instruction stringclasses 1
value | input stringlengths 6 8.98k | output stringlengths 5 3.11k |
|---|---|---|
Generate impression based on findings. | 10-day-old male with bilateral hydronephrosis, bilateral hydroureters and bilateral hydroceles on prenatal ultrasound.VIEW: Abdomen AP (one view) 2/17/2015 10:30 Nonobstructive bowel gas pattern. No free air or portal venous gas. | Normal examination. |
Generate impression based on findings. | History of FIGO IB2 poorly differentiated cervical squamous cell carcinoma status post definitive chemotherapy and radiation, completed 11/24/2014. Please evaluate disease status as above.RADIOPHARMACEUTICAL: 12.1 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 87 mg/dL. Today's CT portion grossly demonstrat... | 1.No evidence of FDG avid tumor. 2.Hepatic steatosis. |
Generate impression based on findings. | 17-year-old male with colicky abdominal pain. Evaluate for obstructionVIEWS: Abdomen AP erect and supine (two views) 2/24/2015 Average stool burden with a nonobstructive bowel gas pattern. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | No evidence of recurrent tongue mass or significant cervical lymphadenopathy. There is an unchanged partly calcified left level 2 lymph node measuring 7 x 5 mm. There is mild atrophy of the left submandibular gland and parotid gland without change. The thyroid and major salivary glands are otherwise unremarkable. The ... | No locally recurrent disease or pathologic cervical lymphadenopathy.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Reason: anterior mediastinal mass History: dysphagia LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Thyroid tissue extends inferiorly as far as the head of the left clavicle, but not into a retrosternal region.There is no anterior mediastinal mass.No lymphadenopathy identified.Severe coronary ... | Prominent thyroid, which does not extend retrosternally. No evidence of a mediastinal mass or other significant abnormality. |
Generate impression based on findings. | 16 year-old male with pain and swelling.VIEWS: Right knee AP, oblique and lateral (3 views) 2/24/2015 Joint effusion about the knee with no evidence of fracture or dislocation. Alignment is normal. | Joint effusion with no evidence of fracture. |
Generate impression based on findings. | Ms. Klipstein is a 68 year old female with a personal history of simple right mastectomy in January 2007 for invasive mammary carcinoma with mixed lobular and ductal features followed by delayed reconstruction and Arimidex therapy. She has no current breast related complaints. Three standard views of the left breast we... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Male 42 years old Reason: knee pain History: pain. We have 4 views of the right knee which show no fracture, malalignment, joint effusion, or frank arthritic changes. A cluster of tiny densities projecting anterior to the proximal fibula may represent dystrophic soft tissue calcifications or perhaps phleboliths, but ar... | Essentially normal-appearing knees with no specific radiographic findings to account for the patient's pain. A small cluster of calcifications anterior to the proximal right fibula may be dystrophic in etiology or, perhaps, represent a small venous malformation but are not necessarily of any clinical significance. |
Generate impression based on findings. | 61 year old male with history of HCV and EtOH cirrhosis s/p OLT and subtotal colectomy with end ileostomy (once revised 2/2 ischemia) here for worsening N/V not related to food intake. Patient reports he has been feeling dizzy and losing consciousness frequently when changing position (orthostatic hypotension?) The sco... | Multiple nonobstructive adhesions adjacent to the ileostomy correlating with pain on palpation. |
Generate impression based on findings. | Male 24 years old; Reason: evaluate for torsion History: pain, swelling RIGHT TESTIS: Measures 4.0 x 2.1 x 2.9 cm. Normal echotexture, no focal mass identified.LEFT TESTIS: Measures 4.0 x 2.8 x 3.2 cm. Normal echotexture, no focal mass identified.RIGHT EPIDIDYMIS: Measures 1.2 x 0.9 x 1.9 cm.LEFT EPIDIDYMIS: Measures 1... | 1.Increased vascularity in the left epididymis, appearance compatible with acute epididymitis.2.No evidence of testicular torsion. |
Generate impression based on findings. | Male 67 years old Reason: r/o DJD History: neck, shoulder, and left hip pain. We have two views of the left hip. Moderate osteoarthritis affects the hip with an approximately 1 cm lucency in the acetabular dome that likely represents a degenerative cyst. Small focus of heterotopic ossification in the posteromedial thig... | Degenerative arthritic changes of the left hip and cervical spine as described above. |
Generate impression based on findings. | Reason: Evaluate lung parenchyma History: RV dysfunction LUNGS AND PLEURA: Bilateral air space and interstitial opacities with a somewhat patchy distribution and moderate bilateral symmetrical pleural effusions, new since the previous scan from 11 days ago.MEDIASTINUM AND HILA: No pericardial effusion..Moderate coronar... | 1. Interval development of airspace and interstitial pulmonary opacity, nonspecific but compatible with edema.2.Moderate bilateral pleural effusions. |
Generate impression based on findings. | 55-year-old female with history of metastatic colon cancer. CHEST:LUNGS AND PLEURA: Solid pulmonary nodule in the left upper lobe (series 4, image 32) measures 0.9 x 1.0 cm, showed increased activity on recent PET, and is suspicious for metastasis. Additional bilateral smaller nodules are also suspicious for metastases... | 1.Postsurgical changes to the colon.2.Metastatic lesions to the liver, abdominal lymph nodes, and lungs. Some retroperitoneal lymph nodes have increased in size compared to the prior outside examination.3.Cholelithiasis. |
Generate impression based on findings. | Male 46 years old Reason: metastatic colon CA to liver History: re-staging CHEST:LUNGS AND PLEURA: No suspicious nodules or masses. No pleural effusion or pneumothorax.MEDIASTINUM AND HILA: Heart size is normal without pericardial effusion. No hilar or mediastinal lymphadenopathy. Right central venous catheter with tip... | Stable examination with diffuse, bilateral calcified hepatic lesions consistent with patient's history of metastatic colonic adenocarcinoma. |
Generate impression based on findings. | Reason: 3 month follow up for lung nodules History: lung nodule LUNGS AND PLEURA: Moderate apical predominant centrilobular emphysema.A right lower lobe irregularly-shaped solid nodule measures 12 x 11 mm (series 5, image 170), previously measuring 7 x 8 mm. An adjacent small peribronchial nodule measuring 6 x 5 mm (se... | Continued increase in size of a 12-mm right lower lobe solid nodule. Findings suspicious for malignancy, including primary lung neoplasm. PET imaging is recommended for additional evaluation. |
Generate impression based on findings. | Male; 78 years old. Reason: tonsillar cancer; compare to previous with measurements. CHEST:LUNGS AND PLEURA: Scattered calcified and noncalcified micronodules, not significantly changed. No suspicious pulmonary nodules or masses. Diffuse bronchial wall thickening, tree-in-bud opacities, and multifocal areas of nodular/... | 1.Stable left infrahilar index lymph node with probable central necrosis, suspicious for metastatic disease.2.No new sites of disease identified. 3.Findings compatible with worsening aspiration as described above, with new superimposed focal infection in the left lower lobe. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: No suspicious nodules or pleural effusions.MEDIASTINUM AND HILA: No significant lymphadenopathy and no pericardial effusion.Mild coronary artery calcification.CHEST WALL: A soft tissue nodule in the right breast (series 3/24... | No evidence of metastases or other significant change. |
Generate impression based on findings. | Ms. Braun submitted outside mammograms dated 05/6/2014 and 11/11/2009, from Advanced Medical Imaging Center. Submitted outside studies were compared to the current mammogram dated 02/05/2015. The breast parenchyma is composed of scattered fibroglandular elements. Scattered benign calcifications are present in both brea... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually, due next in Feb 2016.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | History of metastatic prostate cancer. Restaging scans. Foci of increased uptake are noted in the posterior left 10th rib and T10 vertebral body, similar to the prior study. Increased uptake of the cortex of the bilateral extremities is suggestive of hypertrophic osteoarthropathy, similar to the prior study. No new ost... | Stable metastatic osseous lesions without evidence of new lesions. |
Generate impression based on findings. | 36-year-old male patient with history of Kaposi sarcoma including lesion at the gastroesophageal junction/cardia diagnosed and subsequently treated presents with persistent dysphasia. Scout radiograph of the chest showed no mediastinal widening or pleural effusions. Possible scarring noted in the right middle lobe.Doub... | 1.Minor esophageal motility abnormality.2.No esophageal stenoses or lesions identified. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.No pleural effusions.MEDIASTINUM AND HILA: No hilar or mediastinal lymphadenopathy.Cardiac size is normal evidence of pericardial effusion.CHEST WALL: Mild degenerative changes in the thor... | No interval change. No evidence of metastatic disease. |
Generate impression based on findings. | 29 years, Male. Reason: SBO History: abd pain/distention Multiple surgical clips project over the right lower lung. Left lung opacity. Several dilated loops of small bowel measuring up to 3 cm with relative paucity of bowel gas distally. No free air. Vascular catheter tip projects over L2-L3 vertebral body. IVC filter ... | Findings consistent with a small bowel obstruction. |
Generate impression based on findings. | Female 81 years old Reason: History of left shoulder arthroplasty fall 1 month ago History: History of left shoulder arthroplasty fall 1 month ago. Hardware components of a left total shoulder arthroplasty device are situated in near anatomic alignment with no radiographic evidence of fracture or hardware complication.... | Total shoulder arthroplasty as described above without evidence of fracture-dislocation. |
Generate impression based on findings. | 75 years, Male. Reason: confirm placement of ureteral stent and any evidence of nephrolithiasis? History: patient reports having ureteral stent for nephrolithiasis and has indwelling Foley, came in with GNR bacteremia Urinary bladder catheter is noted. Overlying bowel gas limits evaluation of the kidneys, however, no a... | No ureteral stent or definite nephrolithiasis. |
Generate impression based on findings. | Reason: evaluate for metastasis. History: ewing sarcoma. LUNGS AND PLEURA: Stable postoperative changes in the lingula.No new suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: No hilar or mediastinal lymphadenopathy identified.Right chest Port-A-Cath with its tip in the SVC.Cardiac size is normal without evi... | No interval change without evidence of recurrent or metastatic disease. |
Generate impression based on findings. | Male 79 years old Reason: rule out fracture History: pain and tenderness from a fall this morning. There is a step-off along the cortex of the lateral femoral epicondyle compatible with a nondisplaced fracture. There is also a nondisplaced hairline fracture the fibular neck. There is a small joint effusion. | Nondisplaced fractures of the lateral epicondyle of the distal femur and the fibular neck.These findings were verbally relayed to Gabriella Borrelli, at 1400 on 2/24/2015. |
Generate impression based on findings. | Frontal sinus: Interval improvement in the aeration of the near complete opacification of the right frontal sinus and frontoethmoidal recess. Interval improvement in the aeration of the near completely opacified diminutive left frontal sinus and frontoethmoidal recess.Anterior ethmoids: Bilateral ethmoidectomies. No s... | Postsurgical changes with interval improvement in the aeration of the paranasal sinuses as above. |
Generate impression based on findings. | Left shoulder pain for many months. Evaluating for degenerative joint disease. Mild osteoarthritis affects the glenohumeral joint. I see no acute fracture or malalignment. | Mild glenohumeral joint osteoarthritis. |
Generate impression based on findings. | 55 years, Female. Reason: abdominal pain with hyperactive bowel sounds History: abdominal pain with hyperactive bowel sounds Slightly greater than average stool burden in the ascending and transverse colon. Nonobstructive bowel gas pattern. | Nonobstructive bowel gas pattern with slightly greater than average stool burden in the ascending and transverse colon. |
Generate impression based on findings. | There are unchanged postoperative findings of neck dissection in the left neck. No discrete mass in the oropharynx. There is a stable left tracheoesophageal groove enhancing nodule measuring 7 mm in short axis on series 6 image 64 just behind the left thyroid lobe posteriorly. Otherwise, there is no recurrent mass or ... | 1. No evidence of locoregional tumor recurrence or cervical lymphadenopathy.2. Enhancing nodule in the left tracheoesophageal groove is favored to represent a parathyroid adenoma and less likely lymph node.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Middle finger, post traumatic arthritis of the PIP joint. There is severe osteoarthritis of the PIP joint of the middle finger with mild deformity of the underlying bone compatible with the stated history of prior trauma. The PIP joint is held in slight flexion and there is mild surrounding soft tissue swelling. Relati... | Severe osteoarthritis of the PIP joint. |
Generate impression based on findings. | 72 years, Male. Reason: Constipation History: R/O Ileus Multiple dilated loops of small and large bowel, compatible with an ileus type pattern. Partially visualized enteric feeding tube is looped in the stomach with tip projecting over the gastric fundus.Lower pelvis is excluded from field of view. | Findings compatible with ileus type bowel gas pattern. |
Generate impression based on findings. | 70 year old male with dysphagia, regurgitation; history of Hodgkin's lymphoma s/p radiation in 1975 with stricture diagnosed 10 years ago. Scout radiograph of the chest showed bibasilar opacities and a right pleural effusion. Calcified granulomas are also noted.Test swallows of contrast demonstrated preferential flow o... | 1.Short segment stenosis in the distal esophagus with adjacent intramural fistula versus tract. 2.Distensible esophageal web or kinking of the cervical esophagus narrowing the esophagus as described above.3.Mild motor abnormality as described above. 4.Preferential flow of contrast to the left suggestive of right sided ... |
Generate impression based on findings. | Reason: r/o PE History: CP PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber.LUNGS AND PLEURA: Scattered benign-appearing micronodules, some calcified. No suspicious pulmonary nodules or masses.Mild pleural scarring in subsegmental cysts/scarring. No focal airspace co... | 1. No evidence of pulmonary embolism or other acute abnormality to account for the patient's symptoms.2. Mildly prominent hilar lymph nodes with calcifications, likely from prior granulomatous disease. No definite evidence of metastatic disease.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: N... |
Generate impression based on findings. | Pain status post PIP arthroplasties There are arthroplasty devices at the PIP joints of the index, middle, and ring fingers. Ulnar angulation/subluxation of the middle phalanges relative to the proximal phalanges of index and middle fingers is more pronounced on the current study than on the prior study. The PIP joint ... | PIP joint arthroplasties as described above, with ulnar angulation/subluxation of the middle phalanges of the index and middle fingers. |
Generate impression based on findings. | Right total knee arthroplasty. Lumbar spine fusion. LUMBAR SPINE: The bones are demineralized. Again seen are rods with screws entering the L1 to S1 vertebrae, with additional screws entering the iliac wings. Lucency around the L1 screws appears more prominent on the current study compared to prior. The tips of the L1 ... | Postoperative changes of total knee arthroplasties and lumbar spine fixation, as above. |
Generate impression based on findings. | 71 years, Female. Reason: incontinence History: as above Nonobstructive bowel gas pattern. Slightly less than average stool burden in the colon. Vascular calcifications are noted and numerous phleboliths project over the pelvis. | Nonobstructive bowel gas pattern with slightly less than average stool burden in the colon. |
Generate impression based on findings. | Female; 61 years old. Reason: ILD History: cough and dyspnea. LUNGS AND PLEURA: Nonspecific scattered micronodules, not significantly changed from previous. Basilar predominant lucent lobules, architectural distortion, and mild traction bronchiectasis are noted, but there is no definite honeycombing. Subpleural reticul... | Findings indicative of fibrosis, including subpleural reticulation, architectural distortion, and lucent lobules in the lung bases. While nonspecific, these findings are compatible with hypersensitivity pneumonitis. |
Generate impression based on findings. | Wrist fusion Two views of the right forearm and three views of the right wrist demonstrate a plate and screw device affixing an osteotomy of the distal ulnar diaphysis in near-anatomic alignment. The osteotomy margins are slightly indistinct, indicating some healing.An orthopedic screw affixes a the lunate and triquetr... | Orthopedic fixation of the distal ulna and wrist, as described above. |
Generate impression based on findings. | 60 year old with history of right lumpectomy in 2011 for DCIS followed by radiation therapy. History of benign left breast stereotactic core biopsy in January of 2012. No new breast complaints. History of breast carcinoma in maternal great aunt and ovarian carcinoma in paternal grandmother. Three standard views of both... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 54-year-old female with history of sinonasal melanoma. CHEST:LUNGS AND PLEURA: Right lower lobe reference nodule now measures 1.1 x 1.2 cm (series 9, image 47), previously 1.1 x 1.2 cm. Adjacent conglomerate of perifissural nodules (series 9, image 45) measures 2.4 x 3.3 cm, previously 1.9 x 3.3 cm. MEDIASTINUM AND HIL... | 1.Pulmonary metastases stable to slightly increased in size. 2.Interval decrease in size of peripancreatic and gastric metastases. SMV remains occluded. |
Generate impression based on findings. | 54-year-old female with a history of left mastectomy June 2013 for breast cancer. Family history of breast cancer in maternal grandmother and ovarian cancer in mother. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scatter... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, right unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Male 27 years old Reason: Multiple surgical teams. History: RFO. We have a frontal view of the right tibia/fibula which was performed in the OR. We see no unexpected retained radiopaque foreign object. There are skin staples, surgical clips, and drains noted within the soft tissues as well as foci of gas density reflec... | Postoperative changes as above without radiographic evidence of retained radiopaque foreign object.These findings were discussed by telephone with Dr. Haydon, the attending surgeon, on 2/24/2015 at 1433. |
Generate impression based on findings. | Follow-up An oblique fracture traverses the distal fibula, with approximately 1 cortical width of lateral displacement of the distal fracture fragment. Soft tissue swelling is present, particularly at the lateral aspect of the ankle. | Distal fibular fracture, as above. |
Generate impression based on findings. | Osteoarthritis of the knee RIGHT KNEE: Severe osteoarthritis affects the right knee, predominantly at the lateral compartment. There is mild valgus angulation at the knee. A large joint effusion is present. Meniscal chondrocalcinosis is noted. Venous varicosities are present in the medial soft tissues.LEFT KNEE: Severe... | Degenerative changes of the knee reflecting a combination of osteoarthritis and CPPD arthropathy. |
Generate impression based on findings. | Ms. Raudabaugh is a 58 year old female with a personal history of left breast lumpectomy in December 2008 for IDC followed by radiation and chemotherapy. Personal history of bilateral benign breast biopsies. Family history of breast cancer in mother diagnosed at the age of 56. Three standard views of both breasts were ... | Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Metastatic prostate cancer. Evaluate for disease progression. Again demonstrated are multiple osseous metastases of the axial and proximal appendicular skeleton, including the right proximal humerus, midthoracic spine and adjacent posterior ribs, lower thoracic spine, and lumbar spine. There has been interval enlargeme... | Probable progression of the metastatic osseous disease. |
Generate impression based on findings. | Reason: HNSCC. Compare to previous. History: as above CHEST:LUNGS AND PLEURA: Surgical changes of right upper lobe resection and postradiation reaction, appearing similar to the prior exam.A new left lower lobe focus of consolidation with surrounding tree in bud opacities (series 5, image 83), with new associated bronc... | 1. New left lower lobe aspiration/mucus plugging and associated pneumonia and bronchiolitis. This is too rapid an evolution for tumor. Additional scattered findings of aspiration/bronchiolitis are not significantly changed.2. No new suspicious pulmonary nodules or masses.3. Mild esophageal wall thickening, mediastinal ... |
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. No pleural effusion or pneumothorax. | Bronchiolitis or reactive airway disease. |
Generate impression based on findings. | 65 years, Male. Reason: 65M with AML, now intubated with OGT placed for AMS/hypoxia, ?OGT placement History: 65M with AML, now intubated with OGT placed for AMS/hypoxia, ?OGT placement Nasogastric tube side-port projects over the gastric cardia with tip over the proximal gastric body. Nonobstructive bowel gas pattern. ... | NG tube tip projects over the proximal gastric body. |
Generate impression based on findings. | 43 years, Female. Reason: Dobbhoff History: Dobbhoff LVAD device, multiple surgical drains and tubes, and cardiac leads are noted. Dobbhoff tube tip projects over the first portion of the duodenum. Guide wire is still in place. Moderate amount of amorphous stool is noted within the rectum and sigmoid colon. Nonobstruct... | Dobbhoff tube tip projects over the first portion of the duodenum. |
Generate impression based on findings. | 2-year-old male with history of Blount's diseaseVIEWS: Standing mechanical axis exam of the lower extremities. 2/24/15 11:28 Bilateral genu varus deformity is again identified. There is thickening of the medial cortices of the femurs and tibias. The tibial metaphyseal diaphyseal angle on the right is 5 degrees and on t... | Physiologic bowing deformities as described above. |
Generate impression based on findings. | 59 years, Male. Reason: eval dobhoff position History: repositioned NG tube tip projects over the distal gastric body. Dobbhoff tube is looped over the stomach and the tip is obscured by overlying enteric contrast. Enteric contrast is pooled in the gastric fundus and body. | Dobbhoff tube is looped over the stomach with tip obscured by overlying enteric contrast in the stomach. |
Generate impression based on findings. | Ms. Starman is a 68 year old female with a personal history of right breast mastectomy in June 2014 for extensive DCIS. She has no current breast related complaints. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 56 years, Male. Reason: bowel pattern History: patient will be having peg placed Nonobstructive bowel gas pattern. Surgical clips project over the left hemipelvis. Penile implant and calcified seminal vesicles again noted. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Male 19 years old Reason: healed scaphoid fracture History: none. An orthopedic screw affixes the fracture of the proximal aspect of the scaphoid waist in near-anatomic alignment. While portions of the fracture remain visible, there appears to be bony union across the majority of the fracture plane, indicating healing.... | Orthopedic fixation of healing scaphoid fracture as above. |
Generate impression based on findings. | Female 36 years old Reason: r/o fx History: fall. AP view of the pelvis and two views of the left hip show no acute fracture. Postoperative changes of a left total hip arthroplasty removal and cement spacer placement appear similar to those seen on the prior study. Components of a right total hip arthroplasty device ar... | Postoperative changes and findings compatible with sickle cell anemia as described above. We see no acute fracture. |
Generate impression based on findings. | Female 33 years old Reason: flank pain, renal stones, hx of nephrolithiasis History: as above Limited exam secondary to lack of intravenous contrast. Evaluation of solid organ and vascular pathology is suboptimal.ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedS... | Obstructing 6 mm calculus at the left ureteropelvic junction with associated moderate left hydronephrosis. |
Generate impression based on findings. | 66 years, Male. Reason: G tube study History: G tube study Gastrostomy tube projects over the gastric body. Enteric contrast is noted pooling in the fundus. Colonic ileus is again noted without pneumoperitoneum. | Gastrostomy tube projects over the gastric body with enteric contrast in the fundus. |
Generate impression based on findings. | intractable seizure This is a surgical/treatment planning exam and not a diagnostic test.Examination is performed while a stereotactic device is secured to the calvarium without detectable complication.There are multiple linear devices inserted through multiple burr holes including, right frontal, right temporal and ri... | Post device insertion status CT scan. Post procedure no unusual finding although precise evaluation is not possible due to multiple metallic artifacts. |
Generate impression based on findings. | 2-year-old male postop cochlear implant placementVIEWS: Skull AP and lateral (two views) 2/24/2015 The leads of the bilateral cochlear implants are coiled within the expected location of the cochlea bilaterally. No evidence of hardware failure. | Leads are coiled within the expected location of the cochlea bilaterally. |
Generate impression based on findings. | Reason: history of lumbar fusion. assess bony fusion History: history of lumbar fusion, assess lumbar fusion Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall height. There is mild anterior subluxation of L4 on L5. There is a levocurvature present to the lumbar spine. There i... | 1.Status post spinous process fusion at L4-5 as detailed above. The L4 spinous process is situated adjacent and anterior to the hardware. There is no osseous bridging appreciated.2.There is a moderate degree of spinal stenosis at L4-5 associated with subluxation and facet hypertrophy as well as encroachment of the righ... |
Generate impression based on findings. | Ms. Simms is a 57 year old female with a personal history of bilateral benign breast biopsies and bilateral calcifications. She has no current breast related complaints. Three standard views of both breasts and two left spot magnification views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breas... | Stable benign morphology masses in the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Dia... |
Generate impression based on findings. | Markedly enlarged hilar and mediastinal adenopathy in 12/2014. Persists after treatment for new CHF. Biopsy proven UIP noted in the pathology report from July of 2013.RADIOPHARMACEUTICAL: 12.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 98 mg/dL. Today's CT portion again demonstrates extensive bibasilar ... | Despite the high FDG activity of the lymph nodes within the mediastinum, the lymph nodes have not changed in size in 3 years. Therefore this activity more likely represents UIP or other inflammatory condition. Minimally increased metabolic activity in the interstitial lung opacities. |
Generate impression based on findings. | FractureVIEWS: Left elbow AP and lateral There is a healing supracondylar fracture in near anatomic alignment. Periosteal reaction and sclerosis are present indicative of healing. The metallic hardware has been removed in the interval. No evidence of elbow joint effusion. | Healing supracondylar fracture as described above. |
Generate impression based on findings. | 11 year old female with right ankle sprain. Evaluate for fracture.VIEWS: Right ankle AP, oblique and lateral (3 views) 2/24/2015 Normal alignment. No evidence of joint effusion. No evidence of fracture or dislocation. | Normal examination. |
Generate impression based on findings. | Male 67 years old Reason: 67 yo male with history of acute pancreatitis in October 2012, with pancreatic duct calcifications seen on EUS, s/p ERCP 2/24/15 with attempted removal of stones but unsuccessful. Pancreas protocol CT to determine stone location for surgery referral History: pancreatic duct stones, with compla... | 1.Limited exam secondary to residual contrast from ERCP from the same day. Within these limitations, there is a focus with increased attenuation in the distal common bile duct which may represent a stone.2.Cystic lesions adjacent to the upper pole of the left kidney which may represent a bilobed exophytic renal cyst. R... |
Generate impression based on findings. | Reason: SVC protocol History: Right arm and face swelling and pain LUNGS AND PLEURA: Bilateral basilar subsegmental atelectasis.Calcified granuloma at the right base.MEDIASTINUM AND HILA: Markedly enlarged thyroid gland with a inhomogeneous mass arising from the left lobe of the gland with cystic areas and calcificatio... | Markedly enlarged inhomogeneous and partially calcified thyroid gland with displacement and compression of the jugular veins, particularly on the left. The nature of the left thyroid mass is indeterminate based on CT and ultrasound could be used for further evaluation if clinically indicated. |
Generate impression based on findings. | 41 year-old female with history of new onset vertigo and headache. There is no evidence of acute intracranial hemorrhage. The gray-white differentiation is preserved. No midline shift or mass effect. The basal cisterns are intact. The ventricles and sulci are symmetric without evidence of hydrocephalus. The imaged para... | No acute intracranial abnormality. If there is continued suspicion for intracranial ischemia, consider MRI for further evaluation. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Reason: vertebral artery dissection vs. aneurysm History: headache, ataxia Neck CTA: There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there... | 1.No evidence for aneurysm.2.Findings suggest a stenosis along the A2 segment of the right anterior cerebral artery.3.No evidence for vertebral dissection. |
Generate impression based on findings. | Female 65 years old Reason: fx? History: fall. We have 3 views of the ribs. Note is made of multiple healed rib fractures bilaterally, but we see no acute rib fracture. The bones are demineralized. There is a posterior stabilization device affixing the thoracic spine and tension wires affixing the sternum. Degenerative... | Postoperative changes and multiple old healed rib fractures. We see no definite acute fracture. |
Generate impression based on findings. | A 95 year old female with symptomatic critical aortic stenosis referred to cardiac CT for evaluation before TAVR procedure.CPT: 75572 Aortic and Aortic Root. There is a left sided aortic arch with normal brachiocephalic branching pattern. No thoracic aortic dissection or aneurysm is noted. The thoracic aorta has mild t... | 1. Severe aortic valve calcification2. Thoracic aorta anatomy as above. 3. Moderate to severe global degree of coronary artery calcification.3. Severe biatrial dilation.4. Mitral annular calcification extends onto the bases of the anterior and posterior leaflets.5. There is a filling defect in the left atrial appendage... |
Generate impression based on findings. | Reason: mets lung cancer, s/p chemo and RT with residual disease. On Crizotinib now for ALK +. Pls c/w previous outside scan to evaluate tx response. History: lung ca CHEST:LUNGS AND PLEURA: Dense focal radiation reaction and bronchiectasis in the right lower lobe with associated volume loss. Radiation reaction extends... | 1. Dense radiation reaction, bronchiectasis and volume loss in the right lower lobe, with no measurable residual tumor. 2. Moderately enlarged subcarinal lymph nodes, unchanged or possibly decreased. |
Generate impression based on findings. | 41-year-old male with metastatic thyroid cancer. Compare to last CT scan, with measurements. LUNGS AND PLEURA: Innumerable basilar predominant pulmonary nodules in a miliary distribution, not significantly changed and compatible with the patient's known metastatic thyroid cancer. Right lower lobe reference nodule measu... | No significant interval change in innumerable pulmonary metastases or mediastinal lymphadenopathy. No new suspicious lesions identified. |
Generate impression based on findings. | Bilateral leg pain. Severe degenerative disk disease affects the L5/S1 level. Moderate degenerative disk disease affects the L2/L3 level. Posterior bulging disks are seen at L3/L4 and L4/L5. We see no frank instability on lateral flexion, neutral, and extension views. | Degenerative disk disease without evidence of instability. |
Generate impression based on findings. | Postoperative findings related to thyroidectomy and bilateral neck dissection. The previously noted fairly discrete nodular lesions along the left paratracheal space are much more ill-defined and appear to occupy a greater quantity of space when compared with the previous examination. There is resultant increased disp... | 1.Lesions along the left paratracheal space have become less well-defined and overall larger. Findings are concerning for disease progression; although, treatment related inflammation may be considered.2.Pulmonary nodules are noted. Please refer to separate CT chest report for additional findings. |
Generate impression based on findings. | Lumbar fusion. Again seen are rods with screws entering the L4 and L5 vertebral bodies, appearing similar to prior. We see no radiographic evidence of hardware complication. Amorphous bone graft is noted along the lateral aspects of the lumbar spine. Moderate degenerative disk disease affects the L5/S1 level. Grade 1 a... | Postoperative changes of lower lumbar spinal fusion, as described above. |
Generate impression based on findings. | Male 55 years old Reason: left shoulder pain History: above. We have 3 views of the right shoulder. There is a suture anchor within the greater tuberosity. A round defect in the proximal humerus may represent prior biceps tenodesis. Mild to moderate osteoarthritis affects the glenohumeral joint. Widening of the acromio... | Postoperative changes and osteoarthritis of the glenohumeral joints as described above. |
Generate impression based on findings. | Lumbar effusion Again seen are fusion rods with screws entering the L4 and L5 vertebral bodies. An intervertebral disk spacer is noted at the L4/L5 level, with early bony bridging at the anterior aspect of the disk space. We see no radiographic evidence of hardware complication. There is mild grade 1 anterolisthesis of... | Postoperative changes, without evidence of instability. |
Generate impression based on findings. | Esophageal cancer status post esophagectomy now with recurrence.RADIOPHARMACEUTICAL: 12.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 78 mg/dL. Today's CT portion grossly demonstrates partial opacification of the bilateral maxillary sinuses. The patient is status post esophagectomy with an intrathoracic ... | 1.Multiple new osseous metastatic lesions. Foci of hypermetabolic activity within the distal stomach are also highly suspicious for metastatic disease.2.Hypermetabolic activity within the right middle lobe, left lingula, and left lung base likely represents infection/inflammation.3.New moderate right hydronephrosis. |
Generate impression based on findings. | There is no evidence of intracranial hemorrhage, mass, or cerebral edema. There are unchanged patchy foci of low attenuation in the supratentorial periventricular and subcortical white matter. The ventricles and basal cisterns are unchanged. There is no hydrocephalus. There is no midline shift or herniation. The image... | 1.No acute intracranial hemorrhage or skull fracture.2.Moderate chronic small vessel ischemic changes. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 12 year old female with right lower quadrant abdominal pain and diarrhea. Colonoscopy with ulcers in the ICV, pathology was normal. Evaluate for Crohn's disease. EXAMINATION: MR enterography without and with IV contrast 2/24/2015 15:08 ABDOMEN:LIVER, BILIARY TRACT: Liver is normal with no evidence of intra-or extrahepa... | No evidence of Crohn's disease as clinically questioned. |
Generate impression based on findings. | 6-month-old male with lower extremity PICC placement.VIEW: Abdomen AP (one view) 2/24/2015 15:43 Feeding tube tip in stomach within the giant omphalocele. Left lower extremity PICC with tip in the left common iliac vein. Interval placement of right lower extremity PICC with tip coiled in the right external iliac vein. ... | Right lower extremity PICC with tip coiled in the right external iliac vein. |
Generate impression based on findings. | Left total knee arthroplasty Two views of the left knee demonstrate hardware components of a left total knee arthroplasty device situated in near-anatomic alignment, without radiographic evidence of hardware complication. Anterior soft tissue gas, surgical drain, and skin staples reflect recent prior surgery. | Postoperative changes of a left total knee arthroplasty device as above. |
Generate impression based on findings. | Thumb pain Severe osteoarthritis affects the basilar joint. The remainder of the right hand is within normal limits. | Severe basilar joint osteoarthritis. |
Generate impression based on findings. | Male 67 years old; Reason: carpal instability s/p screw fixation 3 yr ago loose screw vs scaphoid fx History: new pain snuffbox Again seen is a screw affixing the scaphoid and lunate in near-anatomic alignment, though there is slight widening of the scapholunate interval on the grip view, which appears similar to the p... | Orthopedic fixation of the scapholunate interval as described above, with findings which may represent loosening of the screw. No scaphoid fracture is seen. |
Generate impression based on findings. | Male 69 years old; Reason: fracture History: fall Mild soft tissue swelling is present along the ulnar styloid. No underlying fracture is seen. Mild osteoarthritis affects the articulation of the scaphoid and trapezium. | Mild soft tissue swelling and osteoarthritis, without fracture evident |
Generate impression based on findings. | 13-year-old male with pain and swellingVIEWS: Right knee, AP, oblique, and lateral (3 views) 2/24/15 15:53 Alignment is anatomic. No fracture is evident. A joint effusion is not present. | Normal examination. |
Generate impression based on findings. | Female 51 years old Reason: eval for fracture; hx of fall History: R hip pain. Two views of the right hip show no fracture.AP view of the pelvis shows no fracture. The hip joints appear normal. Degenerative disk disease affects the lower lumbar spine. | No fracture evident. Degenerative disk disease of the lower lumbar spine. |
Generate impression based on findings. | Male, 25 years old, with deviated nasal septum, prior nasal fracture. Evaluate sinuses and nasal passages. The frontal sinuses and frontoethmoidal recesses are clear. Minimal patchy thickening/opacification is seen through the ethmoid air cells. The sphenoid sinuses and sphenoethmoidal recesses are clear. Maxillary sin... | 1.Deformity of the nasal bones compatible with history of prior fracture.2.Mild leftward deviation of the nasal septum.3.No significant sinus inflammatory disease. |
Generate impression based on findings. | Female 60 years old; Reason: please perform CT abdomen/ pelvis with and without contrast History: surveillance of hx of renal cell ca ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality ... | 1.No evidence of recurrence. Bilateral renal hypodense lesions are likely simple cysts, several of which are too small to accurately characterize. |
Generate impression based on findings. | The frontal sinuses are unformed. Mild opacification of the anterior ethmoid air cells. No significant opacification of the maxillary sinuses. Mild mucosal thickening of the posterior ethmoid air cells. The sphenoid sinuses are clear bilaterally. There is mild opacification at the right sphenoethmoidal recess. Mastoid... | 1.Mild opacification of the anterior and posterior ethmoid sinuses.2.No evidence of significant acute or chronic sinusitis. |
Generate impression based on findings. | Female 67 years old Reason: eval for SBO History: recent SBO s/p small bowel resection, now with pain and vomiting again ABDOMEN:LUNG BASES: Interval resolution of small right pleural effusion. LIVER, BILIARY TRACT: Interval placement of percutaneous biliary drain. Pneumobilia which is likely iatrogenic in nature. Comm... | 1.No evidence of small bowel obstruction.2.Interval resolution of small right pleural effusion.3.Resolution of intrahepatic biliary ductal dilatation status post percutaneous biliary drain.4.Stable peripancreatic/pancreatic head mass with pancreatic atrophy and pancreatic ductal dilatation. |
Generate impression based on findings. | The internal auditory canals are symmetrical and normal in size and signal intensity. The inner ears are normal, with normal T2 signal and no pathological enhancement. No abnormal mass or abnormal enhancement is seen within the cerebellopontine angle, cisterns bilaterally or within the internal auditory canals. No abn... | 1. No acute infarct. Mild chronic small vessel ischemic changes.2. No MR abnormality within the IACs or involving the facial nerves bilaterally. |
Generate impression based on findings. | Clinical information PULMONARY ARTERIES: Large filling defect in the right main pulmonary artery, extending into the lobar and segmental branches throughout the right lung. The main pulmonary artery is normal in caliber. No evidence of right heart strain.LUNGS AND PLEURA: Wedge-shaped area of groundglass and consolidat... | Large pulmonary embolus in the right main pulmonary artery, extending into the lobar and segmental branches, with associated right upper lobe infarct and hemorrhage, as well as atelectasis/consolidation involving the middle and right lower lobes. Small pleural effusion.PULMONARY EMBOLISM: PE: Positive.Chronicity: Acute... |
Generate impression based on findings. | PICC placement. Neuroblastoma.VIEW: Chest AP (one view) 02/24/15, 1613 Right central line tip is in right atrium. Left upper extremity PICC tip is at junction of brachiocephalic veins. Surgical clips are seen in the left upper quadrant.Cardiothymic silhouette is normal. No focal lung opacity is present. A pleural effus... | Left upper extremity PICC tip at junction of brachiocephalic veins. |
Generate impression based on findings. | 28 years, Male, Reason: 28 y/o male with history of Crohn's disease with ileal stricture, entero-enteric fistula, recurrent SBO History: bloating, constipation. ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS:... | 1.Mild active inflammation of the distal and terminal ileum in a similar distribution to the prior exam.2.Small stricture in the distal ileum is unchanged from the prior exam. |
Generate impression based on findings. | Male 52 years old; Reason: Evaluate for malignancy History: lumbar polyradiculopathy CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Small prevascular and paratracheal lymph nodes measuring up to 8 mm in maximum short axis dimension. Additional calcified mediastinal and hilar lymph nodes ... | Sequela of prior granulomatous disease, unremarkable exam otherwise. |
Generate impression based on findings. | Female, 35 years old, with chronic sinusitis, worsening PND, cough and asthma. The frontal sinuses are small but the sinuses and the sinus recesses are unobstructed. The sphenoid sinuses and sphenoethmoidal recesses are clear and obstructed. The ethmoid air cells are clear.Maxillary sinuses are free of significant muco... | No evidence of significant sinus inflammatory disease. |
Generate impression based on findings. | Squamous cell cancer of tongue and new dx prostate CA eval bone mets. Abnormal increased cavity is visualized throughout the cervical, thoracic and lumbar spine, in particular within the mid-cervical, T4-T6 and T10-L2 levels. Increased activity suspicious for metastases are also noted within the right acetabulum and ri... | Abnormal activity correlating with likely osseous metastases within the spine, ribs, and right acetabulum. Questionable osseous activity is noted adjacent to the bilateral SI joints. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.