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Generate impression based on findings. | Male; 30 years old. Reason: obstructing stones? History: prior stones, dark urine, pain Lack of intravenous and oral contrast limits sensitivity for solid organ and bowel pathology, respectively.ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Small bilateral non obstructing renal calculi, the largest of which measures 5 mm in the superior pole of the left kidney. Symmetric attenuation of the kidneys. Minimal left perinephric fatty stranding, which may be chronic. No hydronephrosis or hydroureter. No evidence of obstructing calculus.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:PROSTATE, SEMINAL VESICLES: No significant abnormality notedBLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality noted | Small bilateral non obstructing renal calculi. |
Generate impression based on findings. | 47 year old with history of left breast cancer and bilateral mastectomy. Physician felt a fullness in the left axilla. Focused ultrasound was performed in the left axilla. Two benign appearing lymph nodes are detected in the left axilla. No suspicious lymph nodes or other abnormal findings are seen in the left axilla. | No suspicious findings in the left axilla BIRADS: 2 - Benign finding.RECOMMENDATION: C - Clinical Correlation Needed. |
Generate impression based on findings. | Reason: Graves disease, need uptake to calculate dose of I-131. The 4-hour radioactive iodine uptake is 59.9% and the 24-hour uptake is 67.6% (normal range 10-30%).Compared to the prior study, these values are increased, consistent with Graves' disease. | Markedly increased thyroid uptake compatible with Graves' disease, increased since the prior study. |
Generate impression based on findings. | Male 85 years old Reason: Evaluate bowel gas pattern History: abdominal distention. Air-distended stomach. Scattered small and large foci of bowel gas with a less than average stool burden. There is no evidence of a mechanical obstruction. Note is made of vascular calcifications. Mild degenerative arthritic changes affect the lower lumbar spine and bilateral hips. Please refer to same day chest radiograph for further chest findings. | Air distended stomach and scattered small and large foci of bowel gas with less than average stool burden. No evidence of a mechanical obstruction. |
Generate impression based on findings. | Female 19 days old Reason: persistence of atelectasis History: hypoxiaVIEW: Chest AP (one view) 3/10/15 at 540 hours. Hardware of the mandible, ET tube, and NG tube are again noted. Right upper extremity PICC terminates at the left innominate vein.Cardiac silhouette size is normal. Interval resolution of right lung atelectasis with no evidence of effusions or pneumothorax. | Interval resolution of right lung opacities. |
Generate impression based on findings. | Male; 62 years old. Reason: expansion of retroperitoneal hemorrhage History: increasing abd pain and fullness Lack of intravenous contrast limits sensitivity for solid organ pathology.ABDOMEN:LUNG BASES: Mild bibasilar dependent subsegmental atelectasis. Paraseptal emphysema. Cardiomegaly.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: No significant abnormality notedRETROPERITONEUM, LYMPH NODES: Grossly stable right retroperitoneal hematoma extending from the level of the diaphragm to the right inguinal and proximal femoral canals and involving the right iliopsoas muscle. The hematoma measures 7.3 x 5 cm in maximal axial dimension (series 4/81), not significantly changed from yesterday's study when it measured 7.3 x 4.9 cm.BOWEL, MESENTERY: G-tube in place. Mild mesenteric fatty stranding around the G-tube tract, likely postsurgical change from recent placement.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:PROSTATE, SEMINAL VESICLES: No significant abnormality notedBLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality noted | Grossly stable large right retroperitoneal hematoma. |
Generate impression based on findings. | Head: There is a new hyperattenuating lesion in the left frontal gyrus that measures up to 8 mm with surrounding edema. The ventricles are unchanged in size. There is no midline shift. There is thickening of the bilateral maxillary mucosa, right greater than left. The mastoid air cells are clear. The imaged portions of the orbits are intact. There are degenerative changes affecting the left temporomandibular joint. Neck: The exam is again limited due to patient positioning, poor contrast opacification, and extensive dental amalgam artifact. There are post-treatment findings in the neck without definite evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. There is partially-imaged mediastinal lymphadenopathy, right apical radiation fibrosis, and left apical cavitary lesions. There is mild atherosclerotic plaque at the carotid bifurcations. The osseous structures appear unchanged. The airways are patent. | 1.Limited exam of the neck without definite evidence of measurable mass lesion or significant cervical lymphadenopathy based on size criteria. A PET may be useful for further evaluation, if clinically warranted.2.Partially imaged upper mediastinal lymphadenopathy and left apical cavitary lesions. Please refer to the seprate CT chest report for additional details.3.A new subcentimeter lesion in the left frontal gyrus may represent metastatic disease. A brain MRI is recommended for further evaluation.Findings discussed with Dr. Nicole Hannigan (pager 7007) at 11:05AM 3/10/2015. |
Generate impression based on findings. | Female 53 years old; Reason: 53 y/o female with pancreatic ca. on chemo. compare to prior History: see above CHEST:LUNGS AND PLEURA: The left upper lobe lesion has undergone cavitation and now measures 1.0 x 0.7 cm (image 31/series 4) previously, 0.7 x 0.6 cm. There are numerous other pulmonary nodules. Including a larger lesion in the right lower lobe on image 53/series 4Pleural spaces remain clear.MEDIASTINUM AND HILA: Heart size is normal. There are mediastinal calcified lymph nodes.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY TRACT: Liver is normal in morphology. There is diffuse hypoattenuation of the right lobe and portion of the left lobe from fatty infiltration. The hepatic and portal veins are patent. No suspicious hepatic lesions.SPLEEN: No significant abnormality noted.PANCREAS: Pancreatic body mass measures 1.8 x 1.4 cm (image 84/series 3) previously, 1.6 x 1.1 cm. there is progressive atrophy pancreatic tail. The head and uncinate process are normal.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Thrombosis of the splenic vein with upper abdominal venous collaterals. No bowel obstruction.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.PELVIS:UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | 1.Slight increase in the size of the reference pulmonary lesion. Numerous pulmonary nodules remain.2.Fat infiltration of the liver limiting evaluation for metastatic disease |
Generate impression based on findings. | Female 13 years old Reason: cyst History: Pathological fracture.VIEWS: Left humerus AP and lateral 3/9/15 (two views) Healed pathological fracture of the mid diaphysis of the left humerus with posterior and medial angulation is unchanged in alignment. | Healed pathological fracture, unchanged in alignment. |
Generate impression based on findings. | 55-year-old male patient with history of bladder cancer status post cystectomy. Evaluate for metastatic disease. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No lesions are identified. Cholelithiasis without CT evidence of cholecystitis.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Bilateral renal cysts are unchanged compared to prior examination. No filling defects seen in the collecting systems bilaterally on delayed images.RETROPERITONEUM, LYMPH NODES: No retroperitoneal lymphadenopathy.BOWEL, MESENTERY: Nonobstructive bowel gas pattern.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:PROSTATE, SEMINAL VESICLES: Status post cystoprostatectomy.BLADDER: Neobladder appears similar compared to prior examination.LYMPH NODES: Partially imaged reference left inguinal lymph node measures 1.5 x 0.9 cm (series 6 image 62), not significantly changed.BOWEL, MESENTERY: Nonobstructive bowel gas pattern. Postsurgical changes from neobladder.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality noted | Examination is not significantly changed. No evidence of metastatic disease. |
Generate impression based on findings. | 68-year-old female with history of myeloid neoplasm, pre-allograft stem cell transplant evaluation. LUNGS AND PLEURA: Biapical scarring. Peribronchial nodules in the right upper and lower lobe are not significantly changed and are likely post infectious/scarring. Unchanged, wedge shaped density in the superior segment of the right lower lobe (series 5, image 98) may represent a resolving infarct from prior pulmonary embolism or postinflammatory scar. No central airways are patent. No pleural effusion or pneumothorax.MEDIASTINUM AND HILA: The heart size is normal. Mild anemia. No pericardial effusion. High superior pericardial calcification may be post-inflammatory in etiology. No significant coronary artery calcifications. Left central venous catheter tip is at the superior cavoatrial junction. No significant mediastinal or hilar lymphadenopathy.CHEST WALL: No axillary, cardiophrenic, or retrocrural lymphadenopathy. The osseous structures demonstrate diffuse sclerosis with loss of trabeculation, particularly in the spine, which may reflect the patient's myeloid neoplasm. UPPER ABDOMEN: Absence of IV and enteric contrast material limits sensitivity for abdominal pathology. No significant abnormality noted. | No specific evidence for infection. Unchanged peribronchial nodules in the right upper and lower lobe are not significantly changed and are likely post infectious/scarring in etiology. |
Generate impression based on findings. | Renal mass vs cyst. Compare to renal US from 2/24. CHEST:LUNGS AND PLEURA: Mild centrilobular and paraseptal emphysema.Patchy ground glass opacities and interstitial thickening consistent with resolving hemorrhage, mildly decreased from prior.MEDIASTINUM AND HILA: Mildly enlarged mediastinal and right hilar lymph nodes, likely reactive, unchanged.Severe cardiomegaly with pacemaker.Severe coronary artery calcification.CHEST WALL: Interval placement of a right subclavian artery IABP, proximal marker terminates in the proximal descending thoracic aorta. Adjacent postprocedural subcutaneous air and soft tissue stranding.ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Markedly atrophic right kidney, likely due to chronic ischemia due to right renal artery ostia noncalcified plaque (series 80476, image 125).The right kidney lesion noted on prior ultrasound is consistent with a column of Bertin. No renal mass. Nonobstructive punctate left renal stone.RETROPERITONEUM, LYMPH NODES: Inflated IABP with distal marker terminating in the abdominal aorta at the level of the IMA. Occlusive short segment thrombus (approximately 1 cm) in the proximal SMA (series 80476) with distal reconstitution of flow likely through the IMA.Calcified atherosclerotic disease of the abdominal aorta and branch vessels.BOWEL, MESENTERY: Colonic diverticulosis without evidence of diverticulitis.BONES, SOFT TISSUES: Mild degenerative changes of the thoracolumbar spine.OTHER: No significant abnormality notedPELVIS:PROSTATE, SEMINAL VESICLES: No significant abnormality notedBLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: Colonic diverticulosis without evidence of diverticulitis.BONES, SOFT TISSUES: Mild degenerative changes of the thoracolumbar spine.OTHER: Occluded left fem-popliteal bypass graft. | 1. Previously noted right renal lesion on US is consistent with a column of Bertin. No renal mass.2. Short segment complete thrombus occlusion of the proximal SMA with distal reconstitution, likely through collateral flow from the IMA.3. Continued mild decrease in pulmonary hemorrhage. |
Generate impression based on findings. | 19 year-old male with injury to the left fourth digit playing basketball one month ago. There is no evidence of fracture or malalignment. No significant soft tissue swelling. Joint spaces appear well-preserved. | No acute fracture or malalignment. |
Generate impression based on findings. | 92 year old with history of left mastectomy in 2010 for ILC. Patient received radiation and hormonal therapy. No new breast complaints. Because of the patient's immobility and intolerance for compression, only CC view of the right breast was performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. Stable benign calcifications are present. No new masses, suspicious microcalcifications or areas of architectural distortion are present. | Limited study. No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, right unilateral diagnostic mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Hip dysplasia.VIEW: Pelvis AP (one view) 03/10/15 Femoral head ossification centers are symmetric. They are well directed into normally formed acetabula. No fracture is identified. | Normal examination. |
Generate impression based on findings. | Male; 75 years old. Reason: eval for cause of periumbilical pain History: periumbilical pain CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. Moderate to severe upper lobe predominant centrilobular emphysema. No pleural effusions.MEDIASTINUM AND HILA: Normal heart size. No pericardial effusion. Severe coronary artery calcifications. No mediastinal or hilar lymphadenopathy.CHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Small hypoattenuating lesions in both kidneys are too small to characterize but most likely benign cysts (e.g. series 3/114).RETROPERITONEUM, LYMPH NODES: Atherosclerosis of the abdominal aorta and its branch vessels.BOWEL, MESENTERY: Severe colonic diverticulosis without evidence of diverticulitis. Normal appendix visualized.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:PROSTATE, SEMINAL VESICLES: Prostatomegaly with the prostate gland measuring up to 5.4 x 4 cm (transverse by AP, series 3/117).BLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: Small fat-containing inguinal hernias.OTHER: No significant abnormality noted | 1. No finding to explain the patient's symptoms.2. Moderate to severe emphysema.3. Severe diverticulosis without evidence of diverticulitis.4. Prostatomegaly. |
Generate impression based on findings. | Difficulty drawing back and central line.VIEW: Chest AP (one view) 03/09/15, 2021 Left-sided Port-A-Cath has its tip in right atrium. No fracture in the tubing is seen.Cardiothymic silhouette is normal. No focal lung opacity is present. A pleural effusion is not identified. | Normal examination. |
Generate impression based on findings. | T4N2a tonsil squamous cell carcinoma treated in 2010. There are post-treatment findings in the neck. There is no evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. The thyroid and remaining salivary glands are unremarkable. There is mild plaque at the carotid bifurcations. The airways are patent. There is multilevel degenerative spondylosis in the cervical spine. The imaged intracranial structures are unremarkable. There is pulmonary emphysema. | Post-treatment findings in the neck without evidence of measurable mass lesions or significant cervical lymphadenopathy. |
Generate impression based on findings. | 68-year-old female for evaluation of resolution of pneumonia seen on prior CT prior to restarting chemotherapy LUNGS AND PLEURA: No pleural effusion or pneumothorax. Interval decrease in size of multifocal groundglass, sub-solid nodules measuring up to 13 x 18 mm, previously 15 x 18 mm (series 5, image 164). Again noted is mild intralobular septal thickening in the right upper lobe with areas of pleural retraction. Mild interval improvement of centrilobular nodules in the left lower lobe. No new pulmonary opacities, nodules, or masses.MEDIASTINUM AND HILA: The heart size is normal. No pericardial effusion. Severe coronary artery calcifications are noted. Mitral annular calcification is present. No significant mediastinal or hilar lymphadenopathy.CHEST WALL: The osseous structures are within normal limits. No axillary, cardiophrenic, or retrocrural lymphadenopathy.UPPER ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pathology. Subcentimeter hypodense lesions in the spleen are likely benign cyst. Status post cholecystectomy. | Interval decrease in size of multifocal groundglass, sub-solid nodules consistent with resolving bronchopneumonia. |
Generate impression based on findings. | 63-year-old male with metastatic head and neck cancer. CHEST:LUNGS AND PLEURA: No significant abnormality noted.Bilateral pulmonary metastases with the following measurements (series 6):Left upper lobe cavitary lesion (image 68): 2.5 x 1.8 cm, previously 2.1 x 1.3 cm. Soft tissue component is slightly decreased.Left lower lobe nodule (image 149): 0.7 x 0.6 cm, previously 0.9 x 0.9 cm. This lesion is no longer cavitary and soft tissue component has increased.Superior right upper lobe nodule (image 171): 1.7 x 0.9 cm, previously 1.8 x 1.0 cm.Inferior right upper lobe nodule (image 213): 2.1 x 1.7 cm, previously 2.2 x 1.3 cm.Right paramediastinal and apical post radiation fibrotic changes are redemonstrated. Streaky left basilar opacity is slightly decreased in confluence and may reflect sequelae of aspiration. Increased patchy right lower lobe ground glass opacities.MEDIASTINUM AND HILA: Reference prevascular necrotic lymph node measures 2.7 cm (series 3, image 28), from previously 2.9 cm. Necrotic subcarinal lymph node measures 2.2 cm (series 3, image 40), from previously 2.1 cm. Pulmonary trunk is enlarged, suggestive of pulmonary arterial hypertension.CHEST WALL: Moderate degenerative changes affect the visualized spine.ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pathology. LIVER, BILIARY TRACT: Stable subcentimeter hepatic hypodensity, too small to further characterize. Cholelithiasis redemonstrated.SPLEEN: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.PANCREAS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Absence of enteric contrast material limits sensitivity for GI pathology.No gross abnormalities noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | No significant change in pulmonary nodules and mediastinal adenopathy.No new metastases are identified.Increased right lower lobe ground glass opacities, nonspecific though atypical infection is a consideration. |
Generate impression based on findings. | 64 year old female status post right lumpectomy and right axillary lymph node dissection for ER/PR positive IDC in 2013, presents today for routine follow up. Patient also received radiation and chemotherapy. Currently taking Arimidex. No current breast complaints. Three standard views of both breasts and two spot magnification 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 elements, unchanged in pattern and distribution. New dystrophic calcifications are noted in the right lumpectomy site. Surgical clips are noted in the right lumpectomy bed and right axilla. No suspicious mass, suspicious microcalcifications or suspicious areas of architectural distortion are noted in either breast. | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 75 years, Male. Reason: NG History: NG Interval placement of Dobbhoff tube with the tip projecting over the prepyloric stomach. There is a nonobstructive bowel gas pattern. The pelvis is excluded from the field of view. Respiratory motion artifact limits evaluation of the upper abdomen and lower chest. | Dobbhoff tube tip projecting over the prepyloric stomach. |
Generate impression based on findings. | Female, 82 years old, with slurred speech and decreased level of consciousness. Periventricular white matter hypoattenuation is again seen, a stable finding. No new evidence of parenchymal edema, mass effect or loss of gray-white distinction is seen. No intracranial hemorrhage or any abnormal extra-axial fluid collection is detected. The ventricles are stable in size and morphology. The osseous structures of the skull are intact and the paranasal sinuses are clear. | 1.Stable white matter hypoattenuation which is nonspecific but may reflect age indeterminate microvascular ischemic disease.2.No new or acute findings. |
Generate impression based on findings. | T3N2c/N3 hypopharyngeal mass treated with chemotherapy. There is persistent asymmetric effacement of the left piriform sinus associated with diffuse swelling in the hypopharyngeal region. There also appear to be secretions within the right piriform sinus. However, the assessment is limited by the lack of intravenous contrast. There is no definite evidence significant cervical lymphadenopathy based on size criteria, although the assessment is also limited by the lack of intravenous contrast. The thyroid and major salivary glands appear unchanged. There is a right internal jugular venous catheter. The osseous structures are unremarkable. The airways are patent. The imaged orbits and intracranial structures are grossly unremarkable. There is left maxillary sinus mucosal thickening. There are multiple nodules within the partially-imaged lungs. There is also pulmonary emphysema, a right pleural effusion, and a left apical calcified granuloma. | 1. Residual asymmetric effacement of the left piriform sinus associated with swelling in the hypopharyngeal region, which likely represents treatment effects, and apparent secretions in the right piriform sinus, although the assessment is limited by the lack of intravenous contrast. 2. No evidence of significant lymphadenopathy in the neck, although the assessment is limited by the lack of intravenous contrast. 3. Multiple nodules within the partially-imaged lungs are compatible with metastases. Please refer to the separate chest CT report for additional details. |
Generate impression based on findings. | 64-year-old with history of left breast cancer and increased size of scarring versus mass in the left breast. No change was seen on the recent mammogram, but evaluation was incomplete at that time due to the fact that the patient left before her ultrasound was performed. A targeted left ultrasound was performed for the palpable area of concern in the left outer breast. A large simple fluid collection is seen at the site of patient concern. This is compatible with a postoperative seroma. There is no suspicious solid mass identified. | Large simple fluid collection compatible with seroma. No suspicious solid mass. The patient should return for annual mammography as long as these findings are compatible with physical exam.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Locoregionally advanced cancer centered within the right fossa of Rosenmuller and right cervical lymphadenopathy status post treatment. There are unchanged post-treatment findings with persistent edematous tissue in the right lateral nasopharyngeal recess, but otherwise no evidence of a discrete mass. There is no evidence of significant cervical lymphadenopathy. The major salivary glands are unremarkable. The major cervical vessels are grossly patent. The airways are patent. The imaged portions of the lungs are clear. There is a left internal jugular central venous catheter. There is an unchanged partially calcified right thyroid nodule, as well as a left thyroid lesion. There is scattered paranasal sinus opacification with suggestion of an air-fluid level in the left maxillary sinus. There are multiple dental caries and periapical lucencies. | 1.Post-treatment findings in the neck without evidence of locoregional tumor recurrence or significant lymphadenopathy in the neck.2.Unchanged bilateral thyroid nodules.3.Dental caries. 4. Possible acute sinusitis. |
Generate impression based on findings. | 60 y/o h/o OHT with h/o aspergillosis PNA presents with ?rejection eval for infection. LUNGS AND PLEURA:Stable left lower lobe nodule measures 16 x 8 mm (series 7, image 53), from previously 15 x 9 mm. Other scattered nodules and micronodules, some calcified not significantly changed in size or numberMild paraseptal emphysema. Bilateral basilar groundglass opacities slightly increased. New trace bilateral pleural effusions.MEDIASTINUM AND HILA: Normal heart size without pericardial effusion. Severe coronary calcifications. Right IJ catheter tip at the cavoatrial junction.CHEST WALL: Mild degenerative changes affect the visualized spine. Sternotomy fixation present.UPPER ABDOMEN: Absence of IV and enteric contrast material limits sensitivity for abdominal pathology. No significant abnormality noted. | Stable pulmonary nodules.New trace bilateral pleural effusions.Basilar groundglass opacities slightly increased. This finding is nonspecific; NSIP or less likely bronchiolitis obliterans are diagnostic considerations. |
Generate impression based on findings. | 71 year old with history of right mastectomy in 2006 for IDC and DCIS. Patient received Aromasin for 5 years. History of left breast surgery for papilloma. No new breast complaints. Three standard views with two spot compression views of the left breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. Stable postsurgical architectural distortion is present in the retroareolar left breast. No suspicious mass, suspicious microcalcifications or suspicious areas of architectural distortion are noted in left breast. | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, left unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 83-year-old female with history of MGUS and Sjogren's syndrome, concern for lytic lesions. SKULL: No significant abnormality noted.CERVICAL SPINE: Mild degenerative disease of the C-spine. No myelomatous lesions identified.THORACIC SPINE: The thoracic spine is diffusely and severely osteoporotic. There is dextroconvex thoracolumbar scoliosis. No myelomatous lesions identified.LUMBAR SPINE: Multilevel degenerative disease, including significant disk space narrowing, subchondral sclerosis and anterior osteophyte formation at L1-L2, L2-L3, L3-L4, and L4-L5. No myelomatous lesions identified.RIBS: Multiple surgical clips are present in the left axilla and right upper quadrant. No myelomatous lesions identified.PELVIS: Degeneration and sclerosis at the bilateral sacroiliac joints, right greater than left. No myelomatous lesions identified.UPPER EXTREMITY: Subcentimeter lucency in the right humeral head is suspicious for myeloma. A second heterogeneous lucency in the proximal metadiaphysis of the right humerus is questionable for myeloma. Moderate osteoarthritic disease of the shoulders. There is osteophyte formation at the left acromioclavicular joint. There is no significant abnormality in the forearms or visualized portion of the hands.LOWER EXTREMITY: Osteoarthritic changes of the bilateral hips, left greater than right, including joint space narrowing, sub-chondral sclerosis, and osteophyte formation. The femurs are unremarkable. Mild joint space narrowing of the medial femorotibial compartment with subchondral sclerosis of the bilateral medial plateaux. | Lucencies in the right humeral head and right humeral proximal metadiaphysis are suspicious for myeloma. The remainder of the skeleton demonstrates diffuse degenerative disease, but no other suspicious lesions. |
Generate impression based on findings. | 43-year-old female patient with pancreatic mass seen on ultrasound presents with abdominal distention. CHEST:LUNGS AND PLEURA: Scattered bilateral airspace opacities, most prominent in the left lower lobe.MEDIASTINUM AND HILA: No significant abnormality noted.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY TRACT: Diffuse fatty replacement of the liver. Liver measures up to 19 cm in craniocaudal dimension.SPLEEN: No significant abnormality notedPANCREAS: There is enlargement and adjacent inflammatory changes in the head of the pancreas with a bilobed cystic component that measures 4.0 x 1.8 cm (series 8 image 58). There is a cystic lesion in the body of the pancreas that measures 1.3 cm (series 8 image 48). No pancreatic ductal dilatation.ADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Bilateral renal cysts.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Submucosal edema in the colon is nonspecific and suggestive of colitis.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Submucosal edema in the colon is nonspecific and suggestive of colitis.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | 1.Inflammation and enlargement of the pancreatic head with bilobed cystic lesion is suggestive of pancreatitis with pseudocyst formation. Recommend correlation with lipase, IgG, and formal evaluation with EUS and aspiration as clinically indicated.2.Cystic neoplasm in the body of the pancreas may represent an IPMN.3.Fatty liver.4.Patchy bilateral airspace opacities may represent infection versus aspiration.5.Submucosal edema in the colon is nonspecific and may represent colitis. |
Generate impression based on findings. | Respiratory insufficiency.VIEW: Chest AP (one view) 3/10/15 at 956 hours. Right mainstem bronchus intubation. Gastrostomy tube noted. Cardiac silhouette is non sizable due to a complete atelectasis of the left ninth. Right upper lobe and right lung base atelectasis is noted as well. | Left lung, right upper lobe and right lower lobe atelectasis, likely related to ETT positioning. |
Generate impression based on findings. | 41 year-old female with new incidental pulmonary nodules. LUNGS AND PLEURA: Innumerable scattered bilateral pulmonary nodules and micronodules. For reference, the largest right sided nodule measures 7 mm in the right upper lobe (series 5, image 166). The largest left-sided nodule measures 15 mm in the lingula (image 150, series 5).MEDIASTINUM AND HILA: Heart size normal with no pericardial effusion. There is mediastinal and symmetric hilar lymphadenopathy. No coronary calcifications are identified. Multiple hypoattenuating thyroid nodules.CHEST WALL: No significant abnormality noted.UPPER ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pathology. Left adrenal thickening. Multiple splenic cysts. Subcentimeter hepatic hypodensities too small to further characterize. | Innumerable scattered bilateral pulmonary nodules and micronodules with reference measurements above. In the absence of known malignancy and given other findings above, including lymphadenopathy, sarcoidosis is strongly favored. |
Generate impression based on findings. | 83 year old female status post right lumpectomy and complete axillary dissection in 2006 for IDC and DCIS with two palpable left axillary lymph nodes with abnormal sonographic appearance. Patient received radiation, chemotherapy, and Arimidex. Left ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is two adjacent left axillary lymph nodes. PROCEDURE: The procedure and its risks, including bleeding, infection, and failure to diagnose, and expected benefits of ultrasound-guided core biopsy with percutaneous placement of a marking clip and post-procedure unilateral mammogram were discussed with the patient. Questions were answered. Consent was obtained both verbally and in writing. The time-out form was completed to confirm patient identity and side/type of procedure.The left breast/axilla was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially , with 1% lidocaine with 1:100,000 epinephrine at depth. A 3 mm incision was made in the skin with a #11 scalpel blade. Using aseptic technique, continuous ultrasound guidance and a inferolateral to superomedial approach, four 14-gauge core needle (Inrad) specimens were obtained of the lesion. Targeting was judged very good. Three specimens sank to the bottom of the prefilled container of 10% formalin. One specimen floated. Specimen quality was judged very good.Specimens were sent to Pathology with an accompanying history sheet. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual manner. Pressure was held over the biopsy site until all bleeding subsided. The skin incision was closed with a Steri-Strip. A pressure dressing was positioned over the biopsy site and an ice pack positioned over the pressure dressing. Post-procedure instructions were reviewed with the patient both verbally and in writing. She tolerated the procedure well with no evident complications and left the Breast Imaging Department in stable condition.The procedure was performed by Dr. Schacht. | Successful ultrasound-guided core biopsy of the two adjacent left axillary lymph nodes and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Avascular necrosis.VIEW: Pelvis AP (one view) 03/10/15 Plate and screw devices are intact. The femoral heads and necks are broadened. The femoral heads are flattened and and fragmented. The articular surfaces are irregular. Lateral uncovering of both femoral heads is present by approximately 25%. The acetabular configurations are normal. The joint spaces are slightly decreased. The osteotomies are well healed. | Lateral uncovering of femoral heads. Continued flattening, fragmentation, and irregularity of femoral heads. |
Generate impression based on findings. | 68 year old with history of right mastectomy for breast cancer in 1991, and left reduction surgery in 1991. Because of patient's immobility, ML view could not be performed. Two standard of the left breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is mostly fatty replaced. Port-A-Cath is partially visualized at posterior aspect. No suspicious mass, suspicious microcalcifications or suspicious areas of architectural distortion are noted in left breast. | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, left unilateral diagnostic mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 59 year old female status post right lumpectomy in 2010 for IDC with DCIS, presents today for routine follow up. Patient received radiation and hormonal therapy (tamoxifen). No current breast complaints. No family history of breast cancer. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. A linear marker has been placed on a scar overlying the upper outer right breast, with expected underlying postsurgical changes, including surgical clips. Scattered benign calcifications are present. No dominant mass, suspicious microcalcifications or areas of architectural distortion in either breast. | Stable postsurgical changes of the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Cerebral palsy.VIEW: Pelvis AP (one view) 03/10/15 The left femoral head is superiorly positioned with respect to the dysplastic acetabulum. Right femoral head is well directed into the acetabulum. Well-healed bilateral varus derotational osteotomies are noted.A moderate amount of feces is seen in the rectosigmoid. | Dislocation of the left femoral head. |
Generate impression based on findings. | Male 66 years old; Reason: hx of bladder cancer s/p radical cystectomy, evaluate for metastatic disease with delayed imaging History: see above ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Liver is normal in morphology. The right hepatic lobe lesion measures 7 mm (image 22/series 8) previously, 9 mm.Status post cholecystectomy.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Small bilateral renal cysts. No hydronephrosis or nephrolithiasis in either kidney.RETROPERITONEUM, LYMPH NODES: No retroperitoneal lymphadenopathyBOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.PELVIS:PROSTATE/SEMINAL VESICLES: Status post cystoprostatectomy and neobladder reconstruction.BLADDER: Status-post cystectomy.LYMPH NODES: No pelvic lymphadenopathy.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | 1.Stable exam following cystoprostatectomy. |
Generate impression based on findings. | 76 year old with history of right lumpectomy in 2000. She also received radiation therapy. History of left breast benign biopsy in 1997. No current breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. Post surgical scar is re-demonstrated at lower inner quadrant in the right breast without significant change. Linear scar marker overlies medial aspect in the left breast with stable postsurgical changes. No suspicious mass, suspicious microcalcifications or suspicious areas of architectural distortion are noted in either breast. | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are digital left mammographic images (7/11/14) and ultrasound images for both breasts (7/17/14) performed at Advocate Trinity Hospital. DIGITAL LEFT MAMMOGRAPHIC IMAGES (7/11/14):The breast parenchyma is composed of scattered fibroglandular elements. A circumscribed asymmetry is present in the posterior aspect on nipple line in the left breast, likely an intramammary lymph node.No dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in the left breast. ULTRASOUND IMAGES FOR BOTH BREASTS (7/17/14):Ultrasound of left breast detected a normal intramammary lymph node at 3 o'clock position, 8 cm from nipple, which likely corresponds to the mammographic asymmetry.On the images annotated as "RIGHT MASTECTOMY PAIN UPPER AXILLA," there is an irregularly shaped hypoechoic lesion, which could be a mass, behind the pectoralis muscle. However, no color Doppler study is performed, and characterization of this lesion is difficult on these given two images. This lesion measures approximately 4 cm. | 1. Hypoechoic lesion in the post-surgical region in the right axilla. 2. No mammographic evidence for malignancy in the left breast.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 78 year old female with HCC and psychosis and confusion. There is no evidence of intracranial hemorrhage. There is mild global volume loss and mild atherosclerotic calcification of the distal internal carotid and vertebral arteries. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The imaged mastoid air cells are clear. There are secretions within the bilateral maxillary sinuses. The skull and extracranial soft tissues are unremarkable. | 1.No evidence of intracranial hemorrhage or mass effect.2.Fluid-levels in the maxillary sinuses which may represent acute sinusitis.3.If there is concern for metastasis or acute infarct, MRI is suggested. |
Generate impression based on findings. | 52-year-old female with history lower back pain. Moderate degenerative disease of the lumbar spine, most significant at L5-S1, where there is significant disk space narrowing, subchondral sclerosis, and vacuum disk phenomenon; there is anterior osteophyte formation of L1 through L5. There is degeneration and sclerosis of the sacroiliac joints. Partially visualized hip joints demonstrate mild osteoarthritic disease, right greater than left, with joint space narrowing and subchondral sclerosis. | Mild osteoarthritis of the lumbar spine, sacroiliac joints, and hips. There is no evidence of instability. |
Generate impression based on findings. | Right Horner's syndrome status post assault. Head: There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. There is mild right frontal scalp swelling without underlying calvarial fracture. There is a right periorbital hematoma and swelling associated with 6 mm medial displacement of right lamina papyracea fracture fragments and herniation of orbital fat. There is mild deformity of the right medial rectus muscle. There is a small amount of hemorrhage within the ethmoid air cells. There is no evidence of retrobulbar hematoma. The left orbit is unremarkable. There is left facial subcutaneous stranding and swelling of the zygomatic major muscle. The temporomandibular joints are intact. Tooth# 13 is absent. The orbits are intact. There is a small left nasal septal spur. The mastoid air cells are clear.Head CTA: There is minimal calcification in the carotid siphons. There is no evidence of significant steno-occlusive lesions or cerebral aneurysms. There is no evidence of venous sinus thrombosis.Neck CTA: There is no evidence of significant steno-occlusive lesions. There is a minimally displaced fracture of the C6 spinous process with sclerotic margins suggesting a chronic fracture. Otherwise, there is no evidence of acute fracture. The vertebral column alignment is within normal limits. The vertebral body and disc space heights are preserved. There is mild degenerative spondylosis, but no significant spinal canal stenosis. The paravertebral soft tissues are unremarkable. | 1. Right periorbital hematoma with a medial orbital blow out fracture, but no evidence of retrobulbar hemorrhage.2. Left facial contusion.3. No evidence of acute intracranial hemorrhage or skull fracture.4. Chronic C6 spinous process fracture, but no evidence of acute cervical spine fracture or subluxation. 5. No evidence of dissection or pseudoaneurysms. |
Generate impression based on findings. | Male, 84 years old, altered mental status and lethargy. Multiple areas of parenchymal hemorrhage are seen, largely clustered along the bilateral cerebral convexities and along the base of the brain. Scattered subarachnoid blood product is seen within the frontal sulci and there may be some minimal subdural blood along the left aspect of the superior sagittal sinus at the vertex.The areas of parenchymal hemorrhage are associated with modest surrounding edema. There are, however, other scattered areas of parenchymal hypoattenuation involving the cerebral hemispheres and the cerebellum which are not associated with hemorrhage and therefore nonspecific.No evidence of midline shift or impending brain herniation is seen. The ventricles may be slightly small in caliber for age but this is an equivocal finding.A nondisplaced fracture is seen traversing the left parietal bone at the level of the coronal suture. The fracture turns posteriorly at the midline and courses along the sagittal suture for some distance. There may possibly be some extension of the fracture to the right along the coronal suture but this is equivocal. | 1. Scattered areas of parenchymal hemorrhage are seen in a pattern consistent with traumatic contusions. A small amount of subarachnoid and subdural blood product is also demonstrated.2. In addition to the edema surrounding the hemorrhages, there are areas of parenchymal hypoattenuation without associated blood product which are nonspecific. They may reflect traumatic injury as well or perhaps age indeterminate microvascular disease or some other pre-existing process.3. No significant generalized mass-effect is suspected in relation to the intracranial hemorrhage.4. Nondisplaced calvarial fractures are seen as above. |
Generate impression based on findings. | 3 year old male. Abnormal eye movement. Evaluate for neuroblastoma. CHEST:LUNGS AND PLEURA: Minimal basilar atelectasis. No focal airspace consolidation.No suspicious pulmonary nodules or masses. No pleural effusion.MEDIASTINUM AND HILA: Normal cardiac size.No mediastinal or hilar lymphadenopathy.CHEST WALL: No focal osseous lesions.ABDOMEN:LIVER, BILIARY TRACT: No focal liver lesions. No biliary ductal dilatation.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: No significant abnormality notedRETROPERITONEUM, LYMPH NODES: No mesenteric or retroperitoneal lymphadenopathy.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No focal osseous lesions.OTHER: No significant abnormality notedPELVIS:PROSTATE, SEMINAL VESICLES: No significant abnormality notedBLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality noted | No acute abnormality. Specifically, no evidence of neuroblastoma. |
Generate impression based on findings. | 70 year old female status post left lumpectomy with reexcision in 2010 for DCIS, and right lumpectomy and in 2005 and 2009 for DCIS, presents today for 6 month follow up. Received radiation therapy and is currently on Aromasin. No current breast complaints. No family history of breast cancer. MAMMOGRAM: Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. A linear marker has been placed on a scar overlying the central outer left breast, with expected underlying postsurgical changes, including surgical clips. A cluster of calcifications is noted within the central outer left breast, which are more prominent on today's examination. On magnification views, these appear to be oriented in a ductal distribution, associated with ectatic ducts. Elsewhere, scattered benign calcifications are present.ULTRASOUND: A targeted left ultrasound was performed for the mammographic area of concern.At the 6 o'clock left retroareolar region there is a parallel, hypoechoic mass with internal areas of echogenicity, compatible with calcification. This mass measures approximately 1.3 x 0.2 x 0.5 cm, and is noted along the dermal border. No significant vascularity is identified within this mass on Doppler imaging. Multiple ectatic ducts are noted throughout the left retroareolar region, without discrete intraductal mass identified. I1 | Hypoechoic mass with internal calcifications, felt to represent the suspicious calcifications on mammography. This mass is noted at the dermal border of the left retroareolar breast, at the 6 o'clock position. Ultrasound guided biopsy of this area is recommended for definitive histologic diagnosis. Results and recommendation were discussed with the patient, and all of her questions were answered.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: H - Percutaneous Biopsy/Aspiration. |
Generate impression based on findings. | 51-year-old male with history of left SER IV ankle fracture s/p surgical repair; follow-up exam. A side plate and screws affixing an oblique fracture of the distal fibula in near anatomic alignment is again demonstrated. The fracture remains visualized on the lateral view. The mildly displaced fractures of the "posterior malleolus" of the distal tibia as well as the medial malleolus appear similar to prior exam. A small lucency in the lateral aspect of the talar dome is unchanged, and likely represent a degenerative cyst or a subchondral defect. There has been mild interval improvement in the degree of soft tissue swelling. | Stable appearance of orthopedic fixation of the distal fibular fracture in near-anatomic alignment. The remaining fracture fragments and talar dome lucency appear similar to prior exam. |
Generate impression based on findings. | Elder abuse. Evaluate for fracture. SKULL: Two views of the skull are without acute fracture. CERVICAL SPINE: One view of the cervical spine shows diffuse osteoporosis without acute abnormality. THORACIC SPINE: One view of the thoracic spine shows multiple wedge deformities compatible with compression fractures of indeterminate age. LUMBAR SPINE: One view lumber spine reveals no acute fracture. There is heavy at the calcification of the abdominal aorta.RIBS: One view of the ribs is without acute fracture.PELVIS: AP view of the pelvis demonstrates severe osteoarthritis of the right hip with joint space narrowing and subchondral sclerosis. There is a left total hip arthroplasty device.UPPER EXTREMITY: Two views of the left humerus reveal no acute fracture. There is deformity of the left scapula consistent with known fracture; this can be better evaluated with CT.Two views of the right humerus are without acute fracture. There is severe osteoarthritis of the right shoulder with sclerosis and osteophyte formation.Single view of the right and left forearms are without acute fracture.LOWER EXTREMITY: Two views of the bilateral femurs are without acute fracture. There is severe osteoarthritis of the right hip. There is a left total hip arthroplasty device.Single view of the bilateral tibia/fibula reveal no acute fracture. | 1. Left scapular deformity consistent with fracture; this can be better evaluated with CT if clinically warranted. No additional acute fractures are identified.2. Multiple thoracic compression deformities of indeterminate age. |
Generate impression based on findings. | 18 year old male with left breast lump. With physical exam, left nipple appears larger than right, and there is a soft thickening behind the left nipple. Focused ultrasound of left retroareolar region detects a small amount of hypoechoic tissue consistent with gynecomastia. No solid or cystic masses are detected. | Left retroareolar thickening, consistent with gynecomastia. Clinical follow up is recommended and no further imaging assessment is needed. Results and recommendations were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 64-year-old female with history of lower back pain. Osteoarthritic disease of the lumbar spine, including large anterior osteophyte formation of L4, as well as joint space narrowing of L4/L5 with vacuum disk phenomenon and subchondral sclerosis. There is no evidence of fracture or malalignment. | Mild/moderate osteoarthritis of the lumbar spine, most significant at L4/L5. No acute fracture or malalignment. |
Generate impression based on findings. | Female; 38 years old. Reason: Pancreas cancer please assess to previous imaging and provide index lesion measurements for RECIST History: As above CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. Scattered pulmonary micronodules are unchanged. No pleural effusions or pneumothorax.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Heart size is normal without pericardial effusion.CHEST WALL: Chest port with catheter tip in the SVC/right atrial junction.ABDOMEN:LIVER, BILIARY TRACT: Numerous hypodense hepatic lesions consistent metastatic disease, not significantly changed. No new lesions.Reference right hepatic lobe lesion measures 1.1 x 0.9 cm, previously 1.0 x 0.8 cm (series 3, image 86).Reference inferior left hepatic lobe lesion measures 1.1 x 1.1 cm, previously 1.0 x 0.9 cm (series 3, image 98).Patent metallic common bile duct stent with persistent associated pneumobilia.SPLEEN: No significant abnormality noted.PANCREAS: No significant interval change in the large pancreatic head mass encasing the distal common bile duct and measuring 4.1 x 3.4 cm, previously 4.1 x 3.4 cm (series 3, image 98). Severe diffuse proximal pancreatic ductal dilatation with pancreatic atrophy, unchanged.The superior mesenteric artery is again noted to be encased by the tumor. The superior mesenteric vein is occluded at the inferior aspect of the mass. Mesenteric haziness surrounding the celiac axis and SMA is again noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: Reference portacaval lymph node measures 1.4 x 0.8 cm (series 3, image 91), unchanged.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: Multiple abdominal venous collaterals are noted.PELVIS:UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: Multiple abdominal venous collaterals are noted. Small amount of pelvic free fluid, likely physiologic. | 1.No significant interval change in the pancreatic head mass which encases the superior mesenteric artery and occludes the superior mesenteric vein.2.No significant interval change in hepatic metastatic disease.3.Stable portacaval lymph node. |
Generate impression based on findings. | 15 year old female w/ hyperextension knee injury. +swelling. History: swelling, tenderness, unable to bear weight.VIEWS: Right knee AP, oblique, lateral, sunrise (4 views) 3/10/2015 at 1025 Small joint effusion between the quadriceps tendon and the anterior surface of the femoral epiphysis. No soft tissue swelling.The osseous structures are normal. | Small joint effusion with no fracture. |
Generate impression based on findings. | There is an oblique, linear fracture through the posterior left mandibular body, immediately anterior to the angle, with minimal displacement. The fracture extends through the root of the posterior-most left lower molar (ADA 17). The mandibular condyles are appropriately positioned and the subcondylar regions appear normal. No additional facial fractures are identified.There is extensive overlying high attenuation soft tissue swelling which is inseparable from the masticator muscle and extends into the submandibular space. The airway is deviated towards the right, but is patent.Incidentally noted, there is a large leftward projecting bony septal spur which contacts and deforms the mucosa of the left middle turbinate.Bilateral mastoid air cells and middle ear cavities are clear. The orbits and visualized brain are grossly normal. | 1.Left mandibular body fracture extending through the root of the posterior most inferior molar.2.Extensive overlying soft tissue swelling and hemorrhage, inseparable from the masticator muscle and extending into the submandibular space.3.Large bony septal spur contacting and deforming the mucosa of the left middle turbinate. |
Generate impression based on findings. | Sickle cell anemia, venoocclusive disease, left lower extremity pain, and left shoulder pain. Question of avascular necrosis. Three views of the left shoulder reveal patchy sclerosis of the superior medial aspect of the humeral head compatible avascular necrosis, which appears similar to the prior study. An additional approximately 1 cm lucent lesion with mildly sclerotic margins within the proximal humeral diaphysis may also represent a small focus of osteonecrosis. No acute fracture or dislocation is evident.Two views of the left tibia/fibula reveal no acute fracture or malalignment. There is patchy sclerosis along the distal tibial metaphysis which likely represents osteonecrosis. | 1. Redemonstration of patchy sclerosis within the left humeral head compatible with avascular necrosis, unchanged from the prior examination.2. Patchy sclerosis within the distal tibial metaphysis which likely represents osteonecrosis. |
Generate impression based on findings. | 51-year-old male patient with history of bladder cancer status post cystectomy with neobladder urinary diversion. Evaluate for metastatic disease with delayed imaging. ABDOMEN:LUNG BASES: No suspicious pulmonary nodules.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No hydronephrosis or filling defects in the collecting systems on delayed imaging. Interval improvement in left upper lobe kidney enhancement.RETROPERITONEUM, LYMPH NODES: Scattered prominent retroperitoneal lymph nodes appear similar to the prior examination. BOWEL, MESENTERY: Scattered subcentimeter mesenteric lymph nodes.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.PELVIS:PROSTATE, SEMINAL VESICLES: Status post cystoprostatectomy.BLADDER: Neobladder appears similar to prior examination.LYMPH NODES: No pathologically enlarged pelvic lymph nodes.BOWEL, MESENTERY: Nonobstructive bowel gas pattern. Postsurgical changes from partial ileal resection.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | Stable examination without evidence of metastatic disease. |
Generate impression based on findings. | Female 47 years old Reason: h/o small and large bowel crohns disease, s/p multiple resection. evaluate for stricturing or acute inflammation History: new symptoms of constipation, nausea alternating with diarrhea. Scout radiograph showed a nonobstructive bowel gas pattern. Transit time to the colon was 45 minutes. Fluoroscopic evaluation showed postsurgical changes of previous bowel resections with an ileocolonic anastomosis in the right upper quadrant and a side-to-side and end-to-side anastomoses in the left upper quadrant near the patient's area of pain. In the region of the left upper quadrant anastomoses is a blind ending pouch, which appears significantly more dilated when compared to the prior exam and contains mobile debris from ingested material. Multifocal areas of non-obstructing adhesions were seen in the left upper quadrant and in the right upper quadrants. No internal hernias or ventral hernias were evident. No sinus tract ulcers were seen.TOTAL FLUOROSCOPY TIME: 9:27 minutes. | 1.Multifocal non-obstructing adhesions.2.Interval progression in marked dilation of left upper quadrant blind ending pouch as described above.3.These findings might account for the patient's symptoms. |
Generate impression based on findings. | TMJ ankylosis and severe mandibular hypoplasia: trismus. Multiple attempts at mandibular lengthening with distraction (x4) and costochondral grafting. There are postoperative findings related to prior orthognathic surgery, with screws and plates in the mandibular body. There is marked deficiency and irregularity of the mandible diffusely with 12 mm of overjet and glossoptosis that results in pharyngeal airway narrowing. In particular, the body of the mandible is very thin such that the screws project onto the oral soft tissues. There are gaps across the bilateral presumed mandibular osteotomy sites and scattered foci of ossification along the margins of the mandible, which may represent heterotopic bone. There is hypertrophy of the left mandibular ramus and condyle, which form bony ankylosis with the zygomatic arch and skull base in the region of the glenoid fossa, respectively. The right mandibular ramus and condyle are diminutive, but also form bony ankylosis with the zygomatic arch and skull base in the region of the glenoid fossa, respectively. There is crowding of the maxillary teeth. There is a high-arching palate with possible clefting of the posterior hard palate. There is a 3 cm wide defect in the midline apical calvarium with overlying subcutaneous soft tissue attenuation and what appears to be a persistent falcine sinus. There is a mildly ectatic and anomalous course of the intracranial left internal carotid artery with associated deformity of the left dorsum sella. There is deformity and mild hyperostosis of the bilateral lateral orbital walls. There is hypertelorism. There is bilateral tympanomastoid opacification, with otherwise underpneumatized mastoid air cells bilaterally. There is mild scattered paranasal sinus opacification. | 1. Postoperative findings related to prior orthognathic surgery for retromicrognatia with apparent nonunion of the osteotomies, 12 mm of overjet and glossoptosis that results in pharyngeal airway narrowing, as well as bony ankylosis between the mandible the skull base and zygomatic arches bilaterally. 2. Anomalous course of the intracranial left internal carotid artery, which appears to be mildly ectatic. An MRA may be useful for further evaluation.3. Dysplastic maxilla and high-arching palate with possible clefting posteriorly.4. Bilateral tympanomastoid opacification, with otherwise underpneumatized mastoid air cells bilaterally may indicate chronic otomastoiditis.5. A defect in the midline apical calvarium with overlying subcutaneous soft tissue attenuation and what appears to be a persistent falcine sinus and atretic encephalocele, perhaps with superimposed postoperative effects. |
Generate impression based on findings. | Fall, trauma. Question of fracture. Three views of the right shoulder reveal no acute fracture or dislocation. There is mild osteophyte formation at the acromioclavicular joint.Two views of the right humerus reveal no acute fracture. | 1. No acute fracture or dislocation is evident.2. Mild osteoarthritis of the acromioclavicular joint. |
Generate impression based on findings. | Reason: evaluate sinus History: right sided nasal polyp, possible antrochoanal polyp Exam is limited by lack of contrast. There is complete opacification of the right maxillary sinus as well as right middle and inferior meatus measuring 19 Hounsfield units, likely mucoid. There is widening of the ostiomeatal complex with silhouetting of the right middle and inferior turbinates. There is additionally a more bulbous component posteriorly in the nasopharynx, discrete from the wall. The medial margin of the opacification abuts the nasal septum with slight rightward deviation of the nasal septum. There is no bony erosion or destruction, compatible with chronic benign process. Frontal sinuses are not pneumatized. Ethmoid sinuses, sphenoid sinuses, and left maxillary sinuses are well developed and clear. Bilateral Haller cells are noted. The cribriform plate, fovea ethmoidalis and lamina papyracea appear normal. The osseous structures are unremarkable. The bilateral orbits are unremarkable. The visualized portions of the mastoid air cells are clear. Limited view of the intracranial structure is unremarkable. | Fluid-density complete opacification of the right maxillary sinus extending through the ostiomeatal complex into the nasopharynx. No evidence of bony erosion or destruction, compatible with chronic benign process, most suggestive of an antrochoanal polyp as clinically suspected. |
Generate impression based on findings. | 56-year-old female with left ankle and foot pain. There is mild hallux valgus deformity, as well as joint space narrowing and subchondral sclerosis of the first metatarsophalangeal joint, consistent with osteoarthritis. A plantar heel spur is present. There is no acute fracture or malalignment. | No acute fracture or malalignment. Mild hallux valgus deformity; osteoarthritis of the first MTP joint. |
Generate impression based on findings. | 72-year-old male patient with history of prostate cancer, status post treatment. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules. Pleural based left lower lobe nodule is unchanged (series 5 image 70). Scattered nonspecific nodules, some of which are calcified.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Cardiac size is within normal limits.CHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: Status post cholecystectomy. Heterogenous liver attenuation noted.SPLEEN: Splenule again noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Right renal cysts are unchanged compared to prior.RETROPERITONEUM, LYMPH NODES: No significant retroperitoneal lymphadenopathy.BOWEL, MESENTERY: No evidence of bowel obstruction or bowel wall thickening.BONES, SOFT TISSUES: No suspicious sclerotic bone lesions seen.OTHER: No significant abnormality noted.PELVIS:PROSTATE, SEMINAL VESICLES: Metallic seeds are again noted in the prostate.BLADDER: No significant abnormality noted.LYMPH NODES: No significant pelvic lymphadenopathy.BOWEL, MESENTERY: No evidence of bowel obstruction or bowel wall thickening.BONES, SOFT TISSUES: No suspicious appearing sclerotic bone lesions.OTHER: No significant abnormality noted | 1.No evidence of recurrent or metastatic disease.2.Heterogenous liver attenuation is suggestive of patchy fatty infiltration. |
Generate impression based on findings. | NSCLC with left neck/shoulder discomfort. Known DJD. The images are degraded by motion artifact.Nevertheless, there is no evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. There is unchanged mild enlargement and heterogeneity of the thyroid gland. The salivary glands are unremarkable. The major cervical vessels are patent. There is multilevel degenerative cervical spondylosis. The airways are patent. The imaged intracranial structures are unremarkable. There is focal prominence of the left superior ophthalmic vein, which likely represents a varix. There are partially-imaged pulmonary opacities. | 1. No significant lymphadenopathy in the neck.2. Partially-imaged pulmonary opacities. Please refer to the separate chest CT report for additional details. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: No significant abnormality noted. Mild dependent atelectasis is noted.MEDIASTINUM AND HILA: There is no mediastinal or hilar lymphadenopathy.There no visible coronary calcifications, and the heart and pericardium appear normal.CHEST WALL: No significant abnormality noted.ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pathology. LIVER, BILIARY TRACT: Previously suspected hemangioma not imaged on this later phase of contrast, and liver appears normal.SPLEEN: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Benign-appearing right renal cysts.PANCREAS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: Aortic atherosclerotic calcifications.BOWEL, MESENTERY: Absence of enteric contrast material limits sensitivity for GI pathology.No gross abnormalities noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | No sign of metastases, or other significant abnormality. |
Generate impression based on findings. | 44-year-old female with a history of left lumpectomy in 2012 for DCIS. Patient received radiation therapy. No new breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. Post surgical scar with multiple surgical clips is re-demonstrated at upper outer quadrant in the left breast without significant change. No suspicious mass, suspicious microcalcifications or suspicious areas of architectural distortion are noted in either breast. | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Hemangioma liver ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant change in large right posterior segment hepatic lobe lesion again consistent with hemangioma measuring 9.4 x 11.4 cm. other bilobar low attenuation foci also stable.No ductal dilatation. Hepatic vessels patent.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: No significant abnormality notedRETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Status post gastric bypass.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:UTERUS, ADNEXA: No significant abnormality notedBLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: Interval resolution of loculated left pelvic subcutaneous tissue collection.OTHER: No significant abnormality noted | Stable right lobe hemangioma and other bilobar low attenuation hepatic foci. Interval resolution of loculated left pelvic subcutaneous tissue collection. |
Generate impression based on findings. | 25 years old Male. Reason: large pelvic mass, presumed lymphoma. History: large pelvic mass, presumed lymphoma. RADIOPHARMACEUTICAL: 9.0 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 80 mg/dL. Today's CT portion grossly demonstrates a large likely retroperitoneal pelvic and left inguinal masses, bilateral renal low attenuation lesions, and left percutaneous nephrostomy tube in place. Subcutaneous edema is seen in the left thigh.Today's PET examination demonstrates intense FDG uptake in the masses in the pelvis and left inguinal regions with a SUVmax in the pelvic mass of 31.9. There is a focus of increased activity in the right proximal thigh. There are multiple foci of increased activity in the right upper neck at paraspinal region, bilateral lower neck and bilateral supraclavicular regions. Multiple foci with increased activity are also seen in the upper mediastinal regions.Numerous foci of increased activity in the abdomen in both kidneys, retroperitoneal cavity, porta hepatis, and peripancreatic space. Multiple hypermetabolic lymph nodes are also seen in the mesentery. Foci of increased activity are seen in the bilateral proximal femurs. | 1.Extensive hypermetabolic lymphadenopathy in the neck, mediastinum, abdomen, pelvis, left inguinal region and right proximal thigh, as well as hypermetabolic masses in the pelvis, consistent with patient's diagnosis of lymphoma.2.Multiple hypermetabolic renal lesions, suspicious for tumor involvement.3.Osseous metastatic lesions in the bilateral proximal femurs. |
Generate impression based on findings. | Reason: evaluate ET placement History: evaluate ET placement, re-intubatedVIEW: Chest AP (one view) 3/10/2015, 1108 Enteric tube with proximal sideport above the level of the GE junction. ET tube tip below the thoracic inlet and above the carina.The cardiac silhouette is enlarged.Diffuse pulmonary opacities compatible with edema. | Diffuse pulmonary edema with increasing cardiac size is concerning for left to right shunt; patent ductus arteriosis is the most common consideration. |
Generate impression based on findings. | Scoliosis.VIEWS: Spine supine AP/lateral (two views) 03/10/15 A gastrostomy tube is present. There is a moderate amount of feces in the rectosigmoid. The left femoral head is displaced superiorly from the dysplastic acetabulum.Right curve between T6 and L4 measures 115 degrees. Hyperlordosis of the lumbar spine is noted. | Right thoracolumbar curve of 115 degrees. |
Generate impression based on findings. | Reason: Additional burden of disease s/p chemoRT History: Persistent laryngeal mass RADIOPHARMACEUTICAL: 12.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 100 mg/dL. Today's CT portion demonstrates asymmetric laryngeal mucosal thickening. A tracheostomy tube is in place. There are scattered calcified and noncalcified mediastinal and hilar lymph nodes. There are also scattered calcified and noncalcified bilateral pulmonary nodules. Opacities in the lung bases are most consistent with scarring/atelectasis. There is cholelithiasis without secondary signs of inflammation. There is a small fat containing umbilical hernia. A gastrostomy tube is in place.Today's PET examination demonstrates focal increased metabolic activity in the right upper larynx just below the right hyoid bone (SUV 7.5), highly suspicious for residual tumor. Linear activity in the left prevertebral space likely reflects muscle activity. Mild activity in the left lower lobe pulmonary opacity, as well as a left axillary lymph node and multiple calcified mediastinal lymph nodes are most likely inflammatory in etiology. There is no focal hypermetabolism to specifically suggest tumor in the chest abdomen or pelvis. Increased activity along the tracheostomy and gastrostomy sites are consistent with postprocedural changes. | 1. Focal hypermetabolism in the right superior larynx at the level of and just below the right hyoid bone is highly suspicious for residual tumor. 2. No evidence of metastatic disease in the chest, abdomen, or pelvis. 3. Basilar pulmonary opacities with mild activity are most compatible with atelectasis and prior inflammation. 4. Scattered pulmonary nodules, the majority of which are calcified, are most likely post-inflammatory in etiology. However, continued CT follow up of the smaller non-calcified nodules is recommended to assure stability if not already documented. 5. Scattered calcified mediastinal and hilar lymph nodes are compatible with prior granulomatous disease. |
Generate impression based on findings. | 67-year-old male with metastatic lung carcinoma to left chest and pleura CHEST:LUNGS AND PLEURA: Significant decrease in loculated left basilar pleural effusion. Reference spiculated left lower lobe nodule cannot be accurately measured due to surrounding atelectasis and pleural effusion.Previously noted superior segment left lower lobe pulmonary opacity is decreased in size now measuring 1.7 x 2 .9 cm, previously 2.5 x 3.7 cm (series 4, image 133). Additional scattered calcified and noncalcified nodules are unchanged since prior exam.Right upper lobe pleural-based nodularity and calcifications.MEDIASTINUM AND HILA: Near complete resolution of necrotic appearing prevascular lymph node. Heart size is normal. No pericardial effusion. Mild to moderate coronary artery calcifications.CHEST WALL: No significant axillary, retrocrural, or cardiophrenic lymphadenopathy. Stable sclerotic focus in the left ninth rib. Lytic focus with a sclerotic margin in the L3 vertebral body. Slight interval decrease in size of the left supraclavicular lymph node (series 3, image 8).ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pathology. LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.ADRENAL GLANDS: Left adrenal nodularity is unchanged since prior exam.KIDNEYS, URETERS: No significant abnormality noted.PANCREAS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Absence of enteric contrast material limits sensitivity for GI pathology.No gross abnormalities noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | 1.Significant interval decrease in loculated left basilar pleural effusion.2.Interval decrease in mediastinal lymphadenopathy as described above.3.Interval decrease in opacity in the superior segment of the left lower lobe as described above. |
Generate impression based on findings. | 49-year-old female with history of esophageal cancer and malignant pleural effusion PULMONARY ARTERIES: Adequate pulmonary artery opacification without evidence of pulmonary embolism segmental arteries. The main pulmonary artery is within normal limits.LUNGS AND PLEURA: Unchanged large right pleural effusion with adjacent atelectasis is again noted. Small left pleural effusion is again noted. New right lower lobe groundglass opacities may reflect aspiration or edema.Bilateral pulmonary nodules are stable. Right upper lobe micronodule (series 8, image 50) is unchanged.Reference left apical nodule (series 8, image 39) measures 7 mm, previously 7 mm.Reference right lower lobe nodule (series 8, image 154) measures 6 mm, previously 5 mm.Medial left lower lobe opacity with traction bronchiectasis is unchanged since prior exam.MEDIASTINUM AND HILA: Hypodense nodule in the left thyroid lobe. Left chest port catheter tip in the SVC. No significant hilar or mediastinal lymphadenopathy. Distal esophageal mass is again noted, unchanged. Esophageal stent with circumferential esophageal wall thickening of the mid and distal esophagus is again noted. Debris is noted within the esophagus. The heart size is normal. No visible coronary artery calcification. Small pericardial effusion. CHEST WALL: Again noted is a right anterior chest wall mass measuring 21 mm (series 7, image 180).UPPER ABDOMEN: Absence of enteric contrast material markedly limits sensitivity for abdominal pathology. No significant abnormality noted. | 1.No evidence pulmonary embolism.2.New right lower lobe ground glass opacities may reflect aspiration or edema.3.Unchanged large right and small left pleural effusions.PULMONARY EMBOLISM: PE: Negative..Chronicity: Not applicable..Multiplicity: Not applicable..Most Proximal: Not applicable..RV Strain: Not applicable.. |
Generate impression based on findings. | Hip dysplasia.VIEWS: Pelvis AP/frog leg (two views) 03/10/15 The femoral head articulates with a pseudoacetabulum bilaterally. The acetabula are dysplastic. Bilateral coxa valga is present.A moderate amount of feces is seen in the rectosigmoid. | Bilateral developmental hip dysplasia. |
Generate impression based on findings. | 57 year old female status post right lumpectomy and axillary lymph node dissection in 2006 for IDC, presents today for 6 month follow up. Patient received radiation and chemotherapy. History of bilateral reduction mammoplasty in 2004 and June 2014. No current breast complaints. Family history of breast carcinoma in her paternal aunt. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. Linear markers have been placed on scars overlying the lower central left breast, upper outer far posterior left breast, and left periareolar regions. Expected underlying postsurgical changes are present. A biopsy clip is present within the upper slightly inner left breast. Scattered benign calcifications are present. The previously identified architectural distortion and increased density within the lateral left breast is not present on today's exam. At the time of the prior examination, these findings were felt to be due to recent postsurgical changes. Nonvisualization on today's examination likely represents resolved postsurgical seroma/hematoma. | Postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Reason: HNSCC. Compare to previous. 12-1972 study. History: as above. CHEST:LUNGS AND PLEURA: Centrilobular emphysema again noted. Increased moderate right and new trace left pleural effusions are present with increased compressive atelectasis as well as right basilar consolidation.Reference lesions are as follows (series 6):Right lower lobe mass has increased markedly in size measuring 6.1 to 6.2 cm (image 156), from previously 5.5 x 4.6 cm. Right basilar consolidation obscures the other reference right lower lobe, though other right-sided nodules are also noted to have increased in size.Left-sided nodules are also slightly increased in size. Left apical spiculated nodule measures 1.8 x 1.4 cm (image 22), from previously 2.0 x 1.0 cm. Additional left upper lobe nodule measures 1.7 cm (image 80), from previously 1.3 cm. Medial left lower lobe mass measures 4.5 x 3.6 cm (image 202), from 3.5 x 3.5 cm.MEDIASTINUM AND HILA: Mediastinal adenopathy again noted. Reference precarinal lymph node measures 14 mm (series 4, image 36), unchanged from previously 14 mm. Heart size normal. Calcified prevascular lymphadenopathy is again noted. Moderate pericardial effusion appears slightly increased. . Right chest wall port catheter tip in the SVC.CHEST WALL: No axillary adenopathy.ABDOMEN: Absence of IV and enteric contrast material limits sensitivity for abdominal pathology. LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: Few granulomata.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Stable right renal cyst.PANCREAS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: Moderate atherosclerotic calcifications affect the abdominal aorta.BOWEL, MESENTERY: Absence of enteric contrast material limits sensitivity for GI pathology.Gastrostomy tube present.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted. | Mild interval progression in size of pulmonary metastases.Increased right lower lobe consolidation.Increased moderate right and new trace left pleural effusions. |
Generate impression based on findings. | 18 year-old male with history of trauma to the left jaw. An oblique fracture through the angle of the left mandible extends to the root of the third left mandibular molar. There is associated mild periapical lucency. | Oblique fracture through the angle of the left mandible. |
Generate impression based on findings. | Female; 78 years old. Reason: GIST: Restaging CHEST:LUNGS AND PLEURA: Left upper lobe nodule (series 8/86) has mildly increased in size and currently measures 6 x 5 mm, previously 4 x 5 mm on 12/2/14 and 4 x 4 mm on 7/1/14. A small, predominantly linear opacity just medial to this nodule is also mildly increased in size. These findings are nonspecific and may be due to post infectious or inflammatory scarring, though metastasis cannot be excluded.Additional scattered pulmonary micronodules, some of which are calcified, are stable. No additional suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: Stable appearance of multinodular thyroid. Normal heart size without pericardial effusion. Severe coronary arterial calcifications. No mediastinal or hilar lymphadenopathy.CHEST WALL: No axillary lymphadenopathy. Left chest wall AICD pacemaker in place.ABDOMEN:LIVER, BILIARY TRACT: Status post cholecystectomy. No biliary ductal dilation. Small, peripheral, wedge-shaped hyperenhancing focus in the posterior dome of the liver seen only on arterial phase is most compatible with THAD (series 6/28). No suspicious liver lesions.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Stable solid heterogeneously-enhancing right upper pole mass measuring 2.9 x 2.6 cm, previously 2.9 x 2.6 cm (series 7/85). Additional hypodense lesions in both kidneys are stable and most compatible with simple cysts.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Partially calcified mass on the posterior aspect of the stomach measures 3.6 x 1.6 cm, previously 3.6 x 1.7 cm and not significantly changed (series 7/77).BONES, SOFT TISSUES: Stable degenerative arthritic changes, including grade 2 anterolisthesis of L5 on S1.OTHER: No significant abnormality noted.PELVIS:UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: Stable degenerative arthritic changes, including grade 2 anterolisthesis of L5 on S1.OTHER: No significant abnormality noted. | 1. Nonspecific left upper lobe pulmonary nodule and adjacent linear opacity has mildly increased in size. The etiology may be post infectious or inflammatory scarring, but metastasis cannot be entirely excluded. Attention at follow-up is recommended.2. Stable right renal solid mass, suspicious for renal cell carcinoma.3. Stable posterior gastric mass. |
Generate impression based on findings. | Status post fracture.VIEWS: Left femur AP and lateral 3/9/15 (two views) Cast material obscures fine bone detail. Healing left femur fracture with profuse callus formation , mild overlapping , medial displacement and dorsal angulation is unchanged in alignment. | Healing fracture, unchanged in alignment. |
Generate impression based on findings. | 21 year old female with right breast 2:00 position palpable area of concern, possible fibroadenoma. Right ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a hypoechoic area measuring 20 mm at the 2 o’clock position without increased vascularity, 3 cm from the nipple. The lesion was readily visible.PROCEDURE: The procedure and its risks, including bleeding, infection, and failure to diagnose, and expected benefits of ultrasound-guided core biopsy with percutaneous placement of a marking clip and post-procedure unilateral mammogram were discussed with the patient. Questions were answered. Consent was obtained both verbally and in writing. The time-out form was completed to confirm patient identity and side/type of procedure.The right breast was cleansed with chlorhexidine over the target area. Transducer was sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially, with 1% lidocaine with 1:100,000 epinephrine at depth. A 3 mm incision was made in the skin with a #11 scalpel blade. Using aseptic technique, continuous ultrasound guidance and a inferior to superior approach, three 14-gauge core needle (Inrad) specimens were obtained of the lesion. Targeting was judged good. All specimens sank to the bottom of the prefilled container of 10% formalin. No specimens floated. Specimen quality was judged good.Specimens were sent to Pathology with an accompanying history sheet. Using continuous ultrasound-guidance a Hydromark clip was placed into the lesion in the usual manner. Pressure was held over the biopsy site until all bleeding subsided. The skin incision was closed with a Steri-Strip. Post biopsy mammogram was deferred based on the patient's age and the ability to see the Hydromark clip on ultrasound. A pressure dressing was positioned over the biopsy site and an ice pack positioned over the pressure dressing. Post-procedure instructions were reviewed with the patient both verbally and in writing. She tolerated the procedure well with no evident complications and left the Breast Imaging Department in stable condition.The procedure was performed by Dr. Lai. Dr. Schacht was present during the procedure at all times. | Successful ultrasound-guided core biopsy of the right breast lesion and clip placement. This is most likely a fibroadenoma or other benign etiology. Pathology is pending at this time.BIRADS: 3 - Probably benign finding.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 26-year-old male with pain and swelling of the second and third PIP joints x 3 weeks since injury to the right hand while ice climbing. There is no acute fracture or dislocation. The joint spaces appear well preserved. There is mild soft tissue swelling surrounding the second and third proximal interphalangeal joints. | Soft tissue swelling surrounding the second and third proximal interphalangeal joint, without acute fracture or malalignment. |
Generate impression based on findings. | Scoliosis.EXAMINATION: Spine AP (one view) 03/10/15 A gastrostomy tube is present. A small to moderate amount of feces is noted in the rectosigmoidLeft curve between T11 and L4 measures 35 degrees. | Increase in left thoracolumbar curve. |
Generate impression based on findings. | 36 year old male with right upper quadrant pain, history of gallstones. LIVER: Liver is normal in echogenicity measuring 18.2 cm in length. Main portal vein is patent with appropriate directional flow. No focal hepatic lesions. GALLBLADDER, BILIARY TRACT: Gallbladder is mildly distended with no evidence of gallbladder sludge or shadowing calculi. Gallbladder wall is thickened measuring 5 mm in thickness. There is trace amount of pericholecystic fluid. Sonographic Murphy's sign is positive. Common bile duct measures 4 mm in caliber. PANCREAS: The visualized portions of the pancreas are normal in echogenicity with no evidence of pancreatic ductal dilatation.RIGHT KIDNEY: Measures 7.9 cm in length with increased echogenicity. No evidence of hydronephrosis.OTHER: Spleen is normal in echogenicity measuring 10.6 cm in length.Left kidney measures 9.4 cm in length with increased echogenicity. There is a partially calcified cyst at the midpole measuring 2.8 cm x 2.0 cm x 2.6 cm. | 1. Findings are suspicious for acute cholecystitis in the appropriate clinical setting with no evidence of shadowing calculi. 2. Increased echogenicity of the kidneys suggestive of parenchymal dysfunction. Left renal cyst with associated calcification. Findings were discussed with ER physician Dr. Benjamin Savitch by phone on 3/10/2015 at 12:30 PM. |
Generate impression based on findings. | 18 year-old female with right thumb pain. Two views of the right thumb reveal normal anatomic alignment. There is no fracture or dislocation. There is no significant soft tissue swelling. | No acute fracture or malalignment. |
Generate impression based on findings. | 63-year-old female with left foot pain; history of left foot fracture. There is an oblique spiral fracture through the body of the fifth metatarsal, with mild medial and dorsal displacement of the distal fracture fragment. There is a linear metallic foreign body in the soft tissues overlying the fifth proximal phalanx. There is joint space narrowing and subchondral sclerosis of the first metatarsophalangeal joint, consistent with osteoarthritis. There is multifocal small vessel calcifications in the distal leg and foot. A large plantar heel spur is present. | Oblique spiral fracture through the body of the fifth metatarsal with mild medial/dorsal displacement of the distal fracture fragment. Metallic foreign body in the soft tissues overlying the fifth proximal phalanx. |
Generate impression based on findings. | Pain. Preoperative evaluation for right total hip arthroplasty MAKO robotic system. CT images of the right hip reveal severe superior joint space narrowing, subchondral sclerosis, and subchondral cyst formation. No fracture is evident.CT images of the pelvis show joint space narrowing, sclerosis, and subchondral cyst formation at the pubis symphysis. There is sclerosis of the superior aspect of the left sacroiliac joint. Extensive facet degenerative changes of the lower lumbar spine are also noted. There is mild to moderate joint space narrowing and subchondral cyst formation of the left hip joint. No fracture is identified.Limited CT images of the bilateral knees are unremarkable. | 1. Severe right hip osteoarthritis and moderate left hip osteoarthritis.2. Degenerative changes of the lower lumber spine, left sacroiliac joint, and pubic symphysis. |
Generate impression based on findings. | 41 year old with history of right breast ILC status post modified radical mastectomy and chemoradiation in 2009. No breast symptoms currently. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. No suspicious mass, suspicious microcalcifications or suspicious areas of architectural distortion are noted in left breast. | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, left unilateral diagnostic mammogram is recommended annually. In view of patient's history of breast cancer in young age, breast MRI is useful for screening. Results and recommendations were discussed with the patient through interpreter. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Reason: followup lung CA, s/p resection, RT. Also bronchiectasis and repeated infections. History: some cough LUNGS AND PLEURA: Decreased centrilobular nodules in the posterior left lower lobe. Near complete resolution of the previous patchy foci of consolidation within the left costophrenic angle.Stable small right pleural effusion. Postsurgical changes reflect prior right upper lobectomy with significant right-sided volume loss. The right middle lobe is nearly completely atelectatic with bronchiectasis and scattered foci of consolidation. The previously described right lower lobe fluid-filled cavity has not significantly changed in size with decreased quantity of internal fluid. Potential interval change in the wall thickening cannot be accurately assessed; however, there is improved aeration around the medial aspect of the abscess cavity.Extensive centrilobular emphysema unchanged.MEDIASTINUM AND HILA: Persistent rightward mediastinal shift secondary to right-sided volume loss. Extensive atherosclerotic disease of aorta and coronary arteries. The heart size remains normal. No pericardial effusion. The density to the blood pool indicative of anemia.No interval mediastinal lymphadenopathy.The esophagus remains patulous. There is debris within the central trachea and central mainstem bronchi..CHEST WALL: Persistent postsurgical changes of the right sided ribs with osseous bridging at multiple levels. UPPER ABDOMEN: Absence of IV and enteric contrast material limits sensitivity for abdominal pathology. No significant abnormality noted. | Persistent fluid filled cavity in the right lower lobe with associated atelectasis and consolidation slightly decreased adjacent to the medial wall.Improved bronchiectasis and centrilobular nodules within the left lower lobe, most likely related to recurrent aspiration/infection. Near resolution of previous consolidation at the left costophrenic angle. |
Generate impression based on findings. | 66-year-old male with head and neck cancer CHEST:LUNGS AND PLEURA: Unchanged biapical scarring. No significant change in small ground glass opacities within the right lung base (series 4, image 250). Interval resolution in cluster of micronodules in the posterior basal segment of the left lower lobe. Unchanged scattered nonspecific micronodules. No suspicious nodules are noted. No pleural effusion or pneumothorax. No consolidations suggest pneumonia.MEDIASTINUM AND HILA: No significant mediastinal or hilar lymphadenopathy. The heart size is normal without pericardial effusion. Moderate coronary artery calcifications. Atherosclerotic calcifications affect the aorta.CHEST WALL: No axillary, retrocrural or cardiophrenic lymphadenopathy. No suspicious osseous lesions.ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pathology. LIVER, BILIARY TRACT: Stable subcentimeter hypoattenuating hepatic lesions, too small to characterized. Cholelithiasis without CT evidence of cholecystitis.SPLEEN: No significant abnormality noted.ADRENAL GLANDS: Unchanged nodularity to the left adrenal gland.KIDNEYS, URETERS: Punctate calcifications within the left likely represent non-obstructing stones. Linear calcification in the right kidney likely represents vascular calcifications. Hypodense lesions in the kidneys bilaterally likely represent benign cysts.PANCREAS: Small punctate calcification in the head of the pancreas is unchanged.RETROPERITONEUM, LYMPH NODES: Scattered retroperitoneal lymph nodes not significantly enlarged CT size criteria.BOWEL, MESENTERY: Absence of enteric contrast material limits sensitivity for GI pathology.No gross abnormalities noted.BONES, SOFT TISSUES: Healing left ninth rib fracture. No suspicious osseous lesions.OTHER: No significant abnormality noted. | No evidence of metastatic disease. No significant interval change since the prior exam. |
Generate impression based on findings. | 85-year-old male with cervical esophageal cancer. CHEST:LUNGS AND PLEURA: Stable left apical and bilateral paramediastinal fibrotic changes, right greater than left. No consolidation or suspicious nodularity. Trace bilateral pleural effusions. MEDIASTINUM AND HILA: Moderate cardiomegaly; the right atrium and the ventricle are mildly dilated. Severe coronary calcifications are noted. No pericardial effusion is present. Enlarged pulmonary trunk is compatible with pulmonary arterial hypertension. Mildly ectatic descending aorta, measuring 4.2 cm in diameter. Tracheostomy again noted. No obvious esophageal lesion is identified.CHEST WALL: Left subclavian AICD.ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pathology. LIVER, BILIARY TRACT: Interval increase in bilobar intrahepatic as well as extrahepatic biliary ductal dilatation. The common duct measures up to 11 mm (coronal image 43).SPLEEN: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Stable right renal parapelvic cyst.PANCREAS: Pancreas is atrophic with increased pancreatic ductal dilatation, up to 7 mm in diameter. RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Absence of enteric contrast material limits sensitivity for GI pathology.The balloon of the gastrostomy tube appears retracted into the tract from the abdominal wall , though not significantly changed from the previous exam.BONES, SOFT TISSUES: Stable degenerative changes of the visualized spine.OTHER: No significant abnormality noted. | 1.Increased intrahepatic and extrahepatic biliary ductal dilatation and pancreatic ductal dilatation of unclear etiology.2.No specific evidence of metastatic disease.3.Gastrostomy tube balloon is partially retracted into its tract.Findings discussed with Dr. Saloura at 3:59 PM on 3/10/2015. |
Generate impression based on findings. | Hip dislocation.EXAMINATION: Pelvis AP/frog leg (two views) 03/10/15 The femoral heads are well directed into normally formed acetabula. No fracture is identified. | Normal examination. |
Generate impression based on findings. | Right hip pain. Two views of the right hip show a right total hip arthroplasty device in anatomic alignment without evidence of loosening or hardware failure. There is heterotopic ossification about the greater trochanter. No acute fracture is evident. Vascular calcifications are noted.Two views of the right femur again show a right total hip arthroplasty. No acute fracture is evident. | Right total hip arthroplasty device without evidence of hardware complication. |
Generate impression based on findings. | Female 80 years old; Reason: evaluate for metastasis. History: leiomyosarcoma of intestine. CHEST:LUNGS AND PLEURA: Scattered, nonspecific micronodules and peripheral reticular opacities and honeycombing, not significantly changed.MEDIASTINUM AND HILA: Redemonstrated cardiomegaly. Coronary artery calcifications. Pulmonary artery upper limits normal measuring up to 30 mm.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: Moderate calcification of the abdominal aorta and its branches.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.PELVIS:UTERUS, ADNEXA: Unchanged 2.5-cm left ovarian cyst.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: Partially visualized, unchanged 3.1 x 1.8cm left labial soft tissue attenuation.OTHER: No significant abnormality noted. | 1.No significant change from prior study.2.Prominence of the pulmonary artery could be secondary to underlying pulmonary artery hypertension. Correlate clinically. |
Generate impression based on findings. | Neck pain, crepitus, limited range of motion with rotation. Question of osteoarthritis, structural abnormality, or chronic problem. Five views of the cervical spine reveal no acute fracture or dislocation. Vertebral body heights are maintained. There is ossification of the anterior longitudinal ligament. There is narrowing and sclerosis of the apophyseal joints of the upper cervical spine. | Anterior syndesmophyte formation of the cervical spine; this appearance raises the question of a seronegative spondyloarthropathy. |
Generate impression based on findings. | Lumbar pain. Three views of the lumbar spine reveal no acute fracture. Vertebral body heights are maintained. There is severe degenerative disk disease of L3/L4 and L4/L5. Alignment is anatomic. | Severe degenerative disk disease of the lower lumbar spine as above. |
Generate impression based on findings. | 57-year-old female with history of DCIS with pulmonary nodule. Follow-up exam. LUNGS AND PLEURA: Single left lower lobe 4-mm pulmonary nodule is stable from exam dated 6/27/2013. No new or suspicious pulmonary nodules identified.MEDIASTINUM AND HILA: Heart size is normal with no pericardial effusion. No mediastinal or hilar lymphadenopathy. Minimal atherosclerotic calcifications of the thoracic aorta. No coronary calcifications are identified.CHEST WALL: No axillary lymphadenopathy.UPPER ABDOMEN: Absence of IV and enteric contrast material limits sensitivity for abdominal pathology. No significant abnormality noted. | Solitary 4-mm left lower lobe pulmonary nodule, stable for one year, likely an intrapulmonary lymph node. It has been almost one year since this examination was performed. |
Generate impression based on findings. | Follow-up examination. History of first MTP joint fusion. There is a plate and screw device affixing the first metatarsophalangeal joint in anatomic alignment. There is no evidence of hardware complication or change in position from the previous study. Mild osteoarthritis affects the interphalangeal joints. | Orthopedic fixation of the first MTP joint as above. |
Generate impression based on findings. | Pain and fall 3 weeks ago. Question of fracture. There is a healing left inferior pubic ramus fracture. There is a left total hip arthroplasty device situated in anatomic alignment. There is no evidence of loosening or hardware complication. aMinimal heterotopic ossification is noted superior to the greater trochanter, unchanged. There are vascular calcifications. Surgical clips project over the left pelvis. | 1. Healing left inferior pubic ramus fracture; a pelvic radiograph should be obtained to assess for additional fractures. Findings communicated via phone to G. Borrelli at 1308 hrs on 3/10/2015.2. Left total hip arthroplasty device without evidence of complication. |
Generate impression based on findings. | Motor vehicle accident on 2/11. Continued pain. Rule-out fracture.VIEWS: Left shoulder internal rotation/external rotation/Y (3 views) 03/10/15 The humeral head is normally positioned with respect to the glenoid fossa. No fracture is identified. The bones are normal in appearance. | Normal examination. |
Generate impression based on findings. | Follow-up for radius and ulnar fractures. Cast material obscures fine bone detail. There is redemonstration of a comminuted distal radius fracture in near anatomic alignment. The ulnar styloid fracture is in near anatomic alignment. | Distal radius and ulnar styloid fractures in near-anatomic alignment. |
Generate impression based on findings. | Impingement. Question of shoulder arthritis. No acute fracture or dislocation is evident. There is irregularity of the posterior lateral humeral head which is likely degenerative. There is mild osteophyte formation at the glenohumeral and acromioclavicular joints. | Mild osteoarthritis of the left shoulder. |
Generate impression based on findings. | Cervical radiculopathy. Question of DJD. No acute fracture is evident. There is moderate to severe degenerative disk disease affecting the entire cervical spine. The neural foramina appear grossly patent on the oblique views. Vertebral body heights are maintained. | Degenerative disk disease of the cervical spine. |
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