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Generate impression based on findings. | Female 55 years old Reason: hx B TKA, s/p MVC, with knee painanterior History: hx B TKA, s/p MVC, with knee pain anterior Right knee: Components of a total right knee arthroplasty device is situated innear-anatomic alignment. No joint effusion. No acute fracture.Left knee: Components of total left knee arthroplasty dev... | No acute fracture or dislocation. |
Generate impression based on findings. | Female 48 years old Reason: pain finger History: pain Mineralization is normal. There is a mild flexion deformity at the DIP joint which may physiologic. No acute fracture or dislocation is evident. The joint spaces are normal.There is soft tissue swelling. | Soft tissue swelling and other findings as detailed above. |
Generate impression based on findings. | 87-year-old female with new diagnosis of vulvar cancer. Now with palpable inguinal lymph node. Evaluate for metastatic disease. RADIOPHARMACEUTICAL: 12.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 86 mg/dL. Today's CT portion grossly demonstrates a large hiatal hernia. There is also extensive atheroscle... | 1.Focal vaginal hypermetabolic activity which may represent patient's known cancer versus benign uptake.2.Single subcentimeter mild to moderately hypermetabolic right medial inguinal lymph node which is equivocal and may represent a lymph node metastasis versus an inflammatory lymph node.3.No other suspicious FDG avid ... |
Generate impression based on findings. | 50-year-old male with ultrasound inconclusive for acute cholecystitis. Angiographic images are unremarkable. Slightly delayed clearance of radiotracer from the blood pool and delayed, uniform accumulation of the tracer by the liver is present. There is normal excretion of tracer into the intrahepatic ducts, common bile... | 1.Patent cystic and common bile ducts. No evidence of acute cholecystitis.2.Mildly delayed clearance of radiotracer suggest mild global hepatocyte dysfunction (likely medical hepatocellular disease). |
Generate impression based on findings. | Fall one week ago. Shoulder and clavicle pain. Assess for fracture. Osteoarthritis affects the shoulder but I see no fracture or malalignment. Degenerative arthritic changes also affect the visualized spine. | Osteoarthritis without fracture evident. |
Generate impression based on findings. | Status post MVC now with pain and bruising of left wrist. Fracture? There is perhaps mild swelling of the soft tissues along the radial aspect of the wrist, but I see no underlying fracture or malalignment. | No fracture evident. |
Generate impression based on findings. | Reason: progression of left MCA ischemic stroke History: right sided weakness and aphasia There is residual contrast present within the vasculature in this patient with chronic renal failure. There is enhancement of the cortical and leptomeningeal structures of the left MCA territory.The visualized portions of the para... | 1.Contrast enhancement within the left MCA territory cortex and leptomeninges likely represent infarcted tissue indicating large left MCA territory infarction. A follow-up CT after the contrast clears, would help assess for any hemorrhagic conversion and extent of reperfusion injury. |
Generate impression based on findings. | Hip pain Components of a right total hip arthroplasty device are situated in near anatomic alignment without radiographic evidence of complication. I see no fracture or dislocation. | Total hip arthroplasty without evidence of fracture. |
Generate impression based on findings. | Left foot gangrene. Assess infection. Since the prior study, there has been resection of the first ray through the tarsometatarsal joint, as well as the second and third rays through the second and third metatarsals, respectively. The medial cuneiform and remaining second and third metatarsals appear to protrude into t... | Postoperative changes of first through third ray amputation as described above. |
Generate impression based on findings. | Status post left total knee replacement Components of a total knee revision are situated in near anatomic alignment without radiographic evidence of hardware complication. Skin staples, a drain, and foci of gas density within the soft tissues reflect recent surgery. | Total knee arthroplasty revision as described above. |
Generate impression based on findings. | Reason: r/o ICH History: hx ICH There is encephalomalacia involving the left inferior and middle frontal gyri as well as the left caudate nucleus. There is encephalomalacia involving the left cuneus and adjacent precuneus. These are associated with ex vacuo effect.The patient status post left craniotomy and aneurysm cl... | 1.Chronic stage infarctions in the left frontal lobe, left caudate nucleus and the left occipital lobe.2.Status post clipping of left carotid terminus aneurysm and coiling of left PCOMA aneurysm.3.No evidence for acute intracranial hemorrhage, mass effect or edema.4.CT is insensitive for the early detection of nonhemor... |
Generate impression based on findings. | Pain in lateral wrist. Pain and swelling at MCP 3. No trauma. History two years ago of wrist sprain. Assess for fracture, arthritis, bony abnormality. Three views of the right wrist are provided. I see no fracture, frank arthritic changes, or other findings to account for the patient's pain.Three views of the right han... | Normal-appearing wrist and hand, without fracture, arthritis, or other findings to account for the patient's pain. |
Generate impression based on findings. | Fever. Osteomyelitis? Three views of the right foot are provided. The bones appear slightly demineralized. There is ulceration of the soft tissues along the posterior aspect of the calcaneus, but the underlying bone appears intact, I see no specific radiographic features of osteomyelitis. There is mild soft tissue swel... | Ulceration of the right heel. I see no radiographic evidence of osteomyelitis. |
Generate impression based on findings. | Female, 34 years old. Reason: Asses for obstipation, ileus History: 34 y.o. woman with a history of gastroschisis, gastroparesis, constipation and weight loss Nonobstructive bowel gas pattern. Large colonic stool burden.IUD projecting over the pelvis. | Large colonic stool burden. |
Generate impression based on findings. | Reason: R/O intracranial mass/blood History: lethargy, vomiting. The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portion... | No evidence for acute intracranial hemorrhage, mass effect or edema. |
Generate impression based on findings. | Male, 60 years old. Reason: bilious output per NG tube, signs of obstruction? History: as above Nonobstructive bowel gas pattern. Moderate stool burden.Enteric tube with tip overlying the gastric body, and distal side-port below the level of the GE junction. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Male, 60 years old. Reason: og tube advanced History: as above Enteric tube with tip overlying the gastric body and distal side port below the level of the GE junction.The lower pelvis is excluded from the field of view. Nonobstructive bowel gas pattern. Moderate stool burden.Pulmonary opacities are better evaluated on... | Enteric tube with tip overlying the gastric body. |
Generate impression based on findings. | Female, 65 years old. Reason: ng placement History: altered mental status Nasogastric tube with tip overlying the gastric body.The pelvis is excluded from the field-of-view. Partially visualized nonobstructive bowel gas pattern. Enteric contrast within the colon from recent prior study. | Nasogastric tube with tip overlying the gastric body. |
Generate impression based on findings. | Male, 68 years old. Reason: assess NG placement History: NG advanced 3-4cm Nasogastric tube with tip overlying the proximal gastric body and distal side-port below the level of the GE junction.The lower abdomen and pelvis are excluded from the field of view. Significant gaseous distention of the colon is partially visu... | Nasogastric tube with tip overlying the proximal gastric body. |
Generate impression based on findings. | Right shoulder pain Mild to moderate osteoarthritis affects or glenohumeral joint, with slight inferior positioning of the humeral head and narrowing of the glenohumeral joint that is new when compared with the prior study. Small foci of calcification along the greater tuberosity may represent calcification within the ... | Progression of degenerative arthritic changes of the right shoulder as described above. |
Generate impression based on findings. | 9-year-old male. ALL, fever, neutropenia, abdominal pain, diarrhea, increased work of breathing. Evaluate for abscess, appendicitis, typhilitis, hepatitis, other pathology. CHEST:LUNGS AND PLEURA: Small right pleural effusion.Septal thickening suggestive of mild interstitial edema. Patchy atelectasis bilaterally.MEDIAS... | 1. Small right pleural effusion and mild interstitial pulmonary edema. 2. Hepatomegaly and mild periportal edema, nonspecific, and can be seen in the setting of hepatitis.3. Diffuse wall thickening of a distended gallbladder, nonspecific in the presence of small amount of ascites. If there is clinical concern for acute... |
Generate impression based on findings. | 47-year-old male with back/flank pain Ribs: We see no fracture or other specific findings to account for the patient's pain. There is slight rightward curvature of the thoracic spine.Lumbar spine: A cortical step-off along the superior endplate of L5 was present on CT dated 2/26/14 and may represent old trauma or devel... | Mild osteoarthritis, degenerative disk disease of the lumbar spine, and other findings as above. No acute fracture is evident. |
Generate impression based on findings. | 41 year old female with bone injury status post fall. Ankle: There are small plantar and calcaneal spurs. No fracture or other specific findings are identified to account for the patient's tenderness. The talar dome appears intact.Foot: No fracture is evident. We see no specific findings to account for the patient's te... | No fracture or other specific findings to account for the patient's symptoms. |
Generate impression based on findings. | Female 58 years old Reason: r/o intra-abdominal abnormality History: AMS at baseline, PEG tube, w/upper abd TTP ABDOMEN:LUNG BASES: Dependent bibasilar atelectasis.LIVER, BILIARY TRACT: The patient is status post cholecystectomy.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL G... | 1.Fluid within the vaginal fornix is nonspecific, and correlation with pelvic examination can be considered as clinically indicated.2.Gastrostomy tube in place without evidence of complication. |
Generate impression based on findings. | 43-year-old male status post fall from 15 feet. Vertebral body heights are maintained. Lumbar spinal alignment is within normal limits. Moderate degenerative disk disease affects L5/S1. Small anterior osteophytes are present along the lower lumbar vertebral bodies. | Degenerative disk disease, but no compression fracture evident. |
Generate impression based on findings. | 78-year-old male with pain and swelling, rule out fracture No fracture is evident. There is a moderate joint effusion containing foci of gas density likely related to recent attempted aspiration. Moderate osteoarthritis affects the knee. Dense chondrocalcinosis is noted within the medial joint compartment. Scattered ar... | Osteoarthritis and joint effusion without fracture evident. |
Generate impression based on findings. | 19 year-old female with right lower quadrant pain, nausea. Evaluate for appendicitis. ABDOMEN:LUNG BASES: No consolidation or pleural effusion.LIVER, BILIARY TRACT: The liver enhances homogeneously without focal lesion. No intra-or extrahepatic biliary ductal dilatation. Gallbladder is normal in appearance. Trace fluid... | Findings suggestive of hemorrhagic right corpus luteum cyst with moderate abdominopelvic hemoperitoneum. No specific evidence of appendicitis.Findings relayed via telephone to Dr. Hendee at 10:12 a.m. on 1/9/2015. |
Generate impression based on findings. | Male, 62 years old. Reason: access stool burden History: significant stool burden on CT abd Nonobstructive bowel gas pattern. Enteric contrast within the colon from recent prior study. Moderate distal burden, predominantly in the rectum. | Moderate distal burden, predominantly in the rectum. |
Generate impression based on findings. | 93 year-old female with right hip pain after fall The bones are demineralized. Mild osteoarthritis affects the right hip. We see no fracture. | Mild osteoarthritis without fracture evident. |
Generate impression based on findings. | cerebrovascular accident No evidence of acute ischemic or hemorrhagic lesion.Chronic ischemic infarction with encephalomalacia on the left external capsule, caudate nucleus head, right external capsule, right caudate nucleus head.The ventricles, sulci, and cisterns are unremarkable. There is no mass effect, edema, midl... | No evidence of acute ischemic or hemorrhagic lesion.Multifocal chronic ischemic infarctions as described above. |
Generate impression based on findings. | 87 year-old female status post fall Hip: No fracture is evident. Mild osteoarthritis affects the hip.Pelvis: Mild osteoarthritis affects both hips. Mild chronic enthesopathic changes along the pelvis are likely of no current clinical significance. Vascular calcifications are noted in the soft tissue. Degenerative disk ... | Mild osteoarthritis without fracture evident. |
Generate impression based on findings. | 61-year-old female status post shoulder reduction Interval reduction of previously seen anterior shoulder dislocation. Glenohumeral alignment is near-anatomic. No fracture is evident. | Reduction of shoulder dislocation without fracture evident. |
Generate impression based on findings. | Female, 84 years old. Reason: r/o ileus History: distention Nonobstructive bowel gas pattern.Percutaneous gastrostomy tube in place over the mid abdomen, in the region of the gastric body.Ossified leiomyoma. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 61-year-old female with pain There is an anterior subcoracoid dislocation of the humeral head. No fracture is evident. | Anterior shoulder dislocation. |
Generate impression based on findings. | 43 rolled male status post fall with pain Note is made of an os acromiale. We see no fracture or malalignment. | Os acromiale without fracture or malalignment. |
Generate impression based on findings. | Female, 67 years old. Reason: assess for obstruction History: abdominal pain Multiple dilated loops of small bowel in left and mid abdomen, measuring up to 3.4 cm, with minimal colonic and rectal gas. Mild bowel wall thickening. Findings most suspicious for small bowel obstruction.Surgical clips, biliary stent, and ent... | Findings most suspicious for small bowel obstruction. |
Generate impression based on findings. | Female 60 years old Reason: evaluate for colonic inflammation History: diarrhea ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Diffuse hepatic hypoattenuation consistent with hepatic steatosis. The degree of hepatic hypoattenuation limits evaluation for focal mass lesions within the liver.SPL... | 1.Pancreatic mass, which encases the SMA, celiac axis, the confluence of the portal vein and SMV, with associated thrombosis of the splenic vein..2.Partially organized peripancreatic fluid collection with associated mesenteric haziness, likely a result of acute or prior pancreatitis.3.Hepatic steatosis.4.Thickening of ... |
Generate impression based on findings. | Female, 66 years old. Reason: bowel perf? History: hypotension Large area of lucency overlying the left upper abdomen likely represents severe gaseous distention of stomach. Rounded lucency overlying the right upper quadrant below the diaphragm is highly suspicious for free air. A few prominent air filled loops of smal... | Findings suspicious for free air. See subsequent decubitus imaging for additional details.Severe gaseous distention of stomach. |
Generate impression based on findings. | Fall. No evidence of acute ischemic or hemorrhagic lesion.Multifocal patchy low attenuations on bilateral periventricular white matter indicate non specific small vessel disease.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid... | No evidence of acute ischemic or hemorrhagic lesion.Nonspecific small vessel disease. |
Generate impression based on findings. | Reason: evaluate for bleed History: headache after MVC The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portions of the p... | 1.No evidence for acute intracranial hemorrhage, mass effect or edema.2.Left maxillary and ethmoid air cell opacification is distributed in a pattern of obstruction located at the hiatus semilunaris. Please note this is not complete evaluation of the paranasal sinuses |
Generate impression based on findings. | Female, 66 years old. Reason: free air? History: septic shock Free air under the right hemidiaphragm on supine imaging and layering non-dependently on left lateral decubitus imaging.Gaseous distention of the stomach and a few mildly prominent air-filled loops of small and large bowel are again seen. Enteric contrast wi... | Free intra-abdominal air. Recommend CT followup as clinically warranted. |
Generate impression based on findings. | fall. No evidence of acute ischemic or hemorrhagic lesion.Multiple vascular calcifications on bilateral distal vertebral arteries and cavernous sinus segments of ICAs indicate atherosclerotic chagnes, no change since prior exam.Patchy low attenuations on bilateral periventricular white matter indicate non specific smal... | No evidence of acute ischemic or hemorrhagic lesion.No change of small vessel ischemic disease and multifocal vascular calcifications since prior exam. |
Generate impression based on findings. | 20 month old female. In C-collar. Evaluate for fracture.VIEWS: Cervical spine 2 views (AP/lateral) 1/8/2015. Straightening of the cervical spine due to placement in cervical collar. No acute fracture or post-traumatic subluxation. Vertebral body heights and intervertebral disk spaces are preserved. NG tube is noted. | No acute fracture or post-traumatic subluxation. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in two sisters. Two standard digital views of both breasts with an additional cleavage view were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and dis... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | 31-year-old female with history of headache and dizziness. Evaluate for ischemic process. CT head without contrast: No evidence of acute intracranial hemorrhage. The gray-white differentiation is preserved. The ventricular configuration is unremarkable. The basal cisterns are intact. The orbits are unremarkable. The vi... | 1.No acute intracranial abnormality.2.Unremarkable CT angiogram of the head and neck.3.Stable left upper lobe pulmonary nodule.4.Parotid findings which may be secondary to the patient's history of lupus. |
Generate impression based on findings. | 6-year-old male. Neck pain status post injury with history of posterior spinal fusion.VIEWS: Cervical spine two views (AP/lateral) 1/8/2015. Os odontoideum is noted. Status post posterior fusion and laminectomies at C1-C2. There is interval partial resorption of the bone graft between the posterior aspect of C1 and C2.... | Predental space widening of 10 mm. Grade 1 anterolisthesis of C2 on C3. Recommend CT cervical spine for further evaluation. |
Generate impression based on findings. | 41 years old, Male, Reason: ascites fluid with +gram positive rods, eval for source History: sepsis, ARDS Evaluation of abdominal parenchyma is limited without intravenous contrast. Within these limitations the following observations are made:CHEST:LUNGS AND PLEURA: Respiratory motion degrades fine detail of the lungs.... | 1.Moderate to large bilateral pleural effusions with associated underlying atelectasis or consolidation as well as upper lobe predominant ground glass opacities consistent with ARDS. Underlying infection cannot be excluded. 2.Moderate pericardial effusion not significantly changed.3.Moderate volume of ascites unchanged... |
Generate impression based on findings. | Female; 25 years old. Reason: fracture of clavicle History: clavicle pain Two views of the left clavicle again demonstrate a transverse fracture of the mid to distal clavicular diaphysis with approximately 1 shaft width inferior displacement of the distal fracture fragment, similar to prior study. Interval increased in... | Clavicular fracture with some interval healing. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Personal history of ovarian cancer, diagnosed at the age of 29. Three standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. Scat... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | Male, 18 years old, status post craniotomy for AVM resection, with headache. Postoperative findings are seen compatible with a right frontoparietal craniotomy. Pneumocephalus is an expected finding. There is a narrow resection tract extending through the right frontal lobe towards the lateral ventricle margin which con... | Expected postoperative findings related to right frontal lobe lesion resection. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in maternal great aunt and two maternal second cousins. Two standard digital views (total of 8 images) of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, u... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | 32 year old female with history of shortness of breath and non-small cell lung cancer. PULMONARY ARTERIES: No pulmonary embolus.LUNGS AND PLEURA: Large right pleural effusion, increased from prior, and small left pleural effusion. Underinflation of this exam affects the appearance of reference lesions. Left paramediast... | 1. No pulmonary embolus.2.Increased large right pleural effusion, and other findings as above.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | 2-year-old male. Rhonchi in right lung. Evaluate for pneumonia.VIEWS: Chest AP/lateral (two views) 1/8/2015. Mild peribronchial wall thickening consistent with bronchiolitis/reactive airway disease. No focal airspace opacity, pleural effusion, or pneumothorax. Normal cardiomediastinal silhouette. | Reactive airway disease/bronchiolitis pattern. |
Generate impression based on findings. | Respiratory insufficiency requiring BiPAPVIEW: Chest AP Left upper extremity PICC with tip in the SVC. Cardiothymic silhouette normal. Improved atelectasis in the right lower lobe and left lower lobe. Probable small bilateral pleural effusions. Multiple surgical clips in the upper abdomen. | Bilateral atelectasis improved in the interval. |
Generate impression based on findings. | Male 73 years old Reason: Concern for intrabdominal process in LUQ. C/f absces vs bleed vs strained muscle. Need to avoid IV contrast due to renal failure History: LUQ pain Within the limits of a non IV contrast enhanced examination which limits ability to evaluate solid parenchymal organs and vascular structures, the ... | 1.No specific findings seen to account for the patient's pain.2.Cirrhotic hepatic morphology.3.Small bowel containing right inguinal hernia without evidence of obstruction. |
Generate impression based on findings. | 21-month-old male. Coughing and fever. Evaluate for pneumonia.VIEWS: Chest AP/lateral (two views) 1/8/2015. Mild peribronchial thickening consistent with bronchiolitis/reactive airway disease. No focal airspace opacity, pleural effusion, or pneumothorax. Normal cardiomediastinal silhouette. Left-sided aortic arch, card... | Reactive airway disease/bronchiolitis pattern. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views and tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses. No suspicious masses, microcalcifications or areas of archi... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.Mammography is optimally performed when prior studies are available to detect changes. If the patient's prior mammograms are submitted, then an addendum to this repor... |
Generate impression based on findings. | Chest tube placementVIEW: Chest AP and abdomen AP ET tube tip below thoracic inlet and above the carina. NG tube tip in the stomach. Left upper extremity PICC with tip in the left brachycephalic vein. There is a urinary catheter in place. Removal of one of the chest tubes and there are now two chest tubes on the right.... | Moderate right pneumothorax with mild mediastinal shift from right to left unchanged. |
Generate impression based on findings. | 15-year-old male. Hemoptysis. Evaluate for AVM, bronchiectasis, mass. LUNGS AND PLEURA: Mild bronchial wall thickening suggestive of bronchitis or asthma. No focal airspace consolidation, pleural effusion, or pneumothorax. No suspicious pulmonary nodules or masses are identified. No evidence of a pulmonary AVM or bronc... | No specific findings to explain the patient's hemoptysis. Mild bronchial wall thickening suggestive of bronchitis or asthma. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. Focal asymmetry present in the right lower inner breast, mid depth. There is no suspic... | Focal asymmetry in the right lower inner breast. Additional imaging, including spot compression views and possible ultrasound, are recommended for further evaluation.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EB - Additional Mammo/Ultrasound Workup Required. |
Generate impression based on findings. | Male; 72 years old. Reason: 72 yo male with history of MM; post-auto SCT evaluation History: evaluate SKULL: Multiple bilateral calvarial lytic lesions, similar to prior study and compatible with myelomatous lesions. The largest in the left parietal region measures approximately 2.2 cm, unchanged.CERVICAL SPINE: Severe... | No significant interval change in myelomatous involvement of both the axial and appendicular skeleton as detailed above. |
Generate impression based on findings. | 86 year old woman with severe aortic stenosis presents for CT for evaluation prior to possible TAVRCPT: 75572 Aortic and Aortic Root. There is a left sided aortic arch with normal brachiocephalic branching pattern. There is mild calcification of the proximal brachiocephalic vessels. No thoracic aortic dissection or ane... | 1. Severe aortic valve calcification2. Thoracic aorta anatomy and measurements as above3. Mild calcification of the coronary arteries4. Mild mitral annular calcification5. Severe left atrial dilation with evidence of a left atrial appendage filling defect, which could represent either a thrombus or "poor flow." This po... |
Generate impression based on findings. | FractureVIEWS: Left wrist AP, oblique and lateral There are healing fractures involving the metaphyses of the distal radius and ulna in near anatomic alignment. There is periosteal reaction reflecting interval healing. The overlying cast obscures fine bony detail. | Healing distal forearm fractures as described above. |
Generate impression based on findings. | Female 59 years old Reason: For abd/pelvis: please re-evaluate retroperitoneal LAD and omental nodularity with Contrast... For Chest: please eval Nodularity in the Distal Third of esophagus seen on recent EGD History: h/o node-positive Colon Cancer (stage 3) in 2012 s/p sigmoidectomy but no chemo/rad, now with abdomina... | 1.Disease progression: Increased lymphadenopathy and peritoneal carcinomatosis.2.Asymmetric wall thickening of the distal esophagus, is nonspecific and correlation with endoscopy is recommended. |
Generate impression based on findings. | 10-month-old male with head trauma, intubated.VIEW: Chest AP (one view) 1/9/2015, 0525 hours. Endotracheal tube tip at the carina. Left subclavian line terminates at the confluence of the brachiocephalic veins. Enteric tube tip in the antropyloric region of the stomach.Moderate bilateral pleural effusions with basilar ... | ET tube tip at the carina. Persistent bilateral effusions and basilar atelectasis. |
Generate impression based on findings. | FractureVIEWS: Left elbow AP, oblique and lateral The supracondylar fracture with three K wires is in near anatomic alignment. No definite periosteal reaction noted. The overlying splint is in place. | Fixation of supracondylar fracture as described above. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Personal history of benign right breast biopsy in December 2011. Family history of breast cancer in mother, two sisters, maternal cousin, and four paternal cousins. Two standard digital views of both breasts were performed and reviewed with the aid of R2 C... | Questionable area of architectural distortion seen in the right lateral breast. Additional imaging, including repeat right CC view, spot compression views and possible ultrasound, are recommended for further evaluation.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EC - Additional Mammo/Ultra... |
Generate impression based on findings. | 10-year-old female with hypoxia.VIEW: Chest AP (one view) 1/9/2015, 0508 hrs. ET tube tip between the thoracic inlet and carina. Right IJ catheter at the RA/SVC junction. Enteric tube tip in the antropyloric region of the stomach.Dense retrocardiac opacity not significantly changed, favor atelectasis over consolidation... | Left pleural effusion unchanged. Improving right basilar atelectasis. |
Generate impression based on findings. | Evaluate pleural effusionVIEW: Chest AP and abdomen AP ET tube tip below thoracic inlet and above the carina. NG tube tip in the stomach. Left upper extremity PICC with tip in the left brachiocephalic vein. Left chest tube in place. Cardiothymic silhouette normal. Diffuse atelectasis bilaterally minimally improved. Bil... | Bilateral small pleural effusions left greater than right minimally increased in the interval. |
Generate impression based on findings. | 15-year-old male. One episode of hemoptysis, 1 cup. Evaluate for hemorrhage or infiltrate.VIEWS: Chest AP/lateral (two views) 1/8/2015. Large lung volumes and mild peribronchial wall thickening suggestive of bronchiolitis/reactive airway disease. No focal airspace opacity, pleural effusion, or pneumothorax. Normal card... | Mild reactive airway disease/bronchiolitis. |
Generate impression based on findings. | There are postoperative findings related to C1-C2 fusion with cables and bone graft material. Compared to the prior exam, there is decreased interval displacement with a decreased atlantodental interval on the neutral view measuring 2 mm as compared to 5 mm previously. However, there is 3 mm wide atlantodental interva... | 1.Atlantooccipital alignment appears intact, however there is dynamic widening of the atlantodental interval on the flexion and extension views as compared to the neutral position suggesting persistent instability. Compared to the prior study, the atlantodental interval on the neutral view has decreased from 5 mm to 2 ... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Personal history of uterine cancer, diagnosed at the age of 42. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern a... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 7 year-old female with 5 day history of abdominal pain, no fevers, no diarrhea. Stool burden palpated on exam. Rule out obstruction, anatomic abnormality, heavy stool burden.VIEW: Abdomen AP (one view) 1/9/2015, 0623 hours. Moderate colonic stool burden. Nonobstructive bowel gas pattern. | Moderate colonic stool burden. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in maternal aunt. Two standard digital views and tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in patte... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 70 year-old female with history of left breast invasive poorly differentiated carcinoma who presents for needle localization prior to surgery. On review of the prior studies, there is left breast 8 o'clock asymmetry with associated clip which is the target for today's procedure. The procedure, risks including bleeding,... | Successful needle localization of the left breast malignancy.BIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 8-year-old female. Will not bear weight. Evaluate for fracture.VIEWS: Left foot AP/oblique/lateral views (3 views). Left ankle AP/oblique/lateral (3 views). Left foot: No fracture or malalignment is identified. Left ankle: Mild soft tissue swelling. Small ankle joint effusion. No fracture is identified. | Mild soft tissue swelling at the ankle and small ankle joint effusion. No fracture is identified. MRI is recommended if there is clinical concern for ligamentous injury. |
Generate impression based on findings. | 83 years old, Female, Reason: abd pain History: abd pain ABDOMEN:LUNG BASES: Respiratory motion limits evaluation of lung parenchyma. Moderate bibasilar reticulonodular opacities consistent with atelectasis. Scattered calcified hilar and mediastinal lymph nodes. Fluid is noted within the distal esophagus compatible wit... | Right inguinal hernia causing likely partial versus early complete obstruction of the right colon with dilated cecum.1.Hiatal hernia is present.2.Left inguinal hernia containing loops of colon without evidence of obstruction.3.Diffuse hepatic steatosis. |
Generate impression based on findings. | Female; 68 years old. Reason: shoulder pain History: same Four views of the right shoulder demonstrate mild osteoarthritis affecting the glenohumeral and acromioclavicular joints. Mild spurring is noted along the greater tuberosity. Glenohumeral joint alignment is within normal limits. No acute fracture is evident. | Mild osteoarthritis as described above. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. Focal asymmetry is identified in the l... | New focal asymmetry in the left inferior breast. Additional imaging, including spot compression views and possible ultrasound, are recommended for further evaluation.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EC - Additional Mammo/Ultrasound Workup Required. |
Generate impression based on findings. | Male, 18 years old, status post craniotomy with headache. Again seen is evidence of lesion resection from the deep right frontal lobe. Pneumocephalus remains within expected limits. A surgical tract extends through the frontal lobe to the right periventricular region. A hypodense lesion seen on the preoperative examina... | No significant change in expected postoperative findings. |
Generate impression based on findings. | Female 44 years old; Reason: diverticulitis History: epigastric, LLQ pain ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNE... | 1.No acute abdominal or pelvic pathology. 1.8-cm lesion posterior to the bladder described above likely represents an exophytic fibroid, but may be more definitively characterized by pelvic ultrasound. |
Generate impression based on findings. | Male; 67 years old. Reason: shoulder pain History: same Three views of the right shoulder demonstrate a metallic surgical anchor within the humeral head, related to prior rotator cuff surgical repair. Mild osteoarthritis affects the glenohumeral and acromioclavicular joints. Alignment is within normal limits. Posterior... | Right shoulder postoperative and degenerative arthritic changes as described above. |
Generate impression based on findings. | 2-year-old female. Rales, SOB. Evaluate for pneumonia.VIEWS: Chest AP/lateral (two views) 1/8/2015. Peribronchial thickening consistent with bronchiolitis/reactive airway disease. Normal cardiothymic silhouette. No focal airspace opacity, pleural effusion or pneumothorax. There is a left-sided aortic arch, cardiac apex... | Bronchiolitis/reactive airway disease pattern. |
Generate impression based on findings. | 18 year old female with severe right hip pain over past 72 hours. History of Crohn's disease and psoriatic arthritis. Evaluate for arthritis, AVM, or other bony changes. BONE AND MARROW: No significant bone marrow or cortical abnormality is identifiedSYNOVIUM: There is a moderate right hip joint effusion with mild enha... | Moderate right hip joint effusion with synovial enhancement suggestive of synovitis. No evidence of internal debris or underlying osseous changes. |
Generate impression based on findings. | 29-year-old male with history of chest pain. Evaluate for PE. Sickle cell patient. PULMONARY ARTERIES: No pulmonary embolus.LUNGS AND PLEURA: Minimal dependent atelectasis. No consolidation, no pleural effusion and pneumothorax.MEDIASTINUM AND HILA: Mild cardiomegaly, unchanged. No pericardial effusion. No significant ... | No pulmonary embolus. Stable findings of sickle cell disease.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Nasal congestion and obstructive sleep apnea. There is moderate mucosal thickening in the left maxillary sinus with suggestion of an air fluid level. There is also opacification of the majority of the left ethmoid sinuses and frontoethmoid recess. There is mild mucosal thickening in the right maxillary sinus and left s... | 1. Findings suggestive of acute rhinosinusitis.2. Mild diffuse prominence of the adenoids are nonspecific and may be reactive. |
Generate impression based on findings. | 8-month-old female. Vomiting. Evaluate for obstruction.VIEWS: Abdomen AP/left lateral decubitus (two views) 1/8/2015. Nonobstructive bowel gas pattern. No pneumoperitoneum, portal venous gas, or pneumatosis. Average stool burden. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Female 46 years old Reason: 46 yo female with ERCP pancreatitis and bile duct leak. History: abdominal pain ABDOMEN:LUNG BASES: Unchanged right lower lobe nodule.LIVER, BILIARY TRACT: The patient is status post cholecystectomy. There is unchanged mild intrahepatic biliary ductal dilatation, presumably postprocedural in... | 1.Interval removal of the cystostomy tube from the previously seen fluid and gas containing collection in the region of the pancreatic tail, which now contains only gas.2.Improved inflammatory changes in the mesentery surrounding the pancreatic tail, but otherwise unchanged findings consistent with sequelae of necrotiz... |
Generate impression based on findings. | 18-month-old female. Fever, cough.VIEWS: Chest AP/lateral (two views) 1/8/2015. Peribronchial wall thickening consistent with bronchiolitis/reactive airway disease. No focal airspace opacity, pleural effusion, or pneumothorax. Normal cardiomediastinal silhouette. Left-sided aortic arch, cardiac apex, and stomach. | Reactive airways disease/bronchiolitis pattern. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. No suspicious masses, microcalcificati... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Female; 71 years old. Reason: burning right leg pain History: burning right leg pain Three views of the lumbar spine demonstrate severe degenerative disk disease affecting L4-5, increased since prior study. Grade 2 anterolisthesis of L4, slightly increased since prior study. Moderate facet joint osteoarthritis affects ... | Progression of degenerative disk disease and anterolisthesis at L4-5 as described above. |
Generate impression based on findings. | There is severe dilatation of the ventricles diffusely. The posterior fossa does not appear significantly enlarged, although there is direct communication of the fourth ventricle with the posterior fossa CSF space. The brainstem is displaced ventrally with flattening posteriorly. Cerebellar tissue is identified and ap... | Severe communicating hydrocephalus, with probable Dandy-Walker variant. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in maternal great grandmother. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern an... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 27 weeks pregnant. Concern for stone versus pyelonephritis. Low-back pain, nausea and vomiting. RIGHT KIDNEY: The right kidney measures 11 cm in length. There is mild hydronephrosis. No stones are identified.LEFT KIDNEY: The left kidney measures 10.2 cm in length. Minimal pelvocaliectasis. No stones are identified.URIN... | Right hydronephrosis and minimal left pelvocaliectasis. These findings were communicated to the clinical service (pager 3551) at the time of dictation. |
Generate impression based on findings. | Female, 84 years old, history of lung cancer, assess for thrombus. Intraluminal thrombus is seen within the SVC (partially visualized), brachiocephalic and internal jugular veins on the right. Thrombus extends superiorly in the internal jugular vein to the level of the hyoid bone, at which point normal venous opacifica... | Persistent thrombosis of the right SVC, brachiocephalic vein, and internal jugular vein with extension superiorly to the level of the hyoid. The distribution of thrombus is similar to that seen on the prior study.4-mm enhancing lesion in the right cerebellar hemisphere suspicious for a metastatic lesion. Further evalua... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in maternal grandfather and mother. BRCA positive. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small ma... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually. Breast MRI given her risk status is also appropriate. BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Male; 77 years old. Reason: PREOP History: PREOP Severe arthritic changes affect the left shoulder. Narrowing of the glenohumeral joint with osteophyte formation, indicative of osteoarthritis. Chronic remodeling of the glenoid articular surface, which appears shallow with compensatory bone formation at the anterior asp... | Severe arthritic changes of the left shoulder as described above, which likely reflect long-standing changes related to rotator cuff arthropathy. However, an underlying inflammatory or neuropathic arthropathy cannot entirely be excluded. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views and tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. Two focal asymmetrie... | Two focal asymmetries in the right central breast. Additional imaging, including spot compression views and possible ultrasound, are recommended for further evaluation.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EC - Additional Mammo/Ultrasound Workup Required. |
Generate impression based on findings. | 3-day-old male with imperforate anus status post ostomy and fistula.VIEWS: Pelvis AP and frog leg (two views) 1/8/2015, 1843 hrs. No fracture or malalignment. No sacral anomalies identified. Previously noted dilated bowel loops are superior to the field of view. No significant abnormality is seen in the pelvis. | No significant abnormality in the pelvis. |
Generate impression based on findings. | 8-month-old male with UTI, possible ileus. Evaluate bowel gas pattern.VIEW: Abdomen AP (one view) 1/9/2015, 0841 hours. Enteric tube tip in the stomach. Persistent absence of bowel gas. No evidence of pneumatosis, portal venous gas, or intraperitoneal free air. Atelectasis/effusions noted in the lung bases. | Persistent absence of bowel gas. |
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