack of intravenous contrast. Evaluation of visceral and facet pathology are suboptimal.ABDOMEN:LUNG BASES: Small right pleural effusion and bibasilar consolidation with air bronchograms. Calcified rig... | 1.Findings consistent with mild colonic ileus without intraperitoneal free air.2.Bibasilar consolidations suspicious for pneumonia. |
Generate impression based on findings. | 75 years, Male. Reason: r/o megacolon History: positive c diff and abdominal pain with distension There are mildly dilated loops of small bowel and gas filled colon, compatible with an ileus pattern. Gastric distention with air fluid level noted. Postsurgical changes at the gastroesophageal junction. | Mildly dilated loops of small bowel and gas filled colon, compatible with an ileus pattern. |
Generate impression based on findings. | 33 years, Female. Reason: assess OG tube placement History: s/p OG tube placement Diffuse bilateral patchy airspace opacities. Enteric feeding tube is coiled within the gastric fundus with tip projected over the gastric body. Nonobstructive bowel gas pattern. The lower pelvis is not imaged. | Enteric feeding tube is coiled within the gastric fundus with tip projected over the gastric body. Patchy airspace opacities bilaterally compatible with clinical diagnosis of pneumocystis pneumonia. |
Generate impression based on findings. | 14-year-old male, rule out dislocationVIEWS: Left knee, AP, oblique, lateral, and sunrise (4 views) 2/24/15 2:51 Large joint effusion. Small linear density anterior to the lateral femoral condyle may represent a small fracture fragment. The patella is laterally subluxed. | Large joint effusion and small fracture fragment anterior to the femoral condyle. If further evaluation is clinically warranted, MRI is recommended. |
Generate impression based on findings. | 43 years, Female, Reason: abdominal pain History: abdominal pain. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: ... | No specific findings to account for the patient's symptoms. If clinical symptoms persist, a contrast-enhanced study may be considered. |
Generate impression based on findings. | 74 years, Male. Reason: SBO, history of cancer. History: N/V/abdominal pain Nonobstructive gas pattern. Moderate osteoarthritis affects the bilateral hips. Lung base are clear. | Nonobstructive gas pattern. |
Generate impression based on findings. | 36 years, Female. Reason: evaluate for obstruction History: constipation, nausea/vomiting Central venous catheter in situ with tip projected over the right atrium. Enteric contrast opacifies the distal large bowel. Nonobstructive bowel gas pattern. Average stool burden. Bilateral lower zone reticulonodular opacities. | Nonobstructive bowel gas pattern. Average stool burden. |
Generate impression based on findings. | Reason: PE History: Chest pain x 3 weeks; DOE PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber.LUNGS AND PLEURA: Mild subsegmental and dependent atelectasis/scarring. No focal air space consolidation. No pleural effusions.No suspicious pulmonary nodules or masses.MED... | No evidence of pulmonary embolism or other acute cardiopulmonary abnormality.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Diaphragmatic hernia repairVIEW: Chest AP and abdomen AP ET tube tip at the level of the thoracic inlet. NG tube tip in the stomach. Right upper extremity tip coiled in the right axillary vein. Cardiothymic silhouette at the upper limits of normal. Postsurgical changes from diaphragmatic hernia repair in the right lung... | Patchy atelectasis in the right lung. |
Generate impression based on findings. | male with sepsis, peritoneal catheter, worsening abdominal painVIEW: Abdomen AP Enteric tube tip and side-port in the stomach. Peritoneal catheter is coiled with its tip in the pelvis. Right femoral catheter tip in the right common iliac vein. Surgical suture in the right lower abdomen. The bowel gas pattern is disorga... | Disorganized bowel gas pattern without obstruction.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | History of subglottic stenosisVIEW: Chest AP 2/24/15 Tracheostomy tube and NG tube again noted. Cardiothymic silhouette normal. Right upper lobe atelectasis has improved. No pleural effusion or pneumothorax. | Right upper lobe atelectasis has improved in the interval. |
Generate impression based on findings. | 4 year old female with cough and fever for 5 days. Evaluate for pneumonia.VIEWS: Chest AP/lateral (two views) 2/23/2015 Cardiothymic silhouette is normal. Peribronchial thickening and left basilar streaky opacities likely atelectasis. No pleural effusion or pneumothorax. | Reactive airway disease or bronchiolitis pattern. |
Generate impression based on findings. | 75 years, Female. Reason: Eval NGT History: NGT Enteric feeding tube in situ with tip projected over the pylorus. Surgical clips projected over the left upper quadrant, left lower quadrant and pelvis. Nonobstructive bowel gas pattern. The lower pelvis is not imaged. | Enteric feeding tube in situ with tip projected over the pylorus. |
Generate impression based on findings. | Feeding tube placementVIEW: Chest AP and abdomen AP Feeding tube tip in the stomach. Left upper extremity PICC with tip at the confluence of the brachiocephalic veins. Cardiothymic silhouette normal. Hyperinflated left lung with patchy atelectasis at the left lower lobe. No pleural effusion or pneumothorax. Disorganize... | Feeding tube tip in the stomach. |
Generate impression based on findings. | There is no acute fracture. There is no soft tissue swelling. There is no orbital fracture. The globes are intact. There is no intraorbital hematoma or stranding. The imaged paranasal sinuses and mastoid air cells are clear.There is a focal left inferior orbital wall bony dehiscence measuring 7 mm in transverse dimens... | No acute fracture. |
Generate impression based on findings. | 14-month-old female with Dobbhoff tube placement.VIEW: Abdomen AP (one view) 2/23/2015 17:19 Dobbhoff tube tip in the gastric antrum or duodenal bulb.Moderate fecal burden with a nonobstructive bowel gas pattern. | Dobbhoff tube tip in the gastric antrum or duodenal bulb. |
Generate impression based on findings. | 2-Year-old male with respiratory distressVIEW: Chest AP (one view) 2/24/15, 4:22 Left PICC tip in SVC. NG tube tip at EG junction. Endotracheal tube has been removed.The cardiothymic silhouette is normal.Interval improvement in right upper lobe and retrocardiac opacities. Right upper lobe opacity has resolved. Some per... | Decrease in lung opacities.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Worsening breathingVIEWS: 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. | Pneumonia and influenza. History of prolonged intubation.VIEW: Chest AP (one view) 02/24/15, 0429 In the interval atelectasis of right lower and middle lobes has developed. Opacity in left lower lobe continues. Cardiac silhouette size is probably normal. Right thoracolumbar curve is again seen. | Development of lobar atelectasis on right. |
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 left lower lobe. No pleural effusion or pneumothorax. | Bronchiolitis or reactive airway disease. |
Generate impression based on findings. | 31-day-old male, evaluate OG placementVIEW: Chest AP, abdomen, AP (two views) 2/23/15 18:41 ETT tip below the thoracic inlet. Enteric tube tip and side-port in the stomach.The cardiothymic silhouette is normal. Mild upper lobe atelectasis is again noted. No pneumothorax. Disorganized bowel gas pattern. | Enteric tube tip and side port in the stomach. Right upper lobe atelectasis is unchanged. |
Generate impression based on findings. | Ms. Jacox is a 54 year old female recalled from screening mammogram for an asymmetry in the left inferior breast. An ML view, MLO view and one spot compression view of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density,... | 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: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | ET placementVIEW: Chest AP 2/23/15 ET tube tip below thoracic inlet and above the carina. Cardiothymic silhouette normal. Cardiac apex and stomach left-sided. Minimal patchy atelectasis in the right upper lobe. No pleural effusion or pneumothorax. The stomach is distended. | ET tube tip below thoracic inlet and above the carina. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are digital mammographic images of left breast (4/21/14) and ultrasound images of left breast (4/21/14) performed at Northwestern Memorial Hospital. For comparison, digital mammographic images of both breasts (1/29/13, 2/27/13) are available. DIGITAL MA... | No mammographic evidence of malignancy. BIRADS: 2 - Benign finding.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 2 old male with history of pneumothorax status post chest tube removalVIEW: Chest AP (one view) 2/24/15, 6:19 Enteric tube side-port at the EG junction. UVC tip in the hepatic vein. The cardiothymic silhouette is normal.Small unchanged right pneumothorax. No focal lung opacity is present. | Small right pneumothorax, unchanged.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of sister and maternal aunts diagnosed with breast cancer. 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, unchanged in patter... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Brain: No acute intracranial hemorrhage or CT evidence of acute large territorial ischemia. Moderate prominence of the ventricles and sulci, likely age related volume loss. Moderate periventricular and subcortical white matter hypoattenuation consistent with small vessel ischemic disease of indeterminate age. There ar... | 1.No acute intracranial hemorrhage.2.No acute fracture or subluxation.3.Multilevel cervical spondylosis with central spinal canal stenosis which is most severe at C3/4 and C4/5. |
Generate impression based on findings. | A 13-year-old male with increasing abdominal pain, concerning x-ray. Evaluate for small bowel obstruction. ABDOMEN:LUNG BASES: Bilateral small pleural effusions with adjacent atelectasis, right greater than left.LIVER, BILIARY TRACT: Normal appearance of the liver with no evidence of intra-or extrahepatic ductal dilata... | 1. Small bowel obstruction with pneumoperitoneum and the appendix not definitively visualized. Constellation of findings are suggestive of a perforated appendix. 2. Large amount of free fluid in the abdomen and pelvis with pneumoperitoneum.3. Bilateral small pleural effusions, right greater left. Findings were discusse... |
Generate impression based on findings. | Ms. Gnutek is a 66 year old female with a personal history of right breast lumpectomy in June 2006 for IDC followed by chemotherapy, radiation, and aromatase inhibitor. Family history of breast cancer in mother (diagnosed at the age of 64) and sister (diagnosed at the age of 61). She has no current breast related compl... | 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. | Female 64 years old Reason: 64 y/o F w/ Hx of Hep C who p/w R back pain radiating to R pelvis and CVA tenderness r/o renal stone. History: CVA tenderness w/ R back and R pelvis pain Limited exam secondary to lack of intravenous contrast. Evaluation of solid organs and vasculature are suboptimal.ABDOMEN:LUNG BASES: No s... | Limited exam secondary to lack of intravenous contrast which makes evaluation of solid organs and vasculature are suboptimal. Given these limitations, there are no acute findings to explain patient's right back/pelvis pain. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of benign left surgical biopsy in 1994. 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 composed of scattered fibroglandular density, unchanged in pattern... | 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: NSB - Screening Mammogram. |
Generate impression based on findings. | 12-year-old male with history of pain/right neck swelling evaluate for abscess. There is marked symmetric enlargement of the palatine and adenoid tonsils. The adenoid tonsils appear heterogeneous, but there is no evidence of fluid collection to suggest an abscess. The retropharyngeal space is within normal limits. Ther... | 1. Marked symmetric enlargement of the palatine and adenoid tonsils. Heterogeneous appearance of the adenoid tonsils may represent phlegmonous transformation but there is no evidence of drainable fluid collections.2. Scattered enlarged cervical lymph nodes, likely reactive in etiology.3. Marked narrowing of the left na... |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are ultrasound images of right breast (4/3/14, 4/30/14) performed at Regenstein Breast Imaging Center. Image quality is limited due to strong shadowing artifacts.A 23 mm round anechoic mass is visualized at 8:30 position in the right breast. There is a ... | Status post cyst aspiration for right simple cyst.BIRADS: 2 - Benign finding.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Female 41 years old Reason: lumbar pain History: lumbar pain. Severe degenerative disk disease affects L5/S1. The remaining intervertebral spaces appear intact and the vertebral body heights are preserved. Alignment is within normal limits. | Degenerative disk disease at L5/S1. |
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