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Generate impression based on findings. | 44-year-old male patient with left lower quadrant pain. Evaluate for infection. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: There is a small hypoattenuating lesion in segment 6 of the liver. There is an additional hyperattenuating lesion in the inferior portion of segment 5 that measures 1... | 1.No acute intra-abdominal abnormalities to account for patient's symptoms.2.Incidental liver lesions are incompletely characterized and are favored to be benign in etiology, such as hemangiomas or focal nodular hyperplasia.3.Right adrenal nodule is incompletely evaluated.4.Splenic lesions are favored to be benign, suc... |
Generate impression based on findings. | Trauma to right maxillary area 6 wks ago with persistent swelling. There is extensive mucosal thickening and fluid within the paranasal sinuses diffusely with relative sparing of the frontal sinuses. The nasal septum is deviated slightly to the right. There is mild stranding in the right cheek subcutaneous tissues. The... | 1. Extensive paranasal sinus inflammatory changes with signs of acute sinusitis.2. Carious tooth # 30 with periodontal disease.3. Apparent residue of a right cheek contusion, but no evidence of maxillofacial fractures. |
Generate impression based on findings. | 67-year-old female with ascites, jaundice and history of cholangiocarcinoma. Evaluate blood flow in liver LIMITED ABDOMENLIVER: Coarse echogenicity of the liver measuring 16.3 cm in length. No focal hepatic lesions.BILIARY TRACT: Gallbladder wall opacification of thickening unchanged. No pericholecystic fluid. Sonograp... | 1. Coarse echogenicity of the liver suggestive of parenchymal dysfunction/fatty infiltration.2. Gallbladder wall thickening and calcification unchanged. 3. Stable mild to moderate bilobar intrahepatic biliary ductal dilatation. 4. Splenomegaly. 5. Patent inflow and outflow hepatic vasculature. |
Generate impression based on findings. | Male 15 months old Reason: pulmonary edema/ pleural effusion History: Status post cardiac surgeryVIEW: Chest AP (one view) 3/12/15 at 1621 hrs. Central line, mediastinal clips, epicardial pacer leads and right-sided chest tube unchanged. Cardiac silhouette size is top normal but stable. Subsegmental atelectasis of the ... | Segmental atelectasis of the right upper lobe. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are digital mammographic images (11/10/14), ultrasound images of left breast (11/10/14), ultrasound images of both breasts (11/25/14), ultrasound images for both breasts (2/18/15) performed at Good Shepherd Hospital. For comparison, digital mammographic... | No mammographic or sonographic evidence for malignancy. Annual mammogram and possible whole breast ultrasound study is recommended.BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Routine Screening Mammogram. |
Generate impression based on findings. | T3N2b squamous cell carcinoma of the right tonsil (HPV+), status post induction chemotherapy and then concurrent chemoradiation. There is a new heterogeneous mass within the left cerebellar hemisphere that measures up to approximately 25 mm with surrounding edema and partial effacement of the fourth ventricle. Otherwis... | 1. A new heterogeneous mass within the left cerebellar hemisphere that measures up to approximately 25 mm with surrounding edema and partial effacement of the fourth ventricle likely represents a metastasis. A brain MRI with contrast is recommended for further evaluation.2. Post-treatment findings without evidence of m... |
Generate impression based on findings. | 53-year-old male with pleural mesothelioma right bidimensional measurements per RECIST1.1 criteria and compare to prior exam. CHEST:LUNGS AND PLEURA: Postsurgical changes of a right thoracotomy are noted. Right pleural nodularity is not significantly changed since the prior exam. Reference measurements as follows:At th... | Slight interval increase in right pleural reference measurements and chest wall tumor. Enlargement of pulmonary nodules. |
Generate impression based on findings. | 67-year-old female with right wrist pain. Three views of the right wrist demonstrate calcification of the triangular fibrocartilage complex as well as the scapholunate ligament, suggestive of calcium pyrophosphate deposition disease. There is positive ulnar variance and sclerosis of the proximal pole of the lunate, sug... | Findings suggestive of moderate osteoarthritis, CPPD, and ulnar abutment syndrome. Significant soft tissue swelling, without discrete fracture identified. |
Generate impression based on findings. | 42 year old female with a history of hyperlipidemia presented to the ED for chest pain radiating to the jaw and left arm. CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of valsalva and bifurcates into the left anterior descending and left circumflex coronary art... | There are no significant coronary artery stenoses present. Mild, diffuse mixed plaques of the mid-LAD and mid-RCA. |
Generate impression based on findings. | 33 year old female with abdominal pain, elevated lipase. Evaluate for acute cholecystitis or pancreatitis LIVER: Normal echogenicity of the liver measuring 17.6 cm in length. No focal hepatic lesions.GALLBLADDER, BILIARY TRACT: Shadowing calculi are noted within the gallbladder. No pericholecystic fluid. No gallbladder... | Cholelithiasis without evidence of cholecystitis. |
Generate impression based on findings. | Bilateral knee pain. History of right knee posterior horn medial meniscal tear. Assess for arthritis. Three views of the right knee reveal moderate to severe medial compartment joint space narrowing and tricompartmental osteophyte formation. A small joint effusion is noted. No acute fracture is evident.Three views of t... | 1. Moderate to severe right knee osteoarthritis.2. Mild left knee osteoarthritis. |
Generate impression based on findings. | Postoperative findings are seen with scattered surgical clips and scarring. PHARYNX/LARYNX: Oropharyngeal, hypopharyngeal and laryngeal mucosal thickening persists. There is further slight increased density within the paraglottic fat, although without discrete mass. The degree of mucosal enhancement appears somewhat d... | Redemonstration of post treatment changes without evidence of cervical lymphadenopathy or recurrent disease. |
Generate impression based on findings. | 44 year old male with mitral valve prolapse, referred for cardiac CT to evaluate aorta and coronary arteries. Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of valsalva and bifurcates into the left anterior descending and left circumflex coronary arteries. There are no signific... | 1.No significant coronary artery stenoses are present.2.Small, non-calcified nodule in the peripheral right upper lobe measuring 3mm in diameter. 3.Mild gynecomastia with asymmetric nodularity of the left breast, please see above.4.Vascular dimensions will be reported later in an addendum to this report. |
Generate impression based on findings. | 59-year-old male with right knee pain. Two views of the right knee demonstrate a healed proximal fibular fracture. There is mild osteoarthritis and a small joint effusion. There is no acute fracture or malalignment. | Mild osteoarthritis and a small joint effusion. |
Generate impression based on findings. | Female 68 years old Reason: fracture, History: swelling, pain Bone mineralization is decreased. There is severe right osteoarthritis there is a small joint effusion. No acute fracture is evident. | Severe right knee osteoarthritis. |
Generate impression based on findings. | Female 64 years old Reason: right knee pain History: right knee pain Moderate osteoarthritis affects the right knee with moderate medial compartment joint space narrowing and tricompartmental osteophytes. There is a small joint effusion. No acute fracture or malalignment. | Moderate right knee osteoarthritis |
Generate impression based on findings. | History of knee surgery. Now with recurrent knee pain. Moderate osteoarthritis affects the knee, particularly the patellofemoral joint, that appears to have progressed slightly since the prior study. There is a small to moderate sized joint effusion. There is a small well corticated ossicle along the tip of fibular sty... | Moderate osteoarthritis and joint effusion. |
Generate impression based on findings. | Male 59 years old Reason: Assess shoulder for arthritis, signs of impringement History: Left shoulder pain Bone mineralization is normal. Alignment is anatomic. The joint space is normal.Mild osteoarthritis affects the AC joint. | Mild osteoarthritis of the AC joint. |
Generate impression based on findings. | Female 63 years old Reason: pre-op History: pain Moderate to severe osteoarthritis affects the right knee with tricompartmental osteophytes. There is a small joint effusion. No acute fracture or malalignment.Mechanical axis right knee is 3 degrees of valgus. | Osteoarthritis of the right knee and mechanical axis as detailed above. |
Generate impression based on findings. | Status post MVA with right hip pain. Question of dislocation, fracture, or other acute abnormalities. Two views of the right hip reveal no acute fracture. There is abnormal offset of the right femoral head/neck junction compatible with a CAM type deformity. | CAM type deformity of the right femur; correlate for hip impingement. |
Generate impression based on findings. | Heel ulcer. Elevated CRP. Rule-out osteomyelitis. There is a soft tissue defect along the plantar aspect of the heel compatible with the known ulcer. The underlying calcaneus appears intact, without radiographic evidence of osteomyelitis. There is diffuse soft tissue swelling. Mild osteoarthritis affects the ankle join... | Soft tissue ulcer without radiographic evidence of osteomyelitis. If there is strong clinical concern for osteomyelitis, MRI may be considered. |
Generate impression based on findings. | Female 44 years old Reason: S/p Rt THA History: S/p Rt THA Components of a total right hip arthroplasty device are situated in near-anatomic alignment without radiographic evidence of hardware complication. Joint drain and soft tissue gas are present.AP view of the pelvis shows the aforementioned right hip arthroplasty... | Right arthroplasty device as detailed above. |
Generate impression based on findings. | Fall on Saturday, bruising on anterior chest, pain with deep breathing, patient reports feeling movement in the rib area. Evaluate for rib fracture. Markers were placed along the left rib cage presumably denoting the site of the patient's pain. I see no fracture or other findings to account for the patient's rib pain. ... | No fracture or other findings to account for the patient's pain. |
Generate impression based on findings. | Male 59 years old Reason: eval fracture History: pain There are healing medial and lateral malleoli fractures with callus formation. The fracture lines remain visible. Alignment is unchanged.No significant joint effusion.The bones are demineralized. The swelling has slightly improved | Healing medial and lateral malleoli fractures. |
Generate impression based on findings. | Pain after hitting chest wall. Rule out rib fracture. I see no fracture or other findings to account for the patient's rib pain. | No fracture or other findings to account for the patient's rib pain are evident. |
Generate impression based on findings. | Male 63 years old; Reason: Preop eval shoulder and glenoid prior to total shoulder arthroplasty History: above There is severe osteonecrosis of the left humeral head with a subchondral fracture and collapse. This fragmentation of the subchondral fracture.Moderate to severe osteoarthritis affects the left glenohumeral j... | 1.Osteonecrosis of the left humeral head and moderate osteoarthritis of the left shoulder joint. |
Generate impression based on findings. | Male 44 years old Reason: knee pain, ankle pain History: same Right lower extremity: There is diffuse soft tissue swelling. The underlyingtibia and fibula are intact. No evidence of osteomyelitis or acute fracture.Right ankle: There is moderate midfoot osteoarthritis. The joint space the ankle isnormal. No acute fractu... | Soft tissue swelling without underlying fracture. |
Generate impression based on findings. | Pain in the hip status post fall. Rule out fracture. Again seen is deformity of the femoral head and acetabulum compatible with hip dysplasia. I see no fracture. | Findings compatible with developmental dysplasia of the hip without acute fracture. |
Generate impression based on findings. | Status post posterior L4 -- 5 arthrodesis/decompression with TLIF and posterior instrumentation. Evaluate arthrodesis at L4 -- 5. There are posterior rods with screws entering the L4 and L5 vertebrae. I see no hardware complications. An Intervertebral spacer device is noted at L4 -- 5 containing faint density presumabl... | Postoperative changes of lower lumbar fusion and degenerative disk disease as above. |
Generate impression based on findings. | 79-year-old man with history of head and neck cancer status post chemotherapy and radiation, now with right mandible draining cutaneous fistula with bone exposure. Evaluate for osteomyelitis. Again seen is a plate and screw device spanning a large defect of the right mandibular body. There is scalloping along the alveo... | Scalloping of the alveolar ridge of the remainder of the right mandibular body along with change in orientation of one of the screws may reflect osteomyelitis, but this is equivocal. This could be further evaluated with CT, if clinically warranted. |
Generate impression based on findings. | Fracture of left foot Orthopedic screws affix the first, second, and third tarsometatarsal joints in near anatomic alignment. Gas density within the adjacent soft tissues reflects recent surgery. There is a bipartite medial sesamoid bone, likely a normal variant. | Orthopedic fixation of the Lisfranc joint as above. |
Generate impression based on findings. | Bilateral hand numbness. Lumbar pain. Hip pain. Rule out disk impingement, disk herniation, osteoarthritis. Six views of the cervical spine are provided. There is severe degenerative disk disease throughout the cervical spine. There is also moderate multilevel facet joint osteoarthritis and neuroforaminal narrowing bil... | Degenerative arthritis of the spine and hip as described above. |
Generate impression based on findings. | Reason: 77M with shortness of breath History: Dry cough, possibly infectious vs oncologic PULMONARY ARTERIES: The examination is adequate for the evaluation of pulmonary embolism. No pulmonary embolus is present. There is mild narrowing at the level of the pulmonic valve which may be due to external compression from su... | No pulmonary embolus. Partially loculated moderate to large left pleural effusion, small right pleural effusion. Chronic pericardial effusion. Mild basilar edema. Nodule lateral right middle lobe which can be followed after resolution of the patient's acute medical issues.PULMONARY EMBOLISM: PE: NoneChronicity: Not app... |
Generate impression based on findings. | New diagnosis of acute leukemia. Infectious process? Several teeth are absent, and note is made of multiple dental fillings and bridges. I see no focal lucencies to suggest bony infection. | No findings to suggest bony infection. If further imaging evaluation is clinically warranted, dedicated dental radiographs may be considered. |
Generate impression based on findings. | 50-year-old recall from screening for a focal asymmetry in the right breast. An ML view and spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. The area ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Foul-smelling discharge from wound. Evaluate for osteomyelitis. Since the prior study, the first and second toes have been amputated. There is a large soft tissue defect distal to the heads of the first and second metatarsals. There is scalloping of the distal aspect of the head of the first metatarsal and mild flatten... | Postoperative changes of first and second toe amputation with a large wound distal to the first and second metatarsal heads. Scalloping of the first metatarsal head and mild flattening of the 2nd metatarsal head may simply represent additional postoperative changes although I cannot exclude the possibility of osteomyel... |
Generate impression based on findings. | Reason: shortness of breath, tachycardia, diagnosed with DVT History: shortness of breath, tachycardia PULMONARY ARTERIES: Examination is technically adequate for the evaluation of pulmonary embolism. No pulmonary embolus is present.LUNGS AND PLEURA: Centrilobular emphysema dependent opacities compatible with atelectas... | No pulmonary embolus.PULMONARY EMBOLISM: PE: NoneChronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Ms. Stone is a 61 year old female with biopsy proven IDC in the right breast. She presents today for needle localization prior to surgery. Targeted right breast ultrasound was performed to re-identify the biopsy proven malignancy in the right lateral breast. However, no sonographic correlate was seen corresponding to t... | Successful needle localization of the right breast malignancy.BIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | History of rheumatoid arthritis. Neck and shoulder pain. The cervicothoracic junction is partially obscured on the lateral views due to overlying anatomy. There is perhaps mild facet joint osteoarthritis affecting the lower cervical spine, and perhaps a minimal retrolisthesis of C4, but vertebral body heights and inter... | Possible minimal facet joint osteoarthritis, but otherwise normal-appearing spine. |
Generate impression based on findings. | 55 year old female with epigastric pain, right upper quadrant pain, elevated alkaline phosphatase LIVER: Liver measures 15.6 cm in length. There is some lobulation along the margins of the liver. No focal hepatic lesions. Portal vein is patent with appropriate directional flow.GALLBLADDER, BILIARY TRACT: Several mobile... | 1. Cholelithiasis and sludge with no evidence of cholecystitis. Suggestion of adenomyomatosis along the fundus of the gallbladder. 2. Slight hypoechogenicity of the visualized pancreas which is nonspecific and can be seen in pancreatitis although no peripancreatic fluid or pancreatic ductal dilatation is noted. Clinica... |
Generate impression based on findings. | 59-year-old female patient with epigastric, right upper quadrant pain, and nausea. Evaluate for pancreatitis. ABDOMEN:LUNG BASES: Trace basilar atelectasis.LIVER, BILIARY TRACT: Status post cholecystectomy. Subcentimeter hypoattenuating lesion in the right lobe of liver is too small to characterize and likely represent... | No acute intra-abdominal abnormality to account for patient's symptoms. Small amount of fluid in the pelvis is abnormal in postmenopausal women. Recommend correlation with menopausal status. |
Generate impression based on findings. | Pain after fall. Evaluate for fracture. The bones appear slightly demineralized, perhaps reflecting osteopenia. I see no fracture or dislocation. There is a slight lateral downsloping of the acromion process and perhaps minimal osteoarthritis of the AC joint, of questionable clinical significance. Mild degenerative art... | No fracture or other acute findings to account for the patient's pain are evident. |
Generate impression based on findings. | Pain. Fracture? There is a comminuted fracture of the proximal half of the distal phalanx of the great toe with extension to the articular surface. There is mild dorsal displacement of a couple of the fracture fragments at the base of the phalanx. | Great toe fracture as above. |
Generate impression based on findings. | Generalized pain. Three views left hand reveal no acute fracture. There is joint space narrowing and osteophyte formation of the first interphalangeal joint, and the DIP joints of the remaining digits, most predominantly the second and fourth digits. Moderate osteoarthritis affects the first metacarpophalangeal joint. ... | 1. Soft tissue swelling of the fifth digit without acute fracture evident.2. Degenerative changes as above. |
Generate impression based on findings. | Fall. Right ankle pain. Right hip pain. Three views of the right ankle are provided. There is mild soft tissue swelling, but I see no acute fracture. A well corticated ossicle distal to the medial malleolus likely reflects old trauma, and was present on the prior study. Small tibiotalar joint osteophytes suggest mild o... | Mild osteoarthritis without acute fracture evident. |
Generate impression based on findings. | 62-year-old male patient status post Frey procedure with RUQ abscess presents with fever and diarrhea. ABDOMEN:LUNG BASES: Small bilateral pleural effusions with overlying atelectasis/consolidation. Moderate to severe coronary artery calcifications are again noted.LIVER, BILIARY TRACT: Posterior changes from cholecyste... | Interval placement of infrahepatic drain with minimal fluid surrounding catheter tip. Mild interval decrease in gallbladder fossa fluid collection and perihepatic fluid. |
Generate impression based on findings. | 70 years, Male. Reason: evaluate Dobbhoff tube placement History: new Dobbhoff tube placement There is a Dobbhoff tube with its tip projecting over the body of the stomach. The pelvis is excluded from the field of view. The pelvis is excluded from the field of view. Retrocardiac opacity suggest atelectasis/consolidatio... | Dobbhoff tube with its tip projecting over the body of the stomach. |
Generate impression based on findings. | Rule-out ICH, Cerebral edema. Status post lung transplant, hepatic failure, ECMO There is diffuse loss of gray-white differentiation throughout the brain parenchyma and diffuse sulcal effacement. There is also diffuse effacement of the basilar cisterns indicative of downward herniation. Ventricular system appears small... | Diffuse cerebral edema and evidence of downward herniation. Global hypoxic ischemic injury is not excluded. |
Generate impression based on findings. | Female, 12 years old. Evaluate for fracture History: medial swelling with increased pain and inability to bear weightVIEWS: Right ankle, AP, lateral, oblique (3 views) 3/12/2015, 2007 The osseous structures and joint spaces are normal.Mild soft tissue swelling about the ankle. No significant joint effusion. | Soft tissue swelling with no acute fracture or dislocation. |
Generate impression based on findings. | RFO trigger: Surgery length greater than 8 hours Suspected RFO location: Abdomen and /or pelvis Name of suspected RFO: Instruments, sponges, needles per protocol Surgery length > 8 hours Attending Surgeon name/pager: Yamada- ROOM 20-Tel 69420 Body Mass Index (BMI): 23.63 There is a nasogastric tube with its tip extendi... | No unexpected radiopaque foreign object identified.These findings were discussed via telephone with Dr. Yamada, the attending surgeon at 20:00 on 3/12/2015 by the radiology resident on call |
Generate impression based on findings. | 68 years, Female. Reason: assess for obstipation History: 68 y.o. woman with a history of abd gas/bloating and excessive gas. Rectal exam suggestive of rectal prolapse with copious st ool in vault Nonobstructive bowel gas pattern with a greater than average stool burden. Levoscoliosis of the lower lumbar spine. | Greater than average stool burden. |
Generate impression based on findings. | Male, 4 months old. History of Trisomy 21 and history of mild pulmonary hypertension p/w resp distress/increased WOB.VIEW: Chest AP (one view) 3/12/2015, 2105 The cardiothymic silhouette is normal.Peribronchial thickening and increased lung volumes. Streaky bibasilar and right upper lobe opacities, compatible with atel... | Bronchiolitis pattern without significant interval change. |
Generate impression based on findings. | 33 years, Male. Reason: Pt is a 32 yo M with h/o ureteroplasty with stent placement in the Left kidney, now presented with abdominal pain, constipation and rectal bleeding. Please assess stool burden and or obstructive disease. . History: abdominal pain and constipation Nonobstructive bowel gas pattern. No subdiaphragm... | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 13-year-old male with foreign object in left foot.VIEWS: Left foot AP, oblique and lateral (3 views) 3/13/15 A 1 cm triangular radiodensity is present in the dorsal soft tissues overlying the second metatarsal. No fracture is identified. | 1 cm triangular radiodense foreign object is present in the dorsal soft tissues overlying the second metatarsal. |
Generate impression based on findings. | Reason: PE History: CP PULMONARY ARTERIES: This examination is technically adequate for the evaluation of pulmonary embolism. No pulmonary embolus is present.LUNGS AND PLEURA: There is respiratory motion artifact with the acquisition obtained in exhalation. Trace pleural effusions. Diffuse bronchial wall thickening, gr... | No pulmonary embolus.Extensive subpectoral, bilateral axillary, hilar and mediastinal lymphadenopathy. Soft tissue fullness noted the base of the neck with mildly enlarged supraclavicular lymph nodes. Fat planes are lost at the porta hepatis, suspicious for intraperitoneal lymphadenopathy. Multiple pulmonary micronodul... |
Generate impression based on findings. | 51 years, Male. Reason: new dht History: please comment on position relative to lap band (hx rygb + lap band w/ erosion) There is a Dobbhoff tube with its tip projecting over the proximal body of the stomach, just distal to the gastric band. Gastric band seen partially en face suggesting possible slippage, further eval... | Dobbhoff tube with its tip projecting over the proximal body of the stomach, just distal to the gastric band.Findings suggestive of possible slipped gastric band, further evaluation with upper GI can be considered as clinically indicated. |
Generate impression based on findings. | Female; 20 years old. Reason: eval for abd pathology History: s/p chole and appy; h/o biliary stent ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Mild dilation of the common bile measuring up to 8 mm with no evidence of distal obstructing lesion; this is likely a normal finding in this patie... | No acute abdominopelvic abnormality. Mild dilation of the common bile duct is likely a normal finding in this patient who is status post cholecystectomy. |
Generate impression based on findings. | 70 year-old male with shortness of breath, hypoxia. History of esophageal adenocarcinoma. LUNGS AND PLEURA: Decrease in small right pleural effusion with increase in adjacent atelectasis. Interval increase in left pleural effusion with adjacent atelectasis. No pneumothorax.Diffuse, upper lobe predominant patchy groundg... | 1.Diffuse, upper lobe predominant patchy groundglass opacities with scattered areas of focal consolidation may represent aspiration and/or atypical infection. 2.Overall increase in pleural effusions and atelectasis. 3.Increasing abdominal ascites. No significant change in central biliary dilatation. 4.New right hydrone... |
Generate impression based on findings. | 31-year-old female with chest pain, elevated d-dimer PULMONARY ARTERIES: Adequate pulmonary artery opacification without evidence of pulmonary embolism.LUNGS AND PLEURA: No pleural effusion or pneumothorax. No focal pulmonary opacities. No suspicious nodules or masses are identified.MEDIASTINUM AND HILA: Mildly promine... | 1.No evidence of pulmonary embolism.2.Contrast extravasation as described above in the technique section.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Female, 8 years old. Reason: Please assess for fracture. History: medial rt foot contusion, trauma, difficulty ambulating.VIEWS: Right foot, AP, lateral, oblique (3 views) 3/12/2015, 2130 A small bone fragment medial to the physis of the distal phalanx of the great toe may represent a Salter-Harris II fracture or a sec... | Possible Salter-Harris II fracture of the medial aspect of the distal phalanx of the great toe. Correlate with the point of maximum tenderness. |
Generate impression based on findings. | Male 12 years old Reason: ETT position History: Cerebral palsy with respiratory insufficiency.VIEW: Chest AP (one view) 3/13/15 at 522 hours. ET tube tip is at the thoracic inlet. Right upper extremity PICC terminates at the right subclavian vein. Thoracolumbar dextroscoliosis unchanged. Cardiac silhouette size is norm... | ET tube positioning as described. |
Generate impression based on findings. | Persistent headache, assess ventricular size No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Mild cerebellar tonsillar ectopia again seen. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal l... | 1. No evidence of acute intracranial hemorrhage or mass effect. Ventricles are within normal limits without evidence of hydrocephalus.2. Mild cerebellar tonsillar ectopia as seen on prior MRI. |
Generate impression based on findings. | 61-year-old male patient with history of narrowing and tumor since with fever and right upper quadrant pain. ABDOMEN:LUNG BASES: Numerous new right lung base micronodules (series 4 image 12).LIVER, BILIARY TRACT: Again seen is extensive tumor involvement throughout the liver with confluent mass involving the central po... | 1.Overall interval increase in size of hepatic metastases with associated compression of the hepatic vasculature and increased compression of the biliary tree with mild intrahepatic biliary ductal dilatation.2.Interval increase in size and number of peritoneal implants compatible with carcinomatosis. Additionally, ther... |
Generate impression based on findings. | Male 15 months old Reason: Status-post VSD repair.VIEW: Chest AP (one view) 3/13/15 at 558 hours Central line tip is at the right atrium. Epicardial pacer leads, right-sided chest tube and mediastinal clips again noted. Cardiac silhouette size is large but stable. Persistent right upper lobe atelectases. No effusions o... | Persistent right upper lobe atelectasis. |
Generate impression based on findings. | 44 years, Female. Reason: Check Dobbhoff placement History: Check Dobbhoff placement There is a Dobbhoff tube, which is looped upon itself with its tip projecting over the proximal body of the stomach. There is a nonobstructive bowel gas pattern. The pelvis is excluded from the field of view. Streaky retrocardiac opaci... | Dobbhoff tube looped upon itself with its tip projecting over the proximal body of the stomach. |
Generate impression based on findings. | Male, 11 years old. Pain. Evaluate for fracture.VIEWS: Left great toe, AP, lateral (2 views) 3/12/2015, 2142 The osseous structures and joint spaces are normal.No significant joint effusion or soft tissue swelling. | No acute fracture or dislocation. |
Generate impression based on findings. | Female 6 months old Reason: 6 mo F HIE, CP/DD, reintubated for hypercarbic respiratory failure. Evaluate lung fields and ETT position. History: Respiratory insufficiency.VIEW: Chest AP (one view) 3/13/15 at 528 hours. ET tube terminates at the carina. Gastrostomy tube again noted. Cardiac silhouette size is normal. Lar... | ET tube terminates at the carina.Persistent left retrocardiac atelectasis a large lung volumes. |
Generate impression based on findings. | Female; 59 years old. Reason: abdominal or pelvis hemorrhage or hematoma History: acute drop in hgb ABDOMEN:LUNG BASES: Mild bibasilar dependent subsegmental atelectasis. Small calcified granuloma right lower lobe.LIVER, BILIARY TRACT: Cholelithiasis.SPLEEN: No significant abnormality notedPANCREAS: No significant abno... | No hemorrhage or other acute abdominopelvic abnormality. |
Generate impression based on findings. | 12 year-old male with facial trauma and bruisingVIEWS: Facial bones PA, lateral (two views) 3/13/15 Nasal bone appears intact. The sinuses are clear and there are no air-fluid levels present. No displaced skull fractures are seen on this exam. Please note that facial bone radiographs are insensitive for the detection o... | No fracture is identified. If there is strong clinical concern for fracture a CT is recommended. |
Generate impression based on findings. | 29-year-old male status post reduction of anterior shoulder dislocation. Previously seen glenohumeral dislocation has been reduced, in near anatomic alignment. Again seen is a Hill-Sachs deformity. Small bony fragments along the inferior aspect of the glenoid and medial aspect of the humeral neck are noted, likely repr... | Reduction of glenohumeral dislocation as above. |
Generate impression based on findings. | Male 0 days old Reason: where is ETT? History: INITIAL XR - increasing respiratory distress; increasing O2 requirementVIEW: Chest and abdomen AP (two views) 3/13/15 at 449 hours. ET tube terminates at the carina. UAC tip is at the RA/SVC junction. UVC terminates at T8. Aortic arch, cardiac apex and stomach are left-sid... | ET tube and umbilical line positioning as described.Bilateral diffuse lung haziness consistent with TTN versus RDS.Disorganized, likely age related and nonspecific abdominal gas pattern. |
Generate impression based on findings. | Kidney stones ABDOMEN: The exam is not sensitive for detecting lesions in the bowel or solid organs due to lack of oral or intravenous contrast.LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Cholelithiasis in a collapsed gallbladder unchanged. No obvious biliary dilatation. Previously described cyst ... | Bilateral renal calculi, nonobstructive. Cholelithiasis. Diverticulosis. |
Generate impression based on findings. | Compare bleed Again seen is a large intraparenchymal hematoma measuring 4.8 x 3.7 x 3.2 cm previously 3.4 x 3.2 x 3.3 cm centered at the left insula and frontoparietal operculum. Again seen is hematocrit effect which may be related to active bleeding and/or coagulopathy. There is mild surrounding edema and mass effect ... | 1. Interval enlargement of intraparenchymal hematoma centered at the left frontal operculum. There is mild increase in local mass effect without significant midline shift or uncal herniation.2. Right parietal lytic calvarial lesion with extra-axial extension and calcification is favored to represent a benign etiology s... |
Generate impression based on findings. | Tonsillar exudate with neck pain. There is diffuse enlargement of the Waldeyer ring structures with associated airway narrowing. There are multiple mildly enlarged cervical lymph nodes. For example, a right level 2 lymph node measures 12 x 18 mm. The thyroid and major salivary glands are unremarkable. The major cervica... | 1. Diffuse enlargement of the Waldeyer ring structures with associated airway narrowing with likely reactive cervical lymphadenopathy likely represents adenotonsillitis without evidence of abscess formation. Nevertheless, an underlying neoplastic process cannot be entirely excluded on the basis of imaging.2. Carious to... |
Generate impression based on findings. | Malignant neoplasm of uterus. Please note that lack of IV contrast limits evaluation for solid organ pathology and lymphadenopathy. Within this limitation, the following observations can be made:CHEST:LUNGS AND PLEURA: Scattered subcentimeter ground-glass and sub solid nodules in both lungs, unchanged since the prior e... | Reference lesions have all decreased in size however there is a new lucent lesion in the L1 vertebral body as discussed above. Findings discussed with Dr. Lee at the time of dictation. |
Generate impression based on findings. | 74 years, Male. Reason: patient with emesis with tube feeds, need to r/o obstruction History: nausea/emesis Nonobstructive bowel gas pattern. No significant abnormality is seen. Partially imaged pacemaker leads unchanged in position. G-tube valve seen en face view, but tubing is not well visualized. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 67 years, Female. Reason: NG History: NG Exclusion of pelvis in field of view. There is a Dobbhoff tube with its tip projecting over the antrum of the stomach. There are bilateral nephroureteral stents, two on the left and two on the right. Nonobstructive bowel gas pattern. | Dobhoff tube with its tip projecting over the antrum of the stomach. |
Generate impression based on findings. | Reason: r/o acute intracranial process History: head trauma, nausa, vomiting The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visual... | No evidence for acute intracranial hemorrhage mass effect or edema. |
Generate impression based on findings. | Facial trauma, maxillary point tenderness. There are comminuted fractures of the nasal skeleton with mild displacement and angulation of the fracture fragments. There is overlying subcutaneous swelling and stranding. There is effacement of the left nasal vestibule. There is mild S-shaped deviation of the nasal septum w... | Comminuted and displaced fractures of the nasal skeleton with overlying soft tissue contusion. |
Generate impression based on findings. | 63-year-old male patient with head and neck cancer, new gastrostomy tube placed 3/9/2015 presents with fever. Evaluate for source of infection. CHEST:LUNGS AND PLEURA: New small bilateral pleural effusions and overlying atelectasis/consolidation. Anterior bilateral upper lobe subpleural groundglass opacities are also n... | 1.Percutaneous gastrostomy tube tip within the stomach without enteric contrast leak. However, there is greater than expected pneumoperitoneum. Correlate with clinical symptoms of peritonitis.2.New pleural effusions with overlying atelectasis/consolidation and subpleural ground glass opacities may represent infection o... |
Generate impression based on findings. | Reason: r/o acute intracranial process History: head trauma, nausa, vomiting The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visual... | No evidence for acute intracranial hemorrhage mass effect or edema. |
Generate impression based on findings. | malaise and fatigue No evidence of acute ischemic or hemorrhagic lesion.Patchy low attenuation on bilateral periventricular white matter indicate minimal to mild non specific small vessel ischemic disease.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, ... | No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | Reason: r/o intracranial process History: slurred speech There is ventriculomegaly present associated with periventricular hypodensities of a moderate degree. The biventricular diameter on the prior exam was a 41 mm and is similar on the current exam. Third ventricular diameter is 7 mm and previously was the same.The v... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction.3.There is ventriculomegaly present which is stable compared to the prior exam4.Periventricular and subcortical white matter signal changes are nonspecific. At thi... |
Generate impression based on findings. | Reason: r/o bleed History: fall, head laceration on aspirin The CSF spaces are appropriate for the patient's stated age with no midline shift. Atherosclerotic calcifications are present along the scalp vasculature . These calcifications could be related to renal failure or diabetes. Atherosclerotic calcifications are p... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction.3.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. At this age they are most likely vascular related. |
Generate impression based on findings. | Left post auricular swelling and erythema. Left: There is mild stranding of the subcutaneous tissues in the postauricular region, but no evidence of drainable fluid collection. There is opacification of the inferior mastoid air cells with intact bony septations. The middle ear is well-pneumatized and clear. The externa... | 1. Findings suggestive of left mastoiditis and overlying postauricular cellulitis without evidence of associated abscess.2. Findings suggestive of sinusitis. |
Generate impression based on findings. | 67 year old male with history of thyroid cancer status post thyroidectomy. Evaluate for adenopathy or recurrence. RIGHT LOBE MEASUREMENTS: Status post thyroidectomy.LEFT LOBE MEASUREMENTS: Status post thyroidectomy.ISTHMUS MEASUREMENTS: Status post thyroidectomy.RIGHT LOBE: No residual thyroid tissue is seen. LEFT LOBE... | Left neck level 4 lymph node is again seen and although similar in size, appears different on today's exam with internal echogenic foci which could be related to sequelae of prior biopsy, although could also represent developing calcifications. Additional benign appearing lymph node in the right neck. |
Generate impression based on findings. | 43-year-old male with history of lymphoma. Evaluate for disease. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: Reference right thoracic inlet lymph node has resolved. Reference right upper paratracheal lymph node measures 1.6 x 1.1 cm (image 17; series 3),... | Mixed response with most of the adenopathy increasing in size. |
Generate impression based on findings. | 46 year old with history of left lumpectomy in 2002 for infiltrating ductal carcinoma followed by radiation and chemotherapy. 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 el... | 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. | known multiple hemorrhagic metastasis No significant interval change of multifocal hemorrhage metastatic lesions on bilateral hemisphere.There is no new evidence of midline shift or significant mass effect comparing to prior scan.The ventricles, sulci, and cisterns are symmetric and unremarkable. The osseous structures... | No interval change of multifocal hemorrhagic metastasis since prior exam. |
Generate impression based on findings. | Female 48 years old Reason: hyperthyroid History: low TSH Small focal area of decreased scintigraphic activity only appreciated on RAO, but not on other projections, likely artifact. The remainder of the gland is homogenous in appearance, with normal size and configuration. The 4-hour radioactive iodine uptake is 20.4%... | Mildly increased 24 hour radioactive iodine uptake, consistent with hyperthyroid state. |
Generate impression based on findings. | 27-year-old female patient with right lower quadrant pain and fever. Evaluate for appendicitis. ABDOMEN:LUNG BASES: Trace dependent atelectasis.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnorm... | Equivocal bowel wall thickening in a portion of the distal ileum is nonspecific and may represent inflammation or edema. Otherwise, no definitive findings to account for patient's symptoms. |
Generate impression based on findings. | 72-year-old male with history of right ankle fracture, follow-up exam. Again seen is a spiral/oblique fracture the distal fibula, with fracture fragments in near anatomic alignment. Callus formation along the fracture is indicative of early healing. A vertically oriented lucency, partially traversing the posterior aspe... | Healing of distal fibular fracture as above. |
Generate impression based on findings. | headache No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The osseous structures are unremarkable. The paranasal sinuses and mastoid air cells ar... | No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | 47-year-old male with history of uncontrolled HIV now with shortness of breath and hypoxia LUNGS AND PLEURA: Severe upper lobe predominant paraseptal emphysema with large right apical bullae is again noted without significant interval change.Bilateral bronchiectasis appears worsened compared to the prior exam. Right lo... | 1.Right lower lobe collapse with right upper lobe and left lower lobe centrilobular nodules, bronchiectasis, and bronchial wall thickening suggestive of bronchitis/bronchiolitis, which is likely partly chronic in nature. New right middle lobe peripheral consolidation consistent with pneumonia. Consider indolent atypica... |
Generate impression based on findings. | headache, follow up of ventriculostomy tube insertion. No evidence of acute ischemic or hemorrhagic lesion.A remained ventriculostomy tube in the right lateral ventricle is still seen and no change. Another ventriculostomy tube inserted through the left parietal lobe and the tip position on the left lateral ventricle f... | No change since prior exam.No evidence of acute ischemic or hemorrhagic lesion on this scan. |
Generate impression based on findings. | 44 year-old male with hematuria. CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnorm... | Normal upper tracts. Enlarged prostate gland. No gross bladder abnormality. |
Generate impression based on findings. | 43-year-old female with history of left wrist fracture. Overlying cast material limits fine bone detail. Again seen is a comminuted intra-articular fracture of the distal radius, with fracture fragments in near anatomic alignment. Adjacent callus formation indicates some interval healing. A minimally displaced ulnar st... | Healing distal radius fracture as above. |
Generate impression based on findings. | Left knee pain and swelling. Left knee injury two weeks ago cheerleading, knee buckled. Evaluate for ACL tear, meniscus tear. MENISCI: There is a complex tear of the posterior horn of the lateral meniscus including a "Wrisberg rip" with additional tearing of the posterior horn near the root. The body and anterior horn ... | Anterior cruciate ligament tear, lateral meniscal tear, and fractures as described above. |
Generate impression based on findings. | Compare hemorrhage Again seen is a large intraparenchymal hematoma measuring 4.6x 3.6 x 3.4 cm centered at the left insula and frontoparietal operculum. Again seen is hematocrit effect. There is mild surrounding edema and mass effect with partial effacement of the left lateral ventricle, similar to prior. Minimal right... | 1. Compared to most recent CT from 3/12/2015, no significant change in size of intraparenchymal hematoma centered at the left frontal operculum. There is local mass effect without significant midline shift or uncal herniation. There is hematocrit effect which may be related to coagulopathy/anticoagulant use. 2. Right p... |
Generate impression based on findings. | 64-year-old male with history of lung cancer. CHEST:LUNGS AND PLEURA: Postoperative changes of left upper lobectomy. Moderate centrilobular and paraseptal emphysema. Small left pleural effusion. Spiculated nodule in the left lower lobe is no longer visualized. Small area of diffuse mild ground glass opacities in the po... | 1. The previously noted 7-mm left lower lobe nodule is no longer visualized.2. New small left pleural effusion.3. Small focus of groundglass opacities in the posterior aspect of the right lower lobe likely the sequela of aspiration. |
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