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Generate impression based on findings. | right distal ICA aneurysm rupture which was coiled, IVH and ICH with bifrontal EVD tube insertion, follow up Re-demonstration of SAH, IVH, ICH and ventriculomegaly, no change of hemorrhage extent as well as the degree of ventricular dilatation.Specifically, bilateral frontal lobe ICH (right on the EVD track and left fr... | Stable bifrontal ICH since prior exam.No significant interval change of the extent of SAH, IVH and ICH as well as ventriculomegaly since prior exam. |
Generate impression based on findings. | Clinical question: Evaluate for bleed. Signs and symptoms: Comatos Nonenhanced head CT:Examination demonstrate near complete effacement of gray -- white matter differentiation. Considering provided clinical information this finding is highly suspected for diffuse cerebral edema. In addition there is a focal region of p... | 1.Effacement of gray -- white matter differentiation suspicious for cerebral edema considering provided clinical data.2.Small focus of low-attenuation involving the left frontal cortex and subcortical white matter suspicious for a small focus of acute to early subacute ischemic stroke.3.Normal size of ventricular syste... |
Generate impression based on findings. | Clinical question: Evaluate for intracranial lesion. Right temporal edema on outside hospital. Signs and symptoms: Decreased mentation. Nonenhanced head CT:Examination demonstrates a large focus of low involving the anterior and mid temporal operculum of right frontal lobe. There is resultant mass effect and partial ef... | 1.Late acute to early subacute right MCA frontal and temporal lobe nonhemorrhagic ischemic stroke with regional mass-effect. Follow-up with MRI examination is recommended.2.Mild age indeterminate small vessel ischemic strokes.3.Small right cerebellar chronic ischemic stroke.4.Normal size of ventricular system and with ... |
Generate impression based on findings. | 16-year-old male, punched someone, positive pain. Evaluate for fracture.VIEWS: Left hand PA, oblique, lateral (3 views) 3/4/2015 Transverse fracture along the proximal diaphysis of the first metacarpal bone which slight medial angulation. There is associated periosteal reaction and callus formation consistent with heal... | Healing transverse fracture of the proximal diaphysis of the first metacarpal bone with slight medial angulation. |
Generate impression based on findings. | follow up tumor resection. There is evidence of left fronto temporal craniotomy as well as air densities, fluid collections and blood products on the left sylvian fissure. The blood product appears to be layered with operation site fluid with evidence of adjacent brain parenchymal swelling, edema or deformity indicatin... | Postop status of the left sylvian fissure area, no unusual finding. |
Generate impression based on findings. | 9 year old female with desaturation, decreased breath sounds on the left. Evaluate for pneumonia.VIEW: Chest AP (one view) 3/4/2015 17:59 Right central venous catheter tip in the right atrium. Four sternotomy wires appear intact.Cardiothymic silhouette is normal. Low lung volumes. No focal pulmonary opacities. No pleur... | No evidence of pneumonia. |
Generate impression based on findings. | 14-year-old female with pain. Evaluate for constipation.VIEW: Abdomen AP (one view) 3/4/2015 Average stool burden. Nonobstructive bowel gas pattern. | Average stool burden. |
Generate impression based on findings. | 53 years, Female, Reason: SBO History: diffuse abdominal pain. ABDOMEN:LUNG BASES: Basilar dependent atelectasis.LIVER, BILIARY TRACT: Scattered granulomas. Hepatic hypodensity formation are too small to characterize.SPLEEN: Splenic granulomas.PANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abn... | 1.No evidence of small bowel obstruction.2.Small hiatal hernia. |
Generate impression based on findings. | 10-week-old male with left arm fracture. Evaluate for fracture, nonaccidental trauma.EXAMINATION: Skull AP/lateral, cervical spine AP/lateral, thoracolumbar spine AP/lateral, right humerus AP, right forearm AP, left forearm AP, right hand PA, left hand PA, chest AP, right ribs AP, left ribs AP, right femur AP, left fem... | Multiple healing fractures along the left posterior 9th, 10th, and 11th ribs as well as right posterior 9th and 10th ribs. Question of a bucket handle fracture of the distal right humerus. Periosteal reaction along the left tibia. Correlation with clinical history is recommended, as constellation of findings can be see... |
Generate impression based on findings. | 86-year-old female with history of abdominal aortic aneurysm dissection with abrupt onset of stabbing back pain. CHEST:LUNGS AND PLEURA: Severe emphysema. Right upper lobe masslike opacity (series 14, image 24) measures 2.2 x 3.6 cm, unchanged from 2/28/2015 and remains suspicious for neoplasm. Right middle lobe periph... | 1.Upper abdominal aortic aneurysm similar to prior. No acute dissection.2.Severe diffuse atherosclerotic disease including significant stenosis at the origin of the celiac trunk, right renal artery, and SMA, similar to prior. Left renal artery not visualized, similar to prior. Focal dissection of the distal abdominal a... |
Generate impression based on findings. | 77 years, Female. Reason: confirm NG tube placement History: SBO Enteric feeding tube with tip at the gastric fundus and sidehole immediately proximal to the gastroesophageal junction. Persistent dilated small bowel in midabdomen compatible with small bowel obstruction. Right lung opacities appear unchanged compared to... | Enteric feeding tube with tip at the gastric fundus and sidehole immediately proximal to the gastroesophageal junction. Findings compatible with persistent small bowel obstruction. Please see subsequent CT abdomen and pelvis for further details. |
Generate impression based on findings. | Female 60 years old Reason: 60 F with GI bleeding with 4 gram Hgb drop, negative EGD/colonoscopy, assess small bowel for mass or lesion causing bleeding History: GI bleeding. History of renal cell cancer. ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Hepatic steatosis. No focal hepatic mass... | 1.No evidence of a small bowel mass or gastrointestinal hemorrhage. 2.Bilateral renal hypodense lesions most likely represent simple cysts, many of which are too small to characterize. |
Generate impression based on findings. | Male 12 years old Reason: ? fx, dislocation History: painVIEWS: Right hand AP, lateral and oblique 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. | 78 years, Male. Reason: assess GJ tube site History: intolerance to feeds Gastrojejunostomy tube balloon projects over the gastric body with jejunostomy tubing coiled in the stomach. Gaseous distended large and small bowel suggestive of ileus. | Gastrojejunostomy tube balloon projects over the gastric body with jejunostomy tubing coiled in the stomach. Ileus type bowel gas pattern. |
Generate impression based on findings. | 61-year-old male with abdominal pain and peritonitis, assess for incarcerated hernia. ABDOMEN:LUNG BASES: Mild basilar atelectasis. Small hiatal hernia.LIVER, BILIARY TRACT: Subcentimeter nonspecific hepatic hypodensities likely benign and unchanged.SPLEEN: No significant abnormality notedPANCREAS: No significant abnor... | 1.Trace right hydronephrosis, improved from prior. Persistent diminished right nephrogram and mildly dilated right ureter similar to prior. 2.Fat containing ventral hernia with inflammatory and postsurgical changes in the adjacent fat. Hernia does not contain bowel. 3.No bowel obstruction. |
Generate impression based on findings. | Female 15 years old Reason: eval for appy vs colitis History: abd pain, 3wks ABDOMEN:LUNG BASES: No evidence of focal opacities, effusions or pneumothorax. No pericardial effusion.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRE... | Normal examination. Specifically no evidence of colitis or appendicitis as clinically questioning |
Generate impression based on findings. | Reason: r/o PE History: SOB and chest pain, hx of PE, missed multiple doses of lovenox PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber.LUNGS AND PLEURA: Mild centrilobular emphysema.No suspicious pulmonary nodules or masses. Moderate dependent atelectasis. Mild basi... | No evidence of pulmonary embolism or other acute abnormality.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | 64 years, Female. Reason: s/p NGT adjustment History: s/p NGT adjustment Enteric feeding tube tip projects over the pyloric area. Dilated loops of small bowel are not significantly changed compared to prior examination and are compatible with small bowel obstruction. Bilateral nephroureterostomy stent again noted. Skin... | Enteric feeding tube tip projects over the pyloric area. Persistent small bowel obstruction. |
Generate impression based on findings. | Clinical question: Evaluate pneumocephalus is status, check for acute changes, status post tumor resection. Signs and symptoms: Drowsy. Nonenhanced head CT:There is normal evidence of an acute new finding since prior study.Large right anterior frontal surgical cavity containing small amount of air and acute blood produ... | 1.No evidence of any acute or new finding since prior exam. 2.Stable extensive postoperative changes of right frontal tumor resection and including a stable pneumocephalus.3.Stable size of ventricular system and with maintained midline. |
Generate impression based on findings. | Female 15 years old Reason: r/o constipation, stool burden History: abdominal pain epigastr and LLQVIEWS: Abdomen AP supine and upright 3/4/15 (two views) Normal abdominal gas pattern. No evidence of free air or obstruction. | Normal examination. |
Generate impression based on findings. | 77-year-old female with known small bowel obstruction, evaluate for lymphadenopathy, PTLD, or adhesive disease. Study somewhat limited by reduced intravenous contrast dose. CHEST:LUNGS AND PLEURA: Right basilar atelectasis/consolidation suspicious for infection. Small right pleural effusion.MEDIASTINUM AND HILA: Modera... | 1.High-grade incomplete small bowel obstruction with transition point in the right lower quadrant thought to be related to adhesive disease. No specific evidence of PTLD such as lymphadenopathy or intussusception.2.Right basilar atelectasis/consolidation suspicious for infection. Small right pleural effusion.3.End stag... |
Generate impression based on findings. | 75 years, Male, Reason: evaluate for primary malignancy, question of intracranial lesion, h/o AICD, cholecystectomy, L CVA CHEST:LUNGS AND PLEURA: Right lower lobe consolidation and small left lower lobe consolidation. Scattered calcified and noncalcified micronodules are nonspecific. No suspicious mass.MEDIASTINUM AND... | 1.No CT evidence of neoplasm in the visualized chest, abdomen or pelvis.2.Bibasilar consolidations, right greater than left, possibly from aspiration. |
Generate impression based on findings. | Female 5 years old Reason: eval lung fields History: first time seizure concern for aspirationVIEW: Chest AP (one view) 3/5/15 0 17 hours ET tube terminates below the thoracic inlet. Cardiac silhouette size is normal. Left retrocardiac streaky opacities, likely subsegmental atelectasis. No effusions or pneumothorax | Subsegmental atelectasis of the left lower lobe. |
Generate impression based on findings. | 61-year-old female with anemia, evaluate for retroperitoneal bleed. 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: Moderate hiatal hernia.LIVER, BILIARY TRACT: ... | 1.New large pelvic multiloculated collection compatible with hematoma. Lack of intravenous contrast and extensive metallic streak artifact limits evaluation.2.Right femoral catheter with tip in the intrahepatic IVC.3.End stage native kidneys. Right iliac fossa renal transplant. Findings discussed by the resident with n... |
Generate impression based on findings. | 53 years, Female. Reason: SBO History: abd distension and diffuse abd pain Suture material projects over the left upper quadrant and surgical clips project over the left hemiabdomen. Prominent loops of jejunum noted in the left hemiabdomen, however, there is air noted in the large bowel. | Prominent loops of jejunum and postsurgical changes in the abdomen may represent early/partial obstruction versus localized ileus. Please see subsequent CT abdomen and pelvis for further details. |
Generate impression based on findings. | Female 64 years old Reason: recent R stent change 1.5wks prior History: diffuse abd pain Limited exam secondary to lack of intravenous and oral contrast. Lack of intravenous contrast makes evaluation of vascular and solid organ pathology suboptimal. Lack of oral contrast makes evaluation of bowel pathology suboptimal. ... | 1.Limited exam secondary to lack of intravenous contrast making evaluation of vascular and solid organ pathology suboptimal. Within these limitations, no evidence of bowel obstruction or intraperitoneal free air. No loculated fluid collections are visualized.2.Right nephroureteral stent is in the expected location with... |
Generate impression based on findings. | 28-year-old female with recent cesarean section (post op day 5) now with fever despite antibiotics. Evaluation of the lung bases and upper abdomen limited by motion.ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Layering material in the gallbladder compatible with cholelithiasis. No adjacent ... | 1.Postsurgical changes of recent cesarean section.2.Foci gas within the anterior uterine wall in the expected distribution of the cesarian section incision. Given that the procedure was only 5 days ago, this is nonspecific but raises the question of dehiscence. Recommend baseline ultrasound exam.3.Foci of gas within th... |
Generate impression based on findings. | 59 years, Male. Reason: ileus perforation History: obese male admitted for management of Acute on chronic chf exacerbation w/ 7 days of constipation Nonobstructive bowel gas pattern. Average stool burden in the colon. AICD leads are partially visualized. Streaky opacities in the right lung base may are present atelecta... | Nonobstructive bowel gas pattern with average stool burden. If there is continued clinical concern for pneumoperitoneum an upright chest radiograph should be obtained. |
Generate impression based on findings. | 7-year-old male with intermittent hip painVIEWS: Chest AP/lateral (two views), right hip, AP and frog leg (2 views) 3/4/15 16:08 Chest: The cardiothymic silhouette is normal. Bronchial wall thickening without focal pulmonary opacity or pleural effusionRight hip: The femoral head is well directed with respect to the nor... | Bronchiolitis or reactive airway disease. No hip subluxation. |
Generate impression based on findings. | COPD, worsening of SOB/DOE. Possible right-sided larynx mass. LUNGS AND PLEURA: Mild centrilobular emphysema.Mild diffuse bronchial wall thickening. Interval resolution of mild lower lobe bronchiectasis and scattered mucus impaction.8 x 12 mm solid nodule in the right middle lobe (series 12, image 56), previously 8 x 1... | Unchanged right middle lobe nodule, likely benign given its stability from 3/2014; one additional follow-up in 1 year is recommended to confirm its benignity. |
Generate impression based on findings. | 10-year-old female with lateral tendernessVIEW: Right ankle, AP, oblique, lateral (3 views) 3/4/15 17:04 Alignment is anatomic. Mild lateral soft tissue swelling. No joint effusion. No fracture is evident. | Normal examination. |
Generate impression based on findings. | Female 52 years old Reason: recent hernia repair 2/19 now with drainage and subjective fevers History: abd pain, wound dehiscence ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedAD... | 1.Extensive anterior abdominal soft tissue induration, gas, and fluid along the midline incision with dehiscence inferiorly consistent with incisional soft tissue infection. 2.Intraperitoneal fluid accumulation adjacent to the transverse colon and small bowel. 3.No evidence of extraluminal contrast, however, given the ... |
Generate impression based on findings. | Fall, alcohol use No intracranial hemorrhage is identified. There is ovoid hypoattenuation involving the right putamen favored to represent a dilated perivascular space. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collec... | 1. No evidence of intracranial hemorrhage or skull fracture.2. No orbital fracture. |
Generate impression based on findings. | Female 42 years old Reason: eval obstruction History: dysphagia. There is no prevertebral soft tissue swelling. The airway is widely patent. Mild arthritic changes affect the cervical spine with disk space narrowing at the C4/C5 and C5/C6 and small posterior vertebral body osteophytes seen at C5/C6. | Patent airway; no radiographic evidence of obstruction. |
Generate impression based on findings. | 15-year-old male, injury during basketballVIEWS: Right hand PA, lateral, and oblique (3 views), right wrist PA, lateral, and oblique (3 views), right forearm AP and lateral (2 views) 3/5/15 7:41 Hand and wrist: Alignment is anatomic. No acute fracture or wrist joint effusion.Forearm: Alignment is anatomic. No joint eff... | No fracture or malalignment. |
Generate impression based on findings. | 15 year-old female with history of anuria, left CVA tenderness. Rule out urinary obstruction. Rule out unilateral right vein thrombosis. Spectral and Doppler evaluation of the inflow and outflow renal vasculature was performedBLADDER Wall Thickness: Normal Contents: Distended and normal. Distal Ureter -- SFU Grade** ... | No evidence of hydronephrosis. No evidence of renal artery or vein occlusion. The kidneys are small in size for age.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all t... |
Generate impression based on findings. | Male 53 years old Reason: fx? History: pain. There is no acute fracture or dislocation. Mild degenerative arthritic changes affect the wrist. | No fracture or dislocation. |
Generate impression based on findings. | Male 11 years old Reason: evaluate for consolidation/collapse History: respiratory distressVIEW: Chest AP (one view) 3/5/15 at 525 hours. VP shunt catheter is noted. A gastrostomy tube is present. Cardiac silhouette size is normal. Left diaphragmatic elevation, E. more likely due to on expiratory film. Streaky subsegme... | Subsegmental atelectasis of the left lower lobe.Interval gastrostomy tube placement |
Generate impression based on findings. | 5-month-old male with emesis, evaluate abdominal gas patternVIEW: Abdomen AP (one view) 3/4/15 17:37 NG tube tip and side-port in the stomach. Gaseous distention of the bowel without bowel wall pneumatosis, portal venous gas or free intraperitoneal air. No evidence of obstruction. | Mild diffuse gaseous distention of the bowel without evidence of obstruction. |
Generate impression based on findings. | Male 18 years old Reason: fx? History: crush injury. There is a nondisplaced comminuted fracture of the second proximal phalanx, with minimal surrounding soft tissue swelling. | Fracture of the second proximal phalanx as described above. |
Generate impression based on findings. | Female 63 years old Reason: fx? History: pain to lateral malleolus and mid shin. There is no acute fracture or dislocation. Degenerative arthritic changes affect the knee. Vascular calcifications are noted in the distal soft tissues. | No acute fracture or dislocation seen. Degenerative arthritic changes of the knee. |
Generate impression based on findings. | Female 28 years old Reason: fracture abnormality History: lateral hip pain. Two views of the left hip show no acute fracture or dislocation. Alignment of the acetabular joints within normal limits.Single AP chest pelvis and shows no acute fracture or dislocation. | Unremarkable left hip joint without fracture or dislocation. |
Generate impression based on findings. | Female 53 years old Reason: r/o fx History: pain. There is no joint effusion. There is no acute fracture or dislocation evident. | No acute fracture or dislocation is evident. |
Generate impression based on findings. | Female 65 years old Reason: RLE wound History: fever, ecchymosis. Three views of the right foot show diffuse soft tissue swelling. The bones appear diffusely demineralized. Large soft tissue defects are seen along the medial aspect of the ankle. Two plates and screws device affixes the distal tibia medially in near ana... | Deep extensive soft tissue defect compatible with patient's nonhealing ulcer, and osteomyelitis cannot be excluded. If additional imaging is clinically warranted, an MRI is recommended. |
Generate impression based on findings. | Male 21 years old Reason: r/o fx History: pain s/p punching wall. There is no acute fracture or dislocation. The right hand appears normal. | Normal-appearing right hand without fracture or dislocation. |
Generate impression based on findings. | Male 1 day old Reason: new admission History: INITIAL XR - increasing respiratory distress; increasing O2 requirementVIEW: Abdomen chest AP (two views) 3/5/15 ET tube terminates below the thoracic inlet. NG tube tip is at the stomach. Esophageal temperature probe terminates at GE junction. UVC is coiled towards itself ... | Misplaced esophageal temperature probe and UVC.Question of small left-sided medial pneumothorax. |
Generate impression based on findings. | Five day old male, evaluate for interval changeVIEW: Chest AP (one view) 3/5/15 4:29 ETT just above carina. Enteric tube tip and side-port in the stomach. UVC tip in the right atrium. Right chest tube tip directed superiorly and across the midline. The cardiothymic silhouette is normal.Small residual right pneumothorax... | Small residual pneumothorax. Unchanged pulmonary opacities. |
Generate impression based on findings. | Reason: tachycardia, SOB, hx of multiple DVTs, new R heart failure on TTE, eval for PE History: tachycardia, SOB, R heart failure on TTE PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber.LUNGS AND PLEURA: New right pleural effusion, with associated near complete atele... | 1. No evidence of pulmonary embolism.2. New large right and small left pleural effusions, with significant atelectasis of the right lung. Scattered ground glass and consolidation throughout the left upper and lower lobes is nonspecific but compatible with edema.3. Left lower lobe nodule is mildly increased from 10/2013... |
Generate impression based on findings. | Five day old male, assess pneumothoraxVIEW: Chest AP (one view) 3/4/15 20:25 Interval placement of right chest tube with tip directed apically. ETT is above the carina. Enteric tube side port is at the EG junction. UVC tip in the right atrium. The cardiothymic silhouette is normal.Hazy bilateral pulmonary opacities are... | Chest tube placement with small residual pneumothorax. |
Generate impression based on findings. | Male 78 years old Reason: obstruction? History: dilated small bowel loops, gas in large intestine with stool ABDOMEN:LUNG BASES: Interval worsening of diffuse bronchial wall thickening and multifocal areas of ground glass opacity with superimposed consolidation in the left lower lobe. Consistent with progressing aspira... | 1.Interval worsening of diffuse aspiration pneumonitis and superimposed focal infection. 2.Gastrojejunostomy tube tip is no longer in the jejunum. The tube is now coiled in the gastric fundus with tip in the stomach. 3.Fluid-filled loops of small bowel without evidence of obstruction. Mild ileus may be present. |
Generate impression based on findings. | One day old male, evaluate intubationVIEW: Chest AP (one view) 3/4/15 19:12 ETT is above the thoracic inlet. NG tube tip in the gastric antrum. UAC tip at T6. UVC likely in the ductus venosus or hepatic vein.Cardiothymic silhouette is normal. No focal pulmonary opacities or pleural effusions. No pneumothorax. | ETT tip above the thoracic inlet. |
Generate impression based on findings. | Male 1 day old Reason: where is UVC. New line placement History: replace UVC lines , encephalopathy.VIEW: Chest and abdomen AP (two views) 3/5/15 at 459 hours ET tube and NG tube are unchanged. Esophageal temperature probe tip is at the mid esophagus. UVC terminates at the SVC. UAC tip is at T8.Cardiac silhouette size ... | Misplaced UVC.Interval repositioning of esophageal temperature probe and UVC as described.Persistent small left-sided medial pneumothorax. |
Generate impression based on findings. | Possible seizure, evaluate for hemorrhage Examination is motion degraded. No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evi... | Examination is motion degraded. There is no evidence of intracranial hemorrhage or intracranial mass effect. If there is continued suspicion for a structural etiology for seizure, MRI may be helpful. |
Generate impression based on findings. | 5-year-old male with cough and fever, history of neuroblastomaVIEW: Chest AP (one view) 3/4/15 19:19 Left central venous catheter tip at the cavoatrial junction. Right upper quadrant surgical clips are again noted. The cardiothymic silhouette is normal. No focal opacities or pleural effusions. | No pneumonia. |
Generate impression based on findings. | Male 18 years old Reason: evaluate for pneumoperitoneum History: abdominal distension.VIEW: Abdomen AP (one view) 3/5/15 at 517 hours. Left lung base atelectasis and central line again noted. Gastrostomy tube and left acetabular osteotomy K wires are present.Interval decreasing in the number of distended bowel loops wi... | Interval decreasing number of distended bowel loops. |
Generate impression based on findings. | Male 70 years old Reason: EUS/ERCP showed mass at ampulla of pancreas: pancreas protocol CT required History: Painless jaundice ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Definitive mass in the common bile duct is not visualized. There is no arterial enhancement. There is a nonspecific, c... | 1.Enhancing periampullary mass is not definitively visualized. There is a nonspecific, circumferential hypodensity in the periampullary common bile duct which may represent the ampullary mass seen on ERCP.2.Nonspecific hypodense lesions within the liver are too small to characterize. Continued to follow with subsequent... |
Generate impression based on findings. | Female 76 years old Reason: 76 yo female with anterior knee pain. Eval for OA. Please shoot weight bearing films. History: left ant knee There is moderate to severe medial compartment joint space loss with near bone-on-bone apposition. There are tricompartmental osteophytes, worst in the medial compartment.There is a t... | Moderate to severe left knee medial compartment osteoarthritis. |
Generate impression based on findings. | Female 49 years old Reason: Evaluate for compression fracture History: as above Thoracic spine: Thoracic vertebral bodies normal in height and alignment. There is mild to space narrowing in the midthoracic spine. No acute fracture or malalignment.Heart size is enlarged. There is a left pulmonary opacity and pleural eff... | No radiographic evidence of compression fracture. |
Generate impression based on findings. | Female 42 years old Reason: right index finger pain at Prox phalanx History: as above There is mild interphalangeal joint space narrowing. No acute fracture or malalignment. Mild osteoarthritic changes affects the metacarpophalangeal jointNo radiopaque foreign body. | Osteoarthritis without acute fracture or malalignment. |
Generate impression based on findings. | Male 58 years old; Reason: Eval interval change, peri-pancreatic fluid collection, r/o pelvic hemorrhage or abscess History: Pancreatitis with infected per-pancreatic cyst s/p cystgastrostomy, US with ?pelvic fluid collection/hemorrhage? Suboptimal study due to beam hardening from patient's arms and lack of intravenous... | Given limitations of a noncontrast exam:1.Bilobed peripancreatic cyst, as described above, now traversed with new drainage catheters between the stomach and cyst. While the greater curvature component of the cyst has decreased in size, the parasplenic/subdiaphragmatic portion has increased, further detailed above.2.Com... |
Generate impression based on findings. | Reason: eval for pe History: h/o pe, discontinued anticoagulation, hemoptysis PULMONARY ARTERIES: No evidence of pulmonary embolism. The main pulmonary artery is normal in caliber.LUNGS AND PLEURA: Scattered benign-appearing micronodules. No suspicious pulmonary nodules or masses. Midline mild basilar subsegmental atel... | 1. No evidence of pulmonary embolism.2. Bronchial wall thickening may relate to bronchitis or asthma.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Female 91 years old Reason: fracture History: L elbow fracture. There is a moderately sized joint effusion. There is no definite fracture line evident, however, an occult radial fracture cannot be entirely excluded. Enthesopathic changes are seen along the olecranon process. | Joint effusion without definite fracture line. Occult proximal radial fracture cannot be excluded and follow-up in 7 to 10 days is recommended. |
Generate impression based on findings. | 31 years, Female. Reason: 31F w/ metastatic colon cancer History: Abdominal pain IUD projects over the mid pelvis. Nonobstructive bowel gas pattern. Lung bases are clear. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 65 years, Male. Reason: DHT coughed up by pt, new DHT replaced History: DHT coughed up by pt, new DHT replaced Dobbhoff tube tip projects over the gastric body. Retrocardiac opacity. Essentially gasless abdomen. Note that the pelvis is excluded from the field-of-view. | Dobbhoff tube tip projects over the gastric body. |
Generate impression based on findings. | Female 47 years old Reason: eval hardware, fracture, malalignment History: R shoulder pain, limited ROM, hx of arthoplasty. Four views of the shoulder show hardware components of a right shoulder hemiarthroplasty device situated in near anatomic alignment with no radiographic evidence of hardware complication. There is... | Right shoulder hemiarthroplasty without radiographic evidence of hardware complication. |
Generate impression based on findings. | 60 years, Male. Reason: presents from OSH with persistent SBO s/p colonic tube placement History: vomiting Cardiomediastinal silhouette is normal. No pleural effusion or pneumothorax. No focal pulmonary opacities. NG tube tip projects over the gastric body. No pneumoperitoneum. Gas is distention of small bowel measurin... | 1.Findings compatible with small bowel obstruction. 2.Colonic tube tip projects over the mid descending colon.3.Featureless appearing ascending colon suggestive of colitis. Clinical correlation is recommended. |
Generate impression based on findings. | 67 year old female with history of mitral valve repair in 1996, chronic atrial fibrillation who is being evaluated for repeat mitral and tricuspid repair. CPT: 75572 Aortic and Aortic Root. There is a left sided aortic arch with a normal brachiocephalic branching pattern is normal . Additionally, and accessory artery (... | 1. Moderate tortuosity and mild to moderate calcification of the thoracic aorta2. Gigantic biatrial dilation.3. There is a mild filling defect in the left atrial appendage which could represent either a left atrial appendage thrombus or poor flow. 4. Moderate aortic valve calcification.5. Mitral anuloplasty ring noted.... |
Generate impression based on findings. | Altered mental status, not following commands Compared to 2/26/2015, there is trace interval increase in size of the lateral ventricles compared to prior. Otherwise ventricular system is unchanged. Right parietal approach ventriculostomy catheter is unchanged in position. Dysmorphic appearance of the brain parenchyma i... | 1. Compared to 2/26/2015, there is minimal increase in size of the lateral ventricles and are similar to 11/20/2014. Dysmorphic ventricular system is otherwise unchanged.2. No intracranial hemorrhage or mass effect.3. Again seen is dysmorphic appearance of the brain parenchyma which can be better assessed with MRI if c... |
Generate impression based on findings. | Metastatic lung cancer. Complaining of increased coughing and shortness of breath. Evaluate disease status. CHEST:LUNGS AND PLEURA: Postsurgical findings of left lower lobectomy.Small partially loculated left pleural effusion. Multiple areas of pleural thickening, for example at the superior aspect of the left upper lo... | 1. Findings suspicious for left pleural metastases with a likely malignant small left pleural effusion. Two left upper lobe nodules suspicious for metastases and right lung micronodules that are indeterminate. 2. Necrotic mediastinal lymphadenopathy.3. T6 vertebral metastasis. 4. Left PICC tip is at the origin of the c... |
Generate impression based on findings. | Female 54 years old Reason: s/p IM nail History: s/p IM nail Status post IM nail placement affixing a comminuted mid to distal tibial fracture.Hardware components are intact with proximal and distal interlocking screws. There is some callus formation. Fracture involving the fibula also shows signs of healing without ch... | Healing tibial fracture status post ORIF. |
Generate impression based on findings. | 49 years, Female. Reason: epigastric pain History: epigastric pain Pigtail catheter projects over the right upper quadrant. Central venous catheter tip is in the right atrium. Left basilar atelectasis and pleural effusion. Moderate stool burden mainly within the ascending and transverse. Nonobstructive bowel gas patter... | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Reason: Pt with mass in R suprascapular region- evaluate for etiology History: R suprascapular mass LUNGS AND PLEURA: Postsurgical changes of a right lower and left upper lobectomy, and radiation fibrosis in the right paramediastinal region, unchanged.Moderate apical predominant centrilobular and paraseptal emphysema.N... | 1. No mass lesion or other abnormality identified in the suprascapular region in the field of view of this exam. CT soft tissue neck may be useful for more complete evaluation.2. No other acute abnormality or significant interval change. |
Generate impression based on findings. | 75 years, Male. Reason: eval NG tube placement from OSH History: eval NG tube placement Residual contrast from prior study in the collecting systems. NG tube projects over the gastric antrum. Nonobstructive bowel gas pattern. Note that the pelvis is excluded from the field-of-view. | NG tube projects over the gastric antrum. |
Generate impression based on findings. | Reason: 64 yo with NSCLC please re-stage History: see above CHEST:LUNGS AND PLEURA: The right lower lobe mass, compatible with a known history of non-small cell lung cancer, measures 5.4 x 5 .0 cm (series 4, image 69), mildly increased from the prior exam dated 09/2014, contiguous with the pleura.Anterior right nodular... | 1. The right lower lobe mass, compatible with known history of non-small cell lung cancer, is mildly increased from 09/2014. The mass is contiguous with the pleura, without evidence of chest wall invasion.2. Mediastinal lymph nodes are mildly decreased in size from the prior exam.3. No new sites of disease identified. |
Generate impression based on findings. | AAA screening, ex smoker, diabetic ABDOMINAL AORTA: Nonaneurysmal abdominal aorta and visualized common iliac arteries, scattered atherosclerotic calcifications. Measurements as follows:Proximal aorta measures 2.3 x 2.3 cm.Midportion of aorta measures 2 x 1.9 cm.Distal aorta measures 1.8 x 1.8 cm.Right common iliac art... | No evidence of aortoiliac aneurysm as above. |
Generate impression based on findings. | Gastrostomy tube and multiple surgical sutures again noted. Generalized, nonspecific bowel distention. No evidence of obstruction or free air. No bowel wall thickening, pneumatosis intestinalis or ascites. | Nonspecific bowel distention as described. |
Generate impression based on findings. | Female 16 years old Reason: Evaluate heart size with effusion as well as pulmonary vascular markings, and for possible thoracic mass. History: Pericardial effusionVIEWS: Chest PA/lateral (two views) 3/5/15 Aortic arch, cardiac apex and stomach are left-sided. Cardiac silhouette is normal in size and shape. Left retroca... | Left costophrenic angle pleural thickening/effusion none of segmental atelectasis of the left lower lobe. |
Generate impression based on findings. | Female 53 years old Reason: s/p r. foot surgery. Assess healing History: foot pain Status post removal of orthopedic hardware involving the medial cuneiform, and base of the first metatarsal.Pin type device involving the proximal phalanx of the first digit is unchanged. There are postsurgical changes in the first metat... | Status post hardware removal as detailed above. |
Generate impression based on findings. | 67-year-old female patient with diverticulum seen on EGD. Evaluate for fistula. Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions. There are postsurgical changes along the left mediastinum, compatible with known left lung resection. Linear lucency along the... | 1.Long segment intramural fistula with associated sinus tract. 2.Intramural pseudodiverticula. |
Generate impression based on findings. | Female 75 years old Reason: s/p femoral neck pinning History: s/p femoral neck pinning Orthopedic screws affix the right femoral neck fracture in near anatomic alignment. No hardware complication is evident. Single view of the pelvis shows aforementioned right hip surgical change. Osteoarthritis affects the lower lumba... | Status post fixation of the right femoral neck fracture without change in alignment. |
Generate impression based on findings. | Evaluate for mass/tumor of the larynx in the setting of worsening right sided throat pain x 2 months, dysphagia, referred ear pain (right), and tender cervical adenopathy. Neck: There is asymmetric enlargement of the right thyroid lobe with suggestion of an ill-defined nodule, although beam hardening artifact limits th... | 1. Asymmetric enlargement of the right thyroid lobe with suggestion of an ill-defined nodule, although beam hardening artifact limits the assessment. A thyroid ultrasound may be useful for further evaluation.2. Nonspecific bilateral cervical lymphadenopathy.3. The aerodigestive track, including the larynx appears to be... |
Generate impression based on findings. | Male 46 years old; Reason: pre-op for left THA Mako Stryker robotic system. History: pain Severe osteoarthritis affects the left hip, with subchondral sclerosis and cyst formation. No fracture is present. Mild osteoarthritis affects the right hip. | Osteoarthritis |
Generate impression based on findings. | Respiratory failure. 2-year-old former 24 week gestational age patient.VIEW: Chest AP (one view) 03/05/15, 0541 Endotracheal tube tip is below thoracic inlet. Left upper extremity PICC tip is at junction of superior vena cava and right atrium. A gastrostomy tube is present. Surgical clips are noted around the GE juncti... | Focal opacities on a background of chronic opacities. |
Generate impression based on findings. | Visualization of the thorax is limited by the field of view and length of scan, which excludes substantial areas of the lungs.CHEST:LUNGS AND PLEURA: Focal streaky opacity in the right middle lobe compatible with scarring, which likely accounts for abnormal opacity seen on the lateral chest radiograph. Calcified and n... | No significant extra cardiovascular abnormalities in the visualized portion of the thorax. |
Generate impression based on findings. | Male 52 years old Reason: assess prothesis History: S/P total elbow arthroplasty. Hardware components of a left total elbow arthroplasty device are situated in near anatomic alignment. There is a lucency about the ulnar aspect of the prosthesis which is compatible with bone resorption, but appears stable when compared ... | Total elbow arthroplasty as described above. |
Generate impression based on findings. | 5-day-old former 32 week gestational age patient with adjustment of PICC.VIEW: Chest AP (one view) 03/05/15, 0435 Left upper extremity PICC tip is in left internal jugular vein. Feeding tube tip is in the stomach. Umbilical venous line tip is at junction of the inferior vena cava and right atrium.Cardiothymic silhouett... | Left PICC tip in internal jugular vein. |
Generate impression based on findings. | 20 year-old female, status post surgery for deformityVIEWS: Left foot, AP, oblique, and lateral (3 views) 3/5/15 8:57 Interval removal of cast and K wires. The bones are demineralized. Mild residual hindfoot valgus, now with slight pes cavus. No fracture. | Removal cast and K wires with improved alignment. |
Generate impression based on findings. | Torticollis. Goldenhar syndrome.VIEWS: Cervical spine AP/lateral (two views) 03/05/15 Multiple segmentation anomalies are identified in the upper thoracic spine associated with a right curve. The head is tilted to the right.The odontoid is slightly flexed with respect to the body of C2. The appearance was similar to th... | Slight flexion of the odontoid on the body of C2 . Flexion and extension views may be helpful now that the anterior arch of C1 is ossified. |
Generate impression based on findings. | Female 75 years old Reason: pain in spine medial to scapulas; hx breast cancer History: pain. There is no acute fracture or subluxation. Vertebral body heights are preserved. There is mild disk space narrowing at the upper thoracic levels. No definite lytic or sclerotic lesions are identified within the thoracic verteb... | No acute fracture or subluxation. If further imaging is clinically warranted, a CT is recommended for better visualization of the scapulas. |
Generate impression based on findings. | 50-year-old recall from screening for a focal asymmetry in the right breast. An ML view and spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. The area ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Reason: s/p sleeve resection of left distal main bronchus and proximal upper and lower bronchus for management of T1N0 typical carcinoid tumor. History: follow up CHEST:LUNGS AND PLEURA: Scattered benign-appearing micronodules, unchanged. No new suspicious pulmonary nodules or masses.No focal airspace consolidation. No... | No evidence of recurrent or metastatic disease. |
Generate impression based on findings. | 30 year old female who has a complaint of focal right breast tenderness. Her physician palpated an area of thickness in the area of reported tenderness. Family history of breast carcinoma in her mother at age 45. BILATERAL DIAGNOSTIC MAMMOGRAM: Three standard views of both breasts were performed digitally and reviewed ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually, to begin at age 35. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | 73 years, Male, Reason: 73 yo with hepatic mass of unclear etiology has been stable History: none. ABDOMEN:LUNG BASES: Calcifications of the aortic and mitral valve. Mild coronary artery calcifications. Left lower lobe nodule measures 0.9 x 0.9 cm (21/37), previously 0.8 x 0.8 cm.LIVER, BILIARY TRACT: Status post chole... | 1.Stable hepatic lesions.2.Stable portal vein and SMV thrombosis.3.Left lower lobe nodule is stable. |
Generate impression based on findings. | 64 years, Male, Reason: evaluate for progression History: seminoma s/p RT. CHEST:LUNGS AND PLEURA: No focal consolidation or pleural effusion. Scattered calcified and noncalcified micronodules are nonspecific.MEDIASTINUM AND HILA: Right chest port tip terminates in the right atrium. Left thyroid nodules unchanged. Seve... | 1.Stable confluent retroperitoneal soft tissue infiltration.2.Slightly increased atrophy of the left kidney. |
Generate impression based on findings. | Reason: h/p laryngeal ca and CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Mild apical predominant centrilobular emphysema.Scattered benign appearing micronodules, some calcified, unchanged. No suspicious pulmonary nodules or masses.No focal airspace consolidation. No pleural effusion... | No evidence of metastatic disease. |
Generate impression based on findings. | 62 year-old female history of vasovagal episode causing hand numbness/inability to grasp status post vaginal hysterectomy/pelvic organ prolapse repair. CT head without contrast: There is no evidence of intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal... | 1. No evidence of intracranial hemorrhage or mass effect. CT is insensitive for the detection of acute ischemic infarction. If patient care warrants further imaging, an MRI may be obtained.2. 10 x 5 mm fusiform aneurysm of the left periophthalmic ICA and 5 x 4 mm saccular aneurysm of the right paraclinoid ICA. Recommen... |
Generate impression based on findings. | There is no acute intracranial hemorrhage, mass effect, or midline shift. The extra-axial spaces appear unremarkable for age. The ventricles, sulci, and cisterns are normal in size and configuration. There is a large scalp complex collection of fluid and blood products crossing sutures compatible with subgaleal hemato... | No acute intracranial hemorrhage or skull fracture. Large scalp subgaleal hematoma as described above. |
Generate impression based on findings. | There is a low density fluid collection with peripheral enhancement anterior to the mandible on the right (series 3, image 108) measuring 2.4 x 1.9 cm consistent with an abscess. No evidence of underlying osseous erosion to suggest osteomyelitis. There are periapical lucencies involving the right lateral second inciso... | 1.Findings consistent with an abscess anterior to the mandible as above without evidence of osteomyelitis.2.Multiple periapical lucencies suggestive of periodontal disease. |
Generate impression based on findings. | 75 years, Male. Reason: Repeat for improvement in known ileus History: has +BS, nontender on exam NG tube tip projects over the gastric antrum. Postsurgical changes from fundoplications surgery are again noted. No pneumoperitoneum. Multiple air fluid levels, increased since the prior exam. Degree of bowel dilation is u... | Ileus type bowel gas pattern not significantly changed since the prior exam. |
Generate impression based on findings. | 4-year-old male with left elbow injury, evaluate for healingVIEWS: Left elbow, AP, oblique, and lateral (3 views) 3/5/15 9:16 Interval removal of cast. Alignment is anatomic. The distal humeral fracture line is longer visible, suggesting healing. | Distal humeral fracture line is no longer visualized, suggesting healing. |
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