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Generate impression based on findings. | Female; 82 years old. Reason: Evaluate right hip s/p revision THA with concern for loosening History: Pain. Right Hip: Hardware components of a right total hip arthroplasty device are in near-anatomic alignment. There is no evidence of hardware complication or loosening. Acetabular protrusio is again noted.Pelvis: Bila... | Bilateral total hip arthroplasty devices without evidence of complication. |
Generate impression based on findings. | 19 year-old male with history of MPNST, one year off therapy. Surveillance. LUNGS AND PLEURA: Tree in bud opacities in the posterior segment of the right upper lobe are noted. No pleural effusion or pneumothorax.MEDIASTINUM AND HILA: Heart size is normal with no pericardial effusion. No mediastinal or hilar adenopathy.... | 1. No evidence of metastatic disease in the chest. 2. Findings are suspicious for infection in the posterior segment of the right upper lobe. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Three standard digital views of both breasts were performed with tomosynthesis and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. Scattered benign calcifications are present. No suspicious masses... | 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. | 21-year-old male with osteosarcoma, off therapy LUNGS AND PLEURA: Interval resolution of previously noted micronodules. No new nodules or masses.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. The heart size is normal.CHEST WALL: No axillary or supraclavicular lymphadenopathy.UPPER ABDOMEN: The visualize... | No evidence of metastatic disease. |
Generate impression based on findings. | Cerebral palsy, contracture.VIEWS: Thoracic and lumbar spine AP. Pelvis AP. 3/4/15 (2 view/s) Minimal thoracolumbar dextrocurvature. No segmentation or fusion defects. Cardiac silhouette size is normal. Left lower lobe opacity, likely atelectasis. No effusions or pneumothorax.Gastrostomy tube noted. Generalized, nonspe... | No evidence of scoliosis.Post surgical changes of both femurs as described. |
Generate impression based on findings. | Male 2 months old Reason: fracture History: tenderness on examVIEWS: Left elbow AP and lateral left arm AP in internal and external rotation 3/4/15 (4 views) There is a left elbow joint effusion. A curvilinear density just adjacent to the inferior margin of the distal metaphyses of the left humerus in lateral view, whi... | Question of a bucket-handle fracture of the left humerus.Left elbow joint effusion.Findings were communicated to and acknowledged by Dr. LIZENBERGS, LARISA on 3/4/15 at 2:40 p.m. hours |
Generate impression based on findings. | Pain and numbness right arm. Right cervical radiculopathy. Severe degenerative disk disease affects C4/5 and C5/6, that appears to have progressed when compared with the prior study. Moderate degenerative disk disease at C3/4 likewise appears to have progressed compared with the prior study. There are grade 1 retrolist... | Degenerative disk disease and neuroforaminal narrowing as described above. |
Generate impression based on findings. | Male; 60 years old. Reason: Follow up status post ORIF of calcaneal fracture. Orthopedic plate and screw device affixes a comminuted intra-articular fracture of the calcaneus in near anatomic alignment. No evidence of hardware complication or loosening. The fracture lines appear more indistinct, consistent with interva... | Healing calcaneal fracture as described above. |
Generate impression based on findings. | Male 4 days old Reason: where is pcvc tip? History: new PCVC placement, respiratory distress.VIEW: Chest AP (one view) 3/4/15 at 1425 hrs. UVC terminates at the right atrium. NG tube proximal side port is above the GE junction. Interval placement of left upper extremity PICC, tip at the at the left internal jugular vei... | Misplaced central line and NG tube as described. |
Generate impression based on findings. | 64 years, Female. Reason: NGT repositioned. Assess location. History: as above Enteric feeding tube tip projects over the pyloric area. Partially visualized bilateral nephroureterostomy stent again noted, unchanged. Mild interval decrease in diffuse small bowel dilatation compatible small bowel obstruction versus ileus... | Enteric feeding tube tip projects over the pyloric area. Interval decrease in diffuse small bowel dilatation compatible small bowel obstruction versus ileus. |
Generate impression based on findings. | 18 year-old male, evaluate for abscess or consolidation LUNGS AND PLEURA: Consolidation and atelectasis of the right lung sparing the apex. Moderate pleural effusion layering within fissure. Debris is noted within the right airways. Small left pleural effusion and scattered patchy pulmonary opacities.MEDIASTINUM AND HI... | Right lung consolidation and atelectasis as well as patchy left pulmonary opacities consistent with pneumonia. Small to moderate pleural effusions. No evidence of abscess. |
Generate impression based on findings. | Pain. Bunion. Again seen is a severe pes planovalgus deformity as well as a hallux valgus deformity appearing similar to prior study. Bandlike sclerosis traversing the anterior aspect of the calcaneus presumably represents a healed osteotomy. Osteoarthritic changes are noted at the talonavicular and calcaneocuboid arti... | Hallux valgus and pes planovalgus deformities as well as other findings described above. |
Generate impression based on findings. | 44 year old woman with history of cyclical breast pain and palpable mass in the right axilla. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. Bila... | 1. No mammographic evidence of malignancy. 2. Stable intradermal lesions in the superior right axilla, probably inclusion cysts.3. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient. BIRADS: 2 - ... |
Generate impression based on findings. | Lung adenocarcinoma. LUNGS AND PLEURA: Left upper lobe mass abutting the major fissure is 22 x 29 mm (series 7, image 27), previously 22 x 28 mm.Numerous bilateral micronodules consistent with metastases are similar to prior.Right middle lobe subsegmental atelectasis, unchanged.Large right pleural effusion, increased f... | Increased size of large right pleural effusion. The primary left upper lobe mass and metastatic lesions are stable. No new sites of disease. |
Generate impression based on findings. | Male; 57 years old. Presents with left knee and right shoulder pain. Knee: No acute fracture or dislocation. Mild degenerative changes are noted. Bony outgrowth projecting from the superior aspect of the medial femoral condyle is likely secondary to remote MCL injury. Shoulder: No acute fracture or dislocation. Moderat... | 1.High riding humeral head, which may represent underlying atrophy or tearing of rotator cuff muscles. MRI is recommended for further evaluation. 2.No acute abnormality identified on knee radiographs. |
Generate impression based on findings. | Female 37 years old Reason: Evaluate for left ankle fracture History: pain, edema lateral left ankle after tripping in a pothole yesterday. We have 3 views of the left ankle. There is mild soft tissue swelling along the lateral aspect of the ankle but we see no underlying fracture or malalignment. | Soft tissue swelling without underlying fracture. |
Generate impression based on findings. | Large cell neuroendocrine carcinoma. Status post resection CHEST:LUNGS AND PLEURA: Postsurgical changes including volume loss on the right with suture material adjacent to the medial margin and mediastinal contour. Overall appearance again suggests more subacute postsurgical fluid and hematoma adjacent and questionably... | Lymphadenopathy with post surgical changes within the right hemithorax with a questionable intrapulmonary nodular densities in the right lung base. Without prior images for comparison, determining the significance is limited. |
Generate impression based on findings. | Acute leukemia. CHEST:LUNGS AND PLEURA: Motion artifact degrades image quality. Peripheral subsegmental area of focal consolidation in the postero-basal right lower lobe. Smaller, approximately 1 cm peripheral airspace opacity slightly higher in the right lower lobe (4/42).No pleural fluid or pneumothorax. Mosaic atten... | 1. Mild diffuse lymphadenopathy throughout visualized chest and upper abdomen.2. Organomegaly involving the liver spleen and kidneys.3. Right lower lobe multifocal consolidation and small groundglass opacities may be infectious or due to leukemic cell infiltration of the parenchyma.4. Distal esophageal wall thickening ... |
Generate impression based on findings. | 68 years, Male. Reason: OGT placement verification History: ogt placement verification Nasogastric tube tip projects over the gastric body. Massive distention of colon measuring up to 9 cm. No pneumatosis. Note that the pelvis and portions of abdomen are excluded from the field-of-view. | Nasogastric tube tip projects over the gastric body. Worsening large bowel ileus versus distal obstruction. |
Generate impression based on findings. | 64-year-old female status post lumbar fusion. Posterior stabilization rods with screws entering the L4 and L5 pedicles/vertebral bodies are again noted. Disk spacer device and bone graft material is present between L4 and L5. Mild degenerative changes and disk space narrowing affect the remaining lumbar spine, most pro... | Postoperative changes status post lower lumbar fusion as described above. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are digital mammographic images (12/22/14) and ultrasound images of left axilla (1/19/15) performed at Advocate Illinois Masonic. DIGITAL MAMMOGRAPHIC IMAGES (12/22/14):The breast parenchyma is composed of scattered fibroglandular elements. A benign app... | Multiple enlarged left axillary lymph nodes. Per outside pathology report, the biopsy result was benign. Pathology slides should be reviewed at University of Chicago.BIRADS: 2 - Benign finding.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 71 years, Female, Reason: 71F with metastatic colon cancer History: surveillance. CHEST:LUNGS AND PLEURA: No focal consolidation or pleural effusion.No suspicious nodules or masses.MEDIASTINUM AND HILA: Prominent paratracheal node measures 1.6 x 1.0 Cm (3/24), previously 1.5 x 0.8 cm. Right chest port tip terminates at... | Grossly stable exam. |
Generate impression based on findings. | Soft tissue contrast is suboptimal despite contrast administration, limiting evaluation. Mild rightward lumbar curvature. Vertebral body heights are well-maintained without evidence of an acute fracture or traumatic subluxation. Osseous structures are diffusely sclerotic likely related to renal osteodystrophy. There a... | 1.No specific CT findings to suggest a focal fluid collection or abscess. Previously identified tiny questioned right psoas fluid collection does not demonstrate corresponding CT abnormality, although soft tissue contrast is limited despite intravenous contrast administration.2.Significant disk height loss at L4/5 and ... |
Generate impression based on findings. | Left upper lobe squamous cell carcinoma LUNGS AND PLEURA: Postsurgical changes and volume loss involving the left partial lobectomy. No suspicious new nodules or masses. No effusions. Mild mediastinal shift and architectural distortion.MEDIASTINUM AND HILA: Enlarged left thyroid lobe with a posterior and inferior nodul... | Interval resolution of the previously described left upper lobe mass, presumably postsurgical. No evidence of residual and or recurrent disease. |
Generate impression based on findings. | Male; 51 years old. Reason: EtOH abuse presenting with fever and back pain after falling at home. No acute fracture or malalignment. Vertebral body heights are preserved. No suspicious osseous lesions are identified. The bilateral sacroiliac joints are unremarkable. Small anterior osteophytes are noted at the L2/L3 dis... | No fracture or other acute findings to account for the patient's pain. |
Generate impression based on findings. | Breast cancer LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.No focal airspace consolidation. No pleural effusions. Small focal calcified pleural plaque along the posterior right lung base.MEDIASTINUM AND HILA: The heart is normal in size, without pericardial effusion. No visible coronary artery calcificat... | Marked left axillary and subpectoral lymphadenopathy compatible with known history of breast cancer. |
Generate impression based on findings. | Male 48 years old Reason: shoulder pain History: as above. Mild osteoarthritis affects the glenohumeral and acromioclavicular joints. The glenohumeral joint alignment is within normal limits. | Mild osteoarthritis. |
Generate impression based on findings. | 12-year-old male, evaluate for fracture/hip subluxationVIEW: Pelvis AP, Right and Left Femur Lateral view (3 view) 3/4/2015 Bilateral coxa valga are again noted. The femoral heads are well directed into normal acetabula. No evidence of fracture or dislocation. | Normal examination. |
Generate impression based on findings. | 78 years, Female. Reason: abdominal pain, eval for obstructive gas pattern, stool burden History: abdominal discomfort Residual enteric contrast within diverticula in the descending colon. Nonobstructive bowel gas pattern. Below average stool burden. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | There is scattered ethmoid sinus opacification. The other paranasal sinuses are clear. The nasal cavity is clear. The nasal septum is deviated to the left with an associated spur. The lamina papyracea and ethmoid roofs are intact. The carotid grooves and optic canals are covered by bone. The nasopharynx, facial soft t... | 1. Nonspecific scattered ethmoid sinus opacification. 2. Multiple dental caries. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 65 years, Male. Reason: eval for ileus History: ams Enteric feeding tube tip projects over the pyloric area. Surgical clips noted in the right quadrant. There is a paucity of bowel gas. Lower portion of the pelvis is excluded from the field-of-view. | Enteric feeding tube tip projects over the pyloric area. |
Generate impression based on findings. | The previously noted mottled sclerosis along the posterior left mandible is slightly less conspicuous, with further analysis confluent ossific density along the margins of the bone consistent with evolving periosteal reaction. The normal fat within the left mandibular foramen remains effaced. No soft tissue mass is id... | 1. Further expected evolution of periosteal reaction along the posterior left mandible, consistent with healing. Slight decreased conspicuity of mottled sclerosis of the left posterior mandible.2. Interval calcification of the left small submandibular lymph node, likely representing posttreatment changes. Stable calcif... |
Generate impression based on findings. | 65 years, Male. Reason: r/o toxic megacolon History: abd distension Enteric feeding tube tip projects over the fourth portion of the duodenum. Support devices are unchanged. Again seen are multiple surgical clips and probable bullet fragment projecting over the pelvis. Nonobstructive bowel gas pattern. Lower portion of... | Nonobstructive bowel gas pattern with normal caliber transverse colon. |
Generate impression based on findings. | 49 years old male. Reason: Evaluating for metastatic disease History: new diagnosis of lung cancer. RADIOPHARMACEUTICAL: 14.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 99 mg/dL. Today's CT portion grossly demonstrates mucosal thickening in the right maxillary sinus. There is a mass in the right upper l... | 1.Hypermetabolic tumor in the right upper lobe with nodal metastasis in the mediastinum including AP window, right lung hilum and right supraclavicular region.2.Multiple hepatic metastases and osseous metastasis in the spine and proximal femur.3.Bilateral adrenal nodules in with increased metabolic activity, suspicious... |
Generate impression based on findings. | T3N0 laryngeal squamous cell carcinoma completed 7/7 TFHX completed 6/21/2013. Excellent recovery, but now concern for recurrence with symptoms of right neck / throat pain and swelling that is getting worse. However, strobe testing in February 2015 revealed no evidence of recurrent malignancy of the right vocal cord. T... | Stable post-treatment findings in the neck without discernible evidence of measurable mass lesions or significant cervical lymphadenopathy. However, if recurrent tumor remains a concern, MRI or PET may be useful for further evaluation. |
Generate impression based on findings. | Evaluate for chronic PE. The comparison chest radiograph performed on 3/4/2015 demonstrates a focal opacity in the right lung base. No pleural effusion. The ventilation images show decreased ventilation bilaterally within the lung bases. There are multiple matched ventilation perfusion defects throughout the lungs bila... | Low probability scanned for a pulmonary embolus. |
Generate impression based on findings. | 58 years, Female. Reason: assess for obstipation History: 58 y.o. woman with celiac disease and constipation. History scoliosis surgery. Gas bloating, abd pain Above average stool burden is noted in the ascending and transverse colon without evidence of bowel obstruction. Posterior fusion hardware, S-shaped scoliosis a... | Nonobstructive bowel gas pattern with above average stool burden. |
Generate impression based on findings. | Male, 52 years old.Elevated BMI. Examination is limited by patient body habitus and motion artifact. No unexpected radiopaque foreign objects. Enteric feeding tube tip projects over the pyloric area. Surgical clips project over the right upper quadrant and right lower quadrant. Foley catheter is in place. Nonobstructiv... | No unexpected radiopaque foreign objects.Findings discussed with Dr. Roggin over the telephone at 3:00 p.m. on 3/4/2015 by Dr. McCann. |
Generate impression based on findings. | Female 68 years old Reason: s/p fall. Pain posterior lateral malleolus. Evaluate for fracture. History: Right ankle pain. There is soft tissue swelling along the lateral aspect of the ankle, but we see no underlying fracture or malalignment. Note is made of a small plantar calcaneal spur. | Soft tissue swelling without fracture. |
Generate impression based on findings. | Female 75 years old Reason: MCL re- eval History: mantle cel lymphoma CHEST:LUNGS AND PLEURA: New right upper lobe air space opacity which is likely inflammatory/infectious in etiology. No suspicious nodules or masses. No pleural effusion. MEDIASTINUM AND HILA: Improvement in the mild mediastinal and hilar lymphadenopa... | Interval improvement in the mildly prominent lymph nodes in the chest, abdomen, and pelvis. No new foci of lymph node enlargement. |
Generate impression based on findings. | 52-year-old male with history of colon cancer, evaluate for metastatic disease. CHEST:LUNGS AND PLEURA: Scattered nonspecific pulmonary micronodules are present. No suspicious nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: Small hiatal hernia. No hilar or mediastinal lymphadenopathy. CHEST WALL: Right-si... | 1.No specific evidence of metastatic disease.2.Moderate-severe hydronephrosis on the right, increased from prior.3.Cholelithiasis |
Generate impression based on findings. | 34 years, Female. Reason: stool burden History: abdominal pain Nonobstructive bowel gas pattern with moderate stool burden in the colon. | Nonobstructive bowel gas pattern with moderate stool burden in the colon. |
Generate impression based on findings. | Thoracic spine: There is no evidence of fracture. The vertebral column alignment is within normal limits. The vertebral body and disc space heights are preserved. There is no significant spinal canal stenosis. The paravertebral soft tissues are unremarkable. There is incompletely imaged pulmonary consolidation and med... | 1. No evidence of spine fracture or significant spinal canal stenosis.2. Pulmonary airspace opacities and lymphadenopathy. Please refer to the separate chest CT report for additional details.3. Partially-imaged retroperitoneal and mediastinal lymphadenopathy. Please refer to the separate chest CT report for additional ... |
Generate impression based on findings. | Female 54 years old Reason: ankle fx History: as above. We have 3 views of the left ankle which again show a plate and screws device affixing a fracture of the distal fibula in near anatomic alignment. We see no hardware complications. The fracture line is indistinct, suggesting healing and appearing similar to the pri... | Orthopedic fixation of healing tibial and fibular fractures. |
Generate impression based on findings. | 39-year-old female patient with infertility. Scout AP film of the pelvis was normal. Opacification of the uterine cavity revealed a normally oriented uterine cavity without mucosal irregularity or filling defects in the uterine cavity. Both tubes were freely opacified with free spillage on both sides into the pelvis, i... | Normal uterine cavity and patent fallopian tubes. |
Generate impression based on findings. | Small cell lung cancer with liver metastasis now with weakness nausea and vomiting ABDOMEN:LUNG BASES: Please see separate chest CT reportLIVER, BILIARY TRACT: Interval increase in size of bilateral hepatic metastases. Reference segment 4 lesion best seen on image 82 of series 3 now measures 5.1 x 4 cm; this is in comp... | Interval increase in size of bilobar hepatic metastases and interval increase in size of reference portacaval metastatic lymph node. |
Generate impression based on findings. | 33-year-old female patient with infertility. Scout AP film of the pelvis was normal. Opacification of the uterine cavity revealed a retroflexed uterine cavity without mucosal irregularity or filling defects in the uterine cavity. Only the left tube was freely opacified with free spillage into the pelvis, indicating tub... | Normal uterine cavity and patent left fallopian tube. There was no free spillage from the thin, nondilated right fallopian tube. |
Generate impression based on findings. | Postoperative changes are seen from previous right floor of mouth resection and right neck dissection. There is further decreased extent and confluence of enhancement along the right neck dissection bed, with areas of minimal 4-5 mm nodular enhancement is seen on 6/46 as well as other areas of scattered lacelike enhan... | Expected evolution of post treatment changes without evidence of discrete mass or cervical lymphadenopathy. |
Generate impression based on findings. | 69 years, Female. Reason: 2 months of diarrhea, weight loss History: see above Gaseous distention of the stomach. Nonobstructive bowel gas pattern. Cholecystectomy clips in the right upper quadrant. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | History of metastatic breast cancer on treatment. Compare to prior imaging, evaluate for response and extent of disease. Increased radiotracer uptake is again seen in the superior thoracic spine and within the soft tissues of the breasts appearing similar to the prior exam. The increased activity within the right anter... | Stable exam with no new osseous metastases. |
Generate impression based on findings. | 41 years, Female. Reason: evaluate for constipation, ? obstruction History: LLQ abdominal pain Right mediastinal silhouette is normal. Small bilateral pleural effusions. No pneumothorax. No focal pulmonary opacities.No pneumoperitoneum. Nonobstructive bowel gas pattern. Below-average stool burden. | Nonobstructive bowel gas pattern. Below-average stool burden. |
Generate impression based on findings. | Right apical mass; assess for malignancy 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: Right renal cystRETROPERI... | No acute, inflammatory, or neoplastic/malignant process within the abdomen or pelvis. |
Generate impression based on findings. | 16-year-old male with painVIEWS: Panorex view of the mandible (one view) 3/4/15 15:12 There is an oblique fracture of the posterior body of the left mandible extending to the unerupted molar. The paranasal sinuses are normal. | Left posterior mandibular body fracture extending to the unerupted molar. |
Generate impression based on findings. | Male 70 years old Reason: CT per living kidney donor protocol History: kidney donor Lack of oral contrast makes evaluation of bowel pathology suboptimal. Within these limitations, the following observations can be made.ABDOMEN: LUNG BASES: No significant abnormality noted LIVER, BILIARY TRACT: Subcentimeter hypodense s... | 1.Three separate right renal arteries are visualized. Conventional vasculature of the left kidney is present.2.Subcentimeter, nonobstructing stones in the right kidney. |
Generate impression based on findings. | 62-year-old male status post gastrostomy tube balloon integrity distruption for evaluation of G-tube placement Anteroposterior and lateral scout images demonstrated a nonobstructive bowel gas pattern with a gastrostomy tube tip projecting over the proximal gastric body. Injection of contrast demonstrates brisk opacific... | Gastrostomy tube without evidence of leak of misplacement. |
Generate impression based on findings. | 45 year old woman with history of right breast masses seen on prior mammogram. Three standard views of the right breast with CC and ML spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small mass... | Stable, benign masses in the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnosti... |
Generate impression based on findings. | 72-year-old male with pelvic mass seen on ultrasound. 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: Basilar groundglass opacities and interstitial thickening c... | 1.Fluid collection within the left inguinal canal which may represent a hematoma but is best considered indeterminate. 2.Prostatomegaly. 3.Cardiomegaly. Basilar pulmonary edema and small left pleural effusion, similar to 2011 exam. |
Generate impression based on findings. | Small cell lung cancer with liver metastases. Now with weakness, nausea/vomiting. Evaluate for worsening metastases. LUNGS AND PLEURA: Increased size of right perihilar heterogeneously enhancing tumor that occludes the upper lobe bronchus. It cannot be measured due to adjacent post-obstructive atelectasis. Moderate to ... | 1. Increased size of right upper lobe/perihilar tumor.2. Slight decreased size of reference mediastinal lymph nodes.3. New foci of pleural air in the right major fissure and along the right middle lobe; correlate for history of thoracentesis. If there is no such history of recent intervention, a bronchopleural fistula ... |
Generate impression based on findings. | History of chronic ear infection. Left: There is a globular soft tissue attenuation lesion that measures up to 6 mm in diameter along the inferior aspect of the retracted tympanic membrane with associated mild scalloping of the external auditory canal wall. There is also patchy opacification of the right mesotympanum a... | A globular soft tissue attenuation lesion that measures up to 6 mm in diameter along the inferior aspect of the retracted left tympanic membrane with associated mild scalloping of the external auditory canal wall may represent a cholesteatoma. Otherwise, partial left tympanomastoid opacification may represent sequela o... |
Generate impression based on findings. | Female 9 years old Reason: eval for fracture History: R arm painVIEWS: Right forearm AP and lateral right elbow AP lateral and oblique on 3/4/15 (3 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Dyspnea. Evaluate for pneumonia, atypical infection as etiology of COPD exacerbation. LUNGS AND PLEURA: Interval resolution of previously seen ground glass opacities and small right pleural effusion.Mucus plugging in right lower lobe segmental bronchi with postobstructive subsegmental atelectasis (series 6, image 68).C... | 1. Interval resolution of previously seen groundglass opacities and small right pleural effusion. Mediastinal/hilar lymphadenopathy has also resolved.2. Focal mucus plugging of right lower lobe segmental bronchi with post-obstructive subsegmental atelectasis. No evidence of pneumonia.3. Small amount of abdominal ascite... |
Generate impression based on findings. | 67 years, Male. Reason: increased drainage from NG, eval for evidence of ileus vs obstruction History: high NG output NG tube is coiled with tip projecting over the gastric fundus. Gas distended bowel in the left hemiabdomen with a relative paucity in the right. Note that the lower abdomen and pelvis is excluded from t... | NG tube is coiled with tip projecting over the gastric fundus. |
Generate impression based on findings. | Female 93 years old Reason: assess for fracture History: left hip pain s/p fall. We have 3 views of the left femur. Again seen are hardware or components of a left bipolar hemiarthroplasty device situated in near anatomic alignment without radiographic evidence of hardware complication. Ossification along the greater t... | Left hip hemiarthroplasty with ossification along the greater trochanter that is favored represent heterotopic bone related to the patient's prior surgery. However, if there is strong clinical concern for a fracture, CT may be considered. |
Generate impression based on findings. | Altered mental status, cough. Right apical mass concerning for malignancy. LUNGS AND PLEURA: Right apical scarring with coarse calcification and associated volume loss and traction bronchiectasis, likely the sequela of remote granulomatous infection such as TB.Mild left apical scarring.Calcified nodules consistent with... | 1. Right apical scarring with coarse calcification and volume loss/traction bronchiectasis, likely the sequelae of remote infection such as TB. No lung mass is identified.2. Left upper lobe 4 mm nodule, likely benign. In a high risk patient, this would be followed-up in 1 year to confirm stability.3. Severe upper lobe ... |
Generate impression based on findings. | Female 45 years old Reason: R shoulder pain History: as above. We have 4 views of the right shoulder. Minimal enthesopathic changes are seen along the greater tuberosity at the expected site of the rotator cuff insertion and are of questionable clinical significance. The shoulder otherwise appears normal for age. The g... | Minimal enthesopathic changes along the greater tuberosity, but otherwise normal-appearing shoulder. |
Generate impression based on findings. | Female 62 years old Reason: follow up History: follow up. We have 4 views of the left foot which again show two orthopedic screws affixing the first tarsometatarsal joint in near-anatomic alignment. There is also postoperative flattening of the medial aspect of the first metatarsal head. There is soft tissue swelling a... | Postoperative changes of bunion correction surgery as described above with possible small fracture fragment along the lateral aspect of the base of the first proximal phalanx. |
Generate impression based on findings. | Female 55 years old Reason: CERVICALGIA History: CERVICALGIA. Evaluation of the cervicothoracic junction on the lateral view is slightly limited due to overlying anatomy. Evaluation of the cervical spine on the AP view is limited due to overlying braids. There is severe degenerative disk disease at C6/C7 and there is m... | Degenerative disk disease of the cervical spine. |
Generate impression based on findings. | Female 48 years old Reason: follow up History: follow up. We have two views of the right tibia/fibula and 3 views of the right ankle, which show a plate and screw device affixing a comminuted fracture of the distal tibial diaphysis in near-anatomic alignment. We see no radiographic evidence of hardware complication. Th... | Orthopedic fixation of a distal tibial fracture and other findings as above. |
Generate impression based on findings. | Female, 72 years old, with large B-cell non-Hodgkin's lymphoma. An enhancing nodule within the right parotid gland has decreased in size, now measuring 8 x 7 mm (image 90 series 4), previously 17 x 17 mm.A nodule in the right submandibular space measures 11 x 6 mm (image 99 series 4), previously 19 x 9 mm. A nodule in ... | Response to therapy with decrease in size of numerous nodules and lymph nodes in the neck. |
Generate impression based on findings. | Status post cystectomy with ileal conduit with pelvic fluid collection status post percutaneous drainage. ABDOMEN:LUNG BASES: Small bilateral pleural effusionsLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No signif... | Interval removal of percutaneous drainage catheter and surgical drain from the pelvis with persistent loculated pelvic collection as described.Interval resolution of small bowel obstruction; small bowel ileus persists. |
Generate impression based on findings. | 17-year-old male with injury to right thumb, pain on movement.VIEWS: Right hand PA, right thumb PA and lateral (3 views) 3/4/2015 No soft tissue swelling or joint effusion. Normal alignment. No evidence of fracture or dislocation. | Normal examination. |
Generate impression based on findings. | Clinical hyperparathyroidism. Elevated Calcium 10.8 with PTH of 102. A large lesion is noted along the posterior aspect of the left thyroid gland which appears separate from the thyroid gland. On delayed washout this lesion persists and is suspicious for a parathyroid adenoma.The right thyroid lobe appears to measure 6... | Findings compatible with a left-sided parathyroid adenoma. |
Generate impression based on findings. | 62 year-old female with history of lung abscess and colitis, follow-up. Within the limits of a non IV contrast enhanced examination which limits the ability to evaluate solid parenchymal organs and vascular structures, the following observations can be made: CHEST:LUNGS AND PLEURA: Mild centrilobular emphysema with low... | 1.Findings again suggestive of aspiration bronchiolitis/infection. Previously described areas of subpleural consolidation with necrotic centers have decreased in size without evidence of abscess currently. There are, however, several new nodular and subpleural opacities. Atypical infection remains in the differential. ... |
Generate impression based on findings. | Male; 52 years old. Reason: Evaluate for osteomyelitis History: Swelling, pain, blistering, discoloration. Three views of the left foot show no acute fracture or dislocation. No specific radiographic evidence of osteomyelitis. Punctate radiodensity between the fourth and fifth toes seen on AP and oblique views is suspi... | Punctate radiopaque foreign body between the fourth and fifth toes. No specific radiographic evidence of osteomyelitis. |
Generate impression based on findings. | Evaluate hepatic vasculature, status post autotransplant for cholangiocarcinoma resection Suboptimal exam due to patient's body habitus and technique.LIVER/VASCULAR: Visualized left liver measures approximately 16.7 cm. Right liver area not well assessed. Patent left portal vein with normal directional flow, velocity a... | Visualized hepatic vasculature patent as above. |
Generate impression based on findings. | History of chronic ear infection. Left: There is a globular soft tissue attenuation lesion that measures up to 6 mm in diameter along the inferior aspect of the retracted tympanic membrane with associated mild scalloping of the external auditory canal wall. There is also patchy opacification of the right mesotympanum a... | A globular soft tissue attenuation lesion that measures up to 6 mm in diameter along the inferior aspect of the retracted left tympanic membrane with associated mild scalloping of the external auditory canal wall may represent a cholesteatoma. Otherwise, partial left tympanomastoid opacification may represent sequela o... |
Generate impression based on findings. | Two month old male with history of humerus fracture. Evaluate for intracranial hemorrhage. There is no evidence of 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. There is opacifica... | No evidence of acute intracranial hemorrhage. |
Generate impression based on findings. | Female; 47 years old. Reason: r/o fx History: pain and swelling after ankle rolled. Three views of the left foot demonstrate a nondisplaced extra-articular fracture at the base of the fifth metatarsal.Three views of the left ankle demonstrate lateral soft tissue swelling and the previously described fracture at the bas... | Nondisplaced fracture at the base of the fifth metatarsal. |
Generate impression based on findings. | Status post insertion of LP shunt for pseudotumor cerebri, POD#2, now with speech changes. There are postoperative findings related to craniofacial reconstructive surgery with dysmorphic features. There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. ... | No evidence of acute intracranial hemorrhage, mass, or cerebral edema. Otherwise stable postoperative findings related to craniofacial reconstructive surgery. |
Generate impression based on findings. | Female; 39 years old. Reason: Right ankle pain, evaluate for fracture. Mild soft tissue swelling is noted about the lateral ankle. However, no acute fracture or dislocation is seen. The ankle mortise is congruent. | Mild soft tissue swelling without fracture evident. |
Generate impression based on findings. | Female; 54 years old. Reason: Left wrist pain Three views of the left wrist demonstrate no acute fracture or dislocation. Alignment is anatomic. No significant degenerative changes are noted. | Normal examination. |
Generate impression based on findings. | Female 47 years old with chronic back pain status post breast cancer. Physiologic activity is present throughout the skeleton, with no suspicious foci of increased activity to suggest metastases. | No evidence of bone metastases. |
Generate impression based on findings. | Posterior mediastinal mass and perigastric mass or suspicious for paraganglioma or possible Gist. RADIOPHARMACEUTICAL: 15.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 99 mg/dL. Today's CT portion grossly demonstrates a mass in the left posterior mediastinum and an additional exophytic mass along the fun... | Left posterior mediastinal and left upper quadrant masses with minimal FDG activity. Direct sampling or contrasted MRI exam may provide further information. |
Generate impression based on findings. | Postoperative changes from previous suboccipital craniotomy are again noted, with associated susceptibility artifact. The resection cavity within the right inferior cerebellar vermis is stable, with minimal persistent marginal FLAIR hyperintensity which may in part be artifactual in etiology. There is also persistent ... | Continued stable postoperative changes within the posterior fossa without evidence of recurrent mass. |
Generate impression based on findings. | Male 85 years old Reason: eval for fracture, dislocation History: knee pain, fall. Four views of the right knee show no acute fracture or dislocation. There is, perhaps, a small joint effusion. Mild osteoarthritis with tricompartmental osteophytes affects the knee joint. | Osteoarthritis with no fracture evident. |
Generate impression based on findings. | Male 21 years old Reason: suspected fb, glass History: puncture wounds. There is no acute fracture or dislocation. Alignment is within normal limits. No radiopaque foreign body is evident. | No underlying fracture or dislocation. No radiopaque foreign body is evident. |
Generate impression based on findings. | There is mild nonspecific prominence of the lateral ventricles. The ventricles and sulci are otherwise within normal limits. The cisterns remain patent. There is no midline shift or mass effect. There are no areas of abnormal signal or pathological enhancement. There is no diffusion abnormality. No extra-axial fluid c... | 1. Unremarkable contrast enhanced MRI of brain except for mild-moderate crowding at the foramen magnum likely relating to mild platybasia. No MR imaging findings to support a Chiari 1 malformation at this time. Please correlate clinically.2. Scattered prominent sinus inflammatory changes including small air-fluid level... |
Generate impression based on findings. | Male 27 years old mandible fracture History: Again seen are maxillary-mandibular fixation wires that have been broken bilaterally. A sideplate device with multiple screws fixes a nondisplaced fracture of the mandibular symphysis, the underlying fracture line is not evident suggestive of interval healing. There has been... | Healed mandibular fracture as described above. |
Generate impression based on findings. | 20 year-old male with testicular mass with plans for orchiectomy, staging exam. 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 notedKIDN... | 1.Prominent para-aortic lymph nodes suspicious for metastatic disease. |
Generate impression based on findings. | Acute tachycardia and shortness of breath. The comparison chest radiograph performed on 3/4/2015 demonstrates a left lung base consolidation consistent with pneumonia. No definite pleural effusion.The ventilation images show decreased ventilation in the left lung base which corresponds to the patient's left lung base p... | High probability scan for pulmonary emboli. Findings were text paged to the primary service represented by Jessica Waite Marin, P.A. (pager # 6839) at the time of this dictation. |
Generate impression based on findings. | The ventricles and sulci are prominent, consistent with moderate age-related volume loss. There is no midline shift or mass effect. There is no intracranial hemorrhage. There are scattered punctate and confluent areas of abnormal low density in the periventricular and subcortical white matter, consistent with mild age... | No acute intracranial hemorrhage. Mild age-indeterminate small vessel ischemic changes. If there remains clinical concern for an acute ischemic event, MRI of the brain is recommended. |
Generate impression based on findings. | Images are degraded by patient motion and other artifact. Sagittal T1 postcontrast images are somewhat limited due to bandlike susceptibility artifact obscuring the upper cervical spinal canal and spanning across the C3-C4 level. Postoperative changes are seen from interval C2 through T2 laminoplasty. There is redemon... | 1. Interval debulking of extensive left paraspinal lobulated enhancing mass with transforaminal extension from C2 through T2 levels into left lateral epidural space. Given extensive involvement, differential diagnosis includes primarily sarcoma, nerve sheath tumor, less likely lymphoma. Abnormal signal and enhancement ... |
Generate impression based on findings. | 85-year-old man with history of HTN, dementia, and hypothyroidism, who presented to ED (3/2/15) with fever, chest pain found to be in A-fib with RVRCPT: 75571 Calcium Score:LM: 0LAD: 57.4LCx: 0RCA: 11.3Total: 69, This represents the 34th percentile for this patients age and gender.Coronary anatomy: LM: The left main co... | 1.Total Calcium score was 69; 34th percentile for age and gender.2. Mild dilation of the Right ventricle, right atrium, and main pulmonary artery.3. Small pericardial effusion.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and upper abdomen will be inte... |
Generate impression based on findings. | 34 year old with history of hypertension and borderline cholesterol presenting to with atypical chest pain. CPT Code: 75574 Coronary arteries: No coronary calcification is noted. LM: The left main coronary artery arises normally from the left sinus of Valsalva and bifurcates into the left anterior descending and left c... | 1. There are no significant coronary artery stenoses present. 2. Variant right coronary artery anatomy. 3. No coronary artery calcification.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and upper abdomen will be interpreted by the attending chest radio... |
Generate impression based on findings. | 53 year old with history of hypertension and tobacco use presenting to emergency department with new onset chest pain. CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of Valsalva and bifurcates into the left anterior descending and left circumflex coronary arteri... | 1. There are no significant coronary artery stenoses present. 2. Minimal coronary atherosclerosis. 3. Mild left ventricular hypertrophy.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and upper abdomen will be interpreted by the attending chest radiolog... |
Generate impression based on findings. | prostate cancer work up, lower extremity weakness No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhag... | No evidence of acute ischemic or hemorrhagic lesion.Right eyeball, phthisis bulbi.If clinically indicated, brain MRI with and without contrast can be considered for metastasis work up. |
Generate impression based on findings. | Clinical question: Rule out subarachnoid hemorrhage in patient with history of ruptured aneurysm. Signs and symptoms: CVA headache. Nonenhanced head CT:There is no detectable acute intracranial process. CT however is insensitive for early detection of an acute nonhemorrhagic ischemic stroke.Large cluster of high densit... | 1.No acute intracranial process. CT is insensitive for early detection of acute nonhemorrhagic strokes.2.High density it regularly shaped material along the medial aspect of the left temporal lobe consistent with embolic agents.3.Low attenuation of the surrounding parenchyma surrounding the embolic agents may be slight... |
Generate impression based on findings. | supratherapeutic INR No evidence of acute ischemic or hemorrhagic lesion.Multifocal patchy low attenuations on especially periventricular white matter and centrum semiovale indicate non specific age indeterminate ischemic lesions.However, if clinically indicated, brain MRI can be considered for more precise evaluation ... | No evidence of acute ischemic or hemorrhagic lesion.Non specific small vessel disease.Brain MRI can be considered if clinically indicated |
Generate impression based on findings. | Bilateral hand weakness starting during chemotheraphy, colon cancer patient No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid ... | No evidence of acute ischemic or hemorrhagic lesion.If clinically indicated, brain MRI with and without contrast can be considered for metastasis work up. |
Generate impression based on findings. | Clinical question: Acute minimally hemorrhagic ischemic stroke on MRI. Signs and symptoms: Word finding difficulties. Nonenhanced head CT:No evidence of change in size or density of a small left frontal MCA territory subacute ischemic stroke.No evidence of any new finding since prior study. Stable normal size of ventri... | 1.Stable small nonhemorrhagic left frontal MCA territory is in the stroke.2.No detectable acute or new findings since prior study. |
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