instruction stringclasses 1
value | input stringlengths 6 8.98k | output stringlengths 5 3.11k |
|---|---|---|
Generate impression based on findings. | 36 year old female status post right lumpectomy in September 2014 for invasive ductal carcinoma, presents today for 6 month follow up. Patient received radiation, chemotherapy, and hormonal therapy. History of additional benign bilateral breast biopsies. No current breast complaints. No family history of breast cancer.... | 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. | Renal cell carcinoma CHEST:LUNGS AND PLEURA: No change in reference right upper lobe cavitary nodule best seen on image 29 of series 5 measuring 1.3 x 1.4 cm. The previously noted subcentimeter left lower lobe nodules are no longer identified.Stable right pleural based mass best seen on image 26 of series 3 measuring 4... | Stable reference lesions; however, previously noted multiple subcentimeter left lower lobe lung nodules are no longer identifiable. No new metastatic disease. |
Generate impression based on findings. | 11-year-old male with history of desaturation and tachycardiaVIEW: Chest AP (one view) 3/16/15 Tracheostomy tube, gastrostomy tube, and musculoskeletal changes of spinal muscular atrophy are not significantly changed. Cardiac silhouette size is not enlarged. Increased lucency of the right upper lobe with new right lowe... | New right lower lobe opacity likely representing atelectasis. |
Generate impression based on findings. | Left ankle pain. Question fracture/dislocation. Three views of the left ankle show soft tissue swelling about the lateral malleolus. No acute fracture or malalignment is evident. No ankle joint effusion is seen. | Soft tissue swelling without acute fracture evident. |
Generate impression based on findings. | Fell playing basketball, pain and swelling to hand (especially thumb area). Question of fracture. Three views of the left wrist reveal no acute fracture. There is mild narrowing of the triscaphe joint.Three views of the left hand reveal no acute fracture or malalignment. | No acute fracture is evident. |
Generate impression based on findings. | Male 77 years old; Reason: hx of pseudocyst, pancreatitis History: epigastric pain ABDOMEN:LUNG BASES: Rounded atelectasis in the right lung base, unchanged compared to prior study. 5mm right middle lobe pulmonary nodule. This should be followed as per Fleischner guidelines.LIVER, BILIARY TRACT: Mild intrahepatic bilia... | 1.Cystogastrostomy tube in situ with near complete resolution of peri-pancreatic pseudocyst/fluid.2.New focal area of hypoenhancement within the pancreatic body consistent with edema/necrosis.3.Mild persistent intrahepatic biliary duct dilatation, somewhat increased compared to prior study.4.5mm right middle lobe pulmo... |
Generate impression based on findings. | 2 months old. Former 30 weeks gestational age patient, distention. Evaluate for obstruction.VIEW: Abdomen AP (one view) 3/17/2015, 0854 Enteric tube terminates in the stomach.Hazy lung base opacities.Generalized bowel distention. Barium has passed to the rectum from the prior exam.No pneumatosis, portal venous gas, or ... | No evidence of obstruction. |
Generate impression based on findings. | Male, 13 years old. Status post osteotomy, follow-up. Leg length discrepancyVIEWS: Right femur, AP, lateral (two views) 3/17/2015, 0913 External fixation device, with screws affixing the proximal and distal femoral diaphysis, without evidence of hardware complication.The osteotomy gap measures approximately 7.2 cm with... | Continued mild increase in bone formation within the osteotomy gap, without evidence of hardware complication. |
Generate impression based on findings. | Clinical question: Rule out CVA in patient with status post TAVR. Signs and symptoms: Right hand weakness Unenhanced head CT:There is no detectable acute intracranial process however CT is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Mild periventricular and subcortical low attenuation white... | 1.No acute intracranial process.2.Mild age indeterminate small vessel ischemic stroke is suspected |
Generate impression based on findings. | 54 year old female status post right mastectomy for invasive ductal carcinoma, presents today for routine follow up. Patient received radiation and chemotherapy. No current breast complaints. No family history of breast cancer. Three standard views of the left breast were performed digitally and reviewed with the aid o... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | The ventricles, sulci and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. Scattered periventricular and subcortical foci of flair signal abnormality likely represent chronic nonhemorrhagic small vessel ischemic disease. There is no mass, midline shift, intra or extra-axial flu... | 1. No evidence of acute ischemia or other specific findings to account for the patient's symptoms.2. Mild chronic nonhemorrhagic small vessel ischemic disease involving only in the periventricular and subcortical white matter. |
Generate impression based on findings. | 47 year old female status post right lumpectomy in 2007 for invasive ductal carcinoma, presents today for routine follow up. Patient received radiation, chemotherapy, and hormonal therapy. No current breast complaints. No family history of breast cancer. Three standard views of both breasts were performed digitally and... | 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. | 55 year old female status post left mastectomy for IDC, May of 2014, presents today for routine follow up. History of right breast reconstruction since her last mammogram. Patient received hormonal therapy (tamoxifen). No current breast complaints. Family history of breast carcinoma in her mother. Three standard views ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral 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. | Male; 33 years old. Reason: 33 m p/w abdominal pain History: abd pain, n/v 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, ... | No appendicitis or other acute abnormality. |
Generate impression based on findings. | 62-year-old female with h/o HNC and CRT, compare to previous measurements. CHEST:LUNGS AND PLEURA: Stable scattered micronodules, some calcified. No focal consolidation or pleural effusion.MEDIASTINUM AND HILA: Normal heart size with no pericardial effusion. No coronary calcifications are seen within the limitations of... | No evidence of metastatic disease. |
Generate impression based on findings. | 10-year-old male with patella pain and concern for fractureVIEWS: Right knee AP, oblique and lateral (3 views) 3/17/15 A small joint effusion is present. No fracture or malalignment. No patella alta. The extensor mechanism appears intact. | Small joint effusion without fracture or malalignment. |
Generate impression based on findings. | 71 year old female presents for diagnostic mammogram. History of bilateral breast cysts. 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 composed of scattered fibroglandular density, unchanged in pattern ... | 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. | 6-month-old female with fever and cough, concern for pneumoniaVIEWS: Chest AP/lateral (two views) 3/17/15 The aortic arch, cardiac apex comment stomach a left-sided. The cardiothymic silhouette is normal. A double manubrial ossification center is present, a normal variant. Bronchial wall thickening and increased lung v... | Bronchiolitis/reactive airway disease pattern. |
Generate impression based on findings. | Reason: History of metastatic breast cancer on treatment. Compare to prior imaging, evaluate for response and extent of disease. History: History of metastatic breast cancer on treatment. Compare to prior imaging, evaluate for response and extent of disease.. CHEST:LUNGS AND PLEURA: Right paramediastinal fibrosis from ... | No significant change in pulmonary nodules/masses and mediastinal adenopathy. Hypoattenuating right liver lesions are redemonstrated and are not accurately compared to prior exams. No new hepatic lesions identified. |
Generate impression based on findings. | Left forearm injuryVIEWS: Left wrist AP and lateral 3/17/15 (two views) There is a greenstick fracture of the distal diaphyses of the left radius and a buckle fracture of the distal metadiaphyses of the left ulna. Alignment is anatomic. | Both left forearm fracture, as described. Alignment is anatomic. |
Generate impression based on findings. | 61 year old female status post right mastectomy in 2008 for invasive ductal carcinoma, presents today for routine follow up. Patient received chemotherapy, radiation, and is on Arimidex. History of benign left breast biopsy and left reduction mammoplasty. No current breast complaints. No family history of breast cancer... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended annually. Given the patient's history mammographically occult malignancy, annual screening MRI should be considered. Results and recommendation were discussed with th... |
Generate impression based on findings. | Pain with weight-bearing. Worsening of left knee DJD? Four views of the left knee are provided. Severe osteoarthritis affects the left knee, particularly the medial compartment where there is near bone-on-bone apposition. Ossification within the soft tissues along the medial condyle of the distal femur probably reflect... | Osteoarthritis appearing similar to that seen on the prior study. |
Generate impression based on findings. | Status post L5 -- S1 PSF. Fusion status? Again seen are posterior rods with screws entering the L5 and S1 vertebrae. Intervertebral spacer devices are again noted at L4/5 and L5/S1. There appears to be some bony bridging along the posterior aspect of the L5/S1 intervertebral disk space, appearing similar to the prior s... | Postoperative and degenerative changes appearing similar to those seen on the prior study. |
Generate impression based on findings. | Male 73 years old; Reason: prostate cancer on therapy with rising PSA. disease reeval History: prostate cancer ABDOMEN:LUNG BASES: Coronary artery calcifications.LIVER, BILIARY TRACT: Stable scattered subcentimeter hypodensities, too small to accurately characterize.SPLEEN: No significant abnormality noted.PANCREAS: St... | 1.Asymmetric density of the right seminal vesicle compared to the left as described above is nonspecific. Given history of rising PSA, further evaluation with MRI could be useful if indicated to better evaluate the bed and seminal vesicles. |
Generate impression based on findings. | Male, 8 years old. Follow-up injuryVIEWS: Left elbow AP and lateral (two views) 3/17/2015, 1015 Alignment is anatomic, with residual mild modeling abnormality of the distal humerus.Periosteal reaction along the posterior aspect of the distal humerus appears similar to the prior exam, without discrete fracture line is i... | Continued healing of supracondylar fracture. |
Generate impression based on findings. | Female; 40 years old. Reason: eval for ovarian pathology History: llq pain, neg preg ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Hepatomegaly. No focal liver lesions.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality... | Acute diverticulitis of the proximal sigmoid colon with finding suspicious for small intramural abscess, microperforation, and adjacent phlegmon. No well-formed, drainable pericolonic abscess. |
Generate impression based on findings. | Right hip pain status post mechanical fall. Evaluate for arthritis versus malalignment or bursitis. I see no fracture or malalignment. Mild osteoarthritis affects the hip. | Mild osteoarthritis without fracture or malalignment evident. Please note that I cannot confirm nor exclude bursitis on the basis of conventional radiography. If further imaging evaluation is clinically warranted, MRI may be considered. |
Generate impression based on findings. | Reason: s/p EVD placement History: s/p EVD placement Since the prior exam a ventriculostomy has been placed. It enters the right frontal lobe and courses into the right lateral ventricle with tip in the region of foramen of Monro air AP and lateral ventricles have not changed in size.There is redemonstration of a hyper... | 1.Redemonstration and no change of a right midbrain hematoma associated with intraventricular blood.2.Sasses ventriculostomy tube placement3.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. At this age they are most likely vascular related. 4.Hypodensity in the right basal gang... |
Generate impression based on findings. | Left TKA Four views of the left knee reveal components of a total knee arthroplasty device situated in near-anatomic alignment without radiographic evidence of hardware complication. Anterior soft tissue swelling and a joint effusion limit evaluation of the extensor mechanism. The previously seen skin staples and drain... | Total knee arthroplasty as above. |
Generate impression based on findings. | Male; 79 years old. Reason: 79M with ESRD on HD and recent episodes of cholecystitis s/p open cholecystectomy with biliary drain placement, now with asymptomatic hypotension not responsive to IVF boluses, ?abscess? ABDOMEN:LUNG BASES: Moderate bilateral pleural effusions with underlying basilar compressive atelectasis,... | 1. Moderate pleural effusions with underlying compressive atelectasis.2. Cirrhotic liver morphology and ascites/anasarca. Ascending colonic wall thickening is likely related to portal colopathy.3. Appendiceal changes likely related to fluid state, but if there is clinical concern for acute appendicitis, short interval ... |
Generate impression based on findings. | 64 year old male. Recurrent colon cancer. Assess for distant metastatic disease. CHEST:LUNGS AND PLEURA: Calcified nodules consistent with prior infection. No suspicious pulmonary nodules. Basilar scarring and/or atelectasis.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Severe coronary artery calcifica... | No evidence of metastatic disease. |
Generate impression based on findings. | History metastatic thyroid cancer, status post right distal femur replacement for deep infection. Complains of right medial proximal leg pain. Please assess for tumor versus infection. There has been interval resection of the distal femur and reconstruction with a total knee arthroplasty with a long stem distal femoral... | 1. No specific evidence of a discrete fluid collection or tumor.2. Persistent heterogeneous soft tissues of the right medial thigh with increased dystrophic calcification. |
Generate impression based on findings. | Left shoulder injury. History of left hip fracture, preop planning. Left humeral shaft pain and ecchymosis. Three views of the left shoulder and two views of the left humerus show a comminuted surgical neck fracture of the proximal humerus with slight impaction. AP view of the pelvis shows shortening of the left femora... | 1. Comminuted, slightly impacted left humeral surgical neck fracture.2. Shortened left femoral neck compatible with prior fracture.3. Lucent lesion within the medial femoral condyle of unknown etiology; given the patient's age and history of malignancy, this is highly suspicious for a metastatic lesion. Findings commun... |
Generate impression based on findings. | Male 68 years old; Reason: prostate cancer evaluation of disease History: prostate cancer ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Mild fatty infiltration of the liver.SPLEEN: No significant abnormality noted.PANCREAS: 6-mm hypodensity in the pancreatic head felt to represent a fatty c... | 1. Indeterminate 2.4-cm mass near an area of surgical clips/sutures in the left upper quadrant, further described above. Please correlate with surgical history in that area, or with prior imaging.2. No definite evidence of metastatic disease. Please correlate with same day bone scan. |
Generate impression based on findings. | 55-year-old male. Melanoma. Compare previous. CHEST:LUNGS AND PLEURA: Scattered micronodules, largest in the right lower lobe is 5 mm (series 5, image 51), unchanged and likely post inflammatory.No new nodules. Mild dependent atelectasis.Mild emphysema.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Mode... | No evidence of metastatic disease. Stable scattered pulmonary micronodules, likely postinflammatory. |
Generate impression based on findings. | Mass right chest. History of breast cancer Three views of the ribs reveal clips in the right axilla secondary to a mastectomy. I do not see any rib lesions. | Negative rib examination |
Generate impression based on findings. | Retroperitoneal malignancy/history of neuroblastoma, elevated LFTs and right upper quadrant tenderness, uptrending creatinine Suboptimal exam due to large amount of overlying bowel gas.LIVER: Left liver poorly assessed due to overlying bowel gas. Visualized liver parenchyma increased in echogenicity. No biliary duct di... | Limited exam, large amount of overlying bowel gas, pancreas, left liver and spleen not able to be evaluated as a result.Increased renal cortical echogenicity, compatible with medical renal disease.Echogenic liver, suggestive of underlying hepatic steatosis/parenchymal dysfunction. Patent hepatic vasculature.Distended s... |
Generate impression based on findings. | 44-year-old female with history of ALL. Pre-allogenic stem cell transplant evaluation. LUNGS AND PLEURA: Few bilateral pulmonary micronodules measuring up to 4 mm, some calcified. No suspicious pulmonary nodules. No focal consolidation or pleural effusion.MEDIASTINUM AND HILA: Heart size is normal with no pericardial e... | No suspicious lymphadenopathy or pulmonary nodules. |
Generate impression based on findings. | Male 16 years old Reason: Evaluate intracardiac mass seen on CT at 3/9/15. Status post resection air History: 16 y/o M recently diagnosed with spinal mass, multiple DVTs in LUE. The previously described hypodense, nonenhancing occupying mass of the SVC, right atrium, and the right ventricle has been resected. The right... | 1. Status post resection of massive thrombus/mass of SVC, right atrium and right ventricle. There was no vitalization likely due to persistent thrombus/mass or ligation of the left innominate , subclavian, left I. J. and axillary vein.2.Interval resolution of left-sided pleural effusion and pericardial effusion.Dr. Pet... |
Generate impression based on findings. | Limited imaging was obtained for stereotactic localization purposes. There is redemonstration of a large heterogeneous left posterior lateral cerebellar intraaxial mass. The multilobulated T1 hypointense and mildly T2 hyperintense to cortex mass appears to measure 2.2 x 2.8 cm in greatest axial dimensions onto a 201/5... | Redemonstration of likely solid and cystic left cerebellar mass with associated vasogenic edema and mild mass effect upon the fourth ventricle, incompletely characterized without contrast. Slight apparent decreased extent of vasogenic edema which previously crossed midline posteriorly. There is narrowing of the left fo... |
Generate impression based on findings. | Left kidney autotransplantation. Two separate arterial anastomoses. RENAL TRANSPLANT: LOCATION: Right iliac fossa.PERITRANSPLANT TISSUES: No fluid collection is identified.KIDNEY: Normal echogenicity. No pelvicaliceal dilation. Kidney measures 9.8 cm in length. Nephroureteral stent is in place extending to urinary blad... | Normal examination of transplant kidney. |
Generate impression based on findings. | 56 year old female with right breast 24 x 6 x 6 mm intraductal lesion, likely papilloma. Right ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a hypoechoic mass measuring 22 x 3 mm at the 6 o’clock position with increased vascularity, 1 cm from the nipple. The lesion was readily visi... | Successful ultrasound-guided core biopsy of the right breast lesion and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 51-year-old male. Patient with colon cancer stage IV with no evidence of disease. CHEST:LUNGS AND PLEURA: Stable left upper lobe micronodule. No suspicious pulmonary nodule.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. No visible coronary artery calcification. Normal heart size without pericardial effu... | No evidence of metastatic disease. |
Generate impression based on findings. | Male, 56 years old. RFO trigger: Renal transplant surgery. No unexpected radiopaque foreign body. Nonobstructive bowel gas pattern. Nephroureteral stent in the right pelvis. Left sided pelvic drain. | No unexpected radiopaque foreign body. Findings were discussed with the attending physician, Dr. Becker, via telephone on 3/17/2015 at 10:40. |
Generate impression based on findings. | No acute intracranial hemorrhage is identified. No evidence of intracranial mass, mass-effect, or hydrocephalus. No intra- or extra-axial fluid collections. Gray-white matter differentiation is preserved. Scattered opacification of the ethmoid air cells, sphenoid sinuses, and sphenoethmoidal recesses. Left sphenoid si... | 1.No evidence for acute intracranial abnormality. 2.Possible active left sphenoid sinusitis. Please correlate clinically. |
Generate impression based on findings. | GIST CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: No significant abnormality noted.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY TRACT: Stable subcentimeter low attenuation left lobe fociSPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality... | Stable examination without evidence for acute, inflammatory, or metastatic process. |
Generate impression based on findings. | Male, 15 months old. S/p VSD repair. Evaluate for interval change.VIEWS: Chest AP/lateral (two views) 3/17/2015 Multiple mediastinal clips are again seen.Cardiothymic silhouette is upper normal in size.Mild scattered atelectasis is unchanged. No new focal air space opacity. No pleural effusions or pneumothorax. | Postsurgical changes and atelectasis, without significant interval change. |
Generate impression based on findings. | Male; 42 years old. Reason: eval for renal stone History: flank pain ABDOMEN:LUNG BASES: Mild left lower lobe bronchial wall thickening with patchy groundglass opacities, most suggestive of aspiration pneumonitis. Mild cardiomegaly. Trace pericardial effusion.LIVER, BILIARY TRACT: Mild hepatic steatosis.SPLEEN: No sign... | 1. No GU calculi.2. Probable left basilar aspiration pneumonitis.3. Mild cardiomegaly.4. Mild hepatic steatosis.5. Nonspecific retroperitoneal and inguinal lymph nodes as described above. |
Generate impression based on findings. | 65-year-old male with head and neck cancer and CRT. Compared to previous measurements. CHEST:LUNGS AND PLEURA: Scattered bilateral pulmonary micronodules, some of which are new. These are nonspecific and may represent sequelae of inflammation. Scattered granular opacities, most prominent in the left lower lobe, remain ... | 1.No specific evidence of metastatic disease.2.Aspiration bronchiolitis. |
Generate impression based on findings. | Left hip pain. Two views of the left hip reveal a bony prominence at the left femoral head/neck junction, best seen on the modified Dunn view, which is suspicious for FAI. There is sclerosis of the acetabulum and osteophyte formation.Additional view of the pelvis shows right acetabular sclerosis and osteophyte formatio... | 1. Moderate osteoarthritis of the bilateral hips.2. Bony prominence of left femoral head/neck junction is suspicious for FAI. |
Generate impression based on findings. | Male, 58 years old, with history of cT3 N2 Mx base of tongue squamous cell carcinoma. Irregular thickened and mildly enhancing tissue is evident centered on the right glossotonsillar sulcus. This lesion extends anteriorly into the floor of mouth, posteriorly into the pharyngeal mucosa, and inferiorly into the vallecula... | 1.Irregularly marginated tumor centered in the right glossotonsillar sulcus with extension into the floor of mouth, pharyngeal mucosa, and vallecula with possible involvement of the epiglottis and pre-epiglottic space.2.Diffuse edema of the supraglottic larynx is likely related to treatment, but direct visual inspectio... |
Generate impression based on findings. | Three weeks of increasing midline tenderness at C7 and upper T-spine with increased pain with C-spine flexion. Five views of the cervical spine reveal no acute fracture. Alignment is anatomic. The neuroforamina are grossly patent. Vertebral body heights are maintained.Two views of the thoracic spine show no acute fract... | No acute fracture is evident. |
Generate impression based on findings. | Female; 27 years old. Reason: r/o acute intraabdominal process History: severe abdominal pain, intractable nausea/vomiting ABDOMEN:LUNG BASES: Mild left basilar streaky subsegmental atelectasis and/or scarring. Mild clustered nodular opacities with tree-in-bud in the right lower lobe, most likely related to infectious ... | 1. Right lower lobe nodular opacities are most likely related to infection as described above. If there is clinical concern for neoplasm, a follow-up dedicated CT chest with contrast can be obtained.2. Distended bladder with mild bilateral hydroureter, most likely related to fluid status but correlation for outlet obst... |
Generate impression based on findings. | Fourth/fifth toe swelling and erythema after trauma. Evaluate for fourth and fifth toe fracture. Two views of the fourth and fifth toes reveal no acute fracture or malalignment. There is mild soft tissue swelling. | No acute fracture is evident. |
Generate impression based on findings. | Symmetric enlargement of the thyroid gland, compatible with history of Graves' disease. Right thyroid lobe measures 4.8 x 4.8 x 9.1 cm. Left thyroid lobe measures 4.9 x 5.2 x 9.3 cm. No discrete thyroid lesion on this noncontrast CT. No significant substernal component. There is no direct compression of the airway by ... | Symmetric diffusely enlarged thyroid gland without airway compression. |
Generate impression based on findings. | Male 58 years old; Reason: h/o RCC History: none ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Nonobstructi... | 1.No evidence of recurrence. |
Generate impression based on findings. | 53 year old male. Fibromatosis. Evaluate for progression. 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: No signi... | Stable small mesenteric lesions with no new sites of disease. |
Generate impression based on findings. | 70 year old female status post right lumpectomy in 2006 for infiltrating ductal carcinoma, presents today for routine follow up. Patient received radiation therapy. No current breast complaints. Family history of breast carcinoma in her maternal grandmother and maternal aunt. Three standard views of both breasts, and t... | High probability benign calcifications in the right breast. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at Shor... |
Generate impression based on findings. | Pain. Left lower extremity weakness. Evaluate for osteoarthritis, degenerative disk disease, compression fracture, rotator cuff tear. Three views of the left shoulder are provided. The bones appear demineralized suggesting osteopenia/osteoporosis. Mild osteoarthritis affects the glenohumeral and acromioclavicular joint... | Degenerative arthritic changes as described above without fracture evident. |
Generate impression based on findings. | Female 63 years old; Reason: rapid weight loss of 30 pounds in 3-4 months, smoking history, early satiety, concerned for pancreatic cancer, lung cancer History: as above CHEST:LUNGS AND PLEURA: There is a 5-mm nodule in the right upper lobe (series 5, image 54). This was present on prior study where it is remeasured at... | 1. Stable 5-mm right pulmonary nodule.2. Nonspecific right external iliac chain lymph nodes. Evaluation of the pelvis is limited due to adjacent streak artifact. |
Generate impression based on findings. | There is an hypodense, nonenhancing occupying mass in the left axillary vein, left internal jugular and left innominate vein as well SVC and azygos vein, which is getting into the right atrium, crossing the tricuspid valve and ending in the right ventricle. The right ventricle outflow tract appears to be free of occlu... | 1.Likely massive thrombus of the left axillary, subclavian, IJ and innominate vein, as well azygos and SVC, which is continuous and getting into the right atrium and ventricle. The very unlikely possibility of intramural mass due to invasion or metastases may be contemplated.2.Pericardial effusion.3.Left pleural effusi... |
Generate impression based on findings. | Male 54 years old; Reason: metastatic prostate cancer, evaluation of disease after 6 cycles of investigational therapy. History: metastatic prostate cancer CHEST:LUNGS AND PLEURA: Apical cystic disease. Small dependent bibasilar atelectasis. No definite suspicious lung nodule seen.MEDIASTINUM AND HILA: No significant a... | 1. No significant change in reference lymph nodes as described.2. Size and extent of metastatic osseous disease subjectively similar to prior study. Please note that bone scintigraphy is a more sensitive indicator of activity of skeletal metastatic disease, see concomitant recent bone scan from same day for additional ... |
Generate impression based on findings. | The ventricles and sulci are within normal limits. The cisterns remain patent. There is no midline shift or mass effect. There are no areas of abnormal signal or pathological enhancement. There is no diffusion abnormality. No extra-axial fluid collection is identified.Normal flow-voids are demonstrated in the major in... | 1. Unremarkable MRI brain and MRA head. No MR evidence of moyamoya disease at this time. No significant perfusion abnormality.2. Moderate fluid opacification of right mastoid air cells with scattered paranasal sinus mucosal disease. |
Generate impression based on findings. | Lumbar pain. Ankle pain. Two views of the lumbar spine are provided. The bones appear slightly demineralized. Mild degenerative disk disease affects L5/S1. I see no spondylolisthesis or frank instability between the flexion and extension views. There is a mild compression deformity of T12 that was present on the prior ... | Mild L5/S1 degenerative disk disease and other findings as above. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Moderate centrilobular emphysema and bronchial thickening compatible with bronchitis.New 3-mm solid micronodule in the right lower lobe (series 5/56), most likely secondary to infection or bronchial mucous plugging, but... | New micronodule in the right lower lobe, most likely benign, but follow-up is recommended to confirm stability or resolution. No other evidence of metastatic disease. |
Generate impression based on findings. | 80 year-old male with history of NSCLC lung cancer CHEST:LUNGS AND PLEURA: Right upper lobe mass with surrounding radiation reaction, infiltrative tumor and consolidation, measuring approximately 6.6 x 6.3 cm at the reference level (series 5, image 79), not significantly changed since prior exam provided differences in... | 1.No significant interval change in size of right apical reference level measurements, though the posterior segment of the right upper lobe is now consolidated and presumably involved by tumor.2.Tumor infiltration into the mediastinum with development of extrinsic compression of the superior vena cava, left brachioceph... |
Generate impression based on findings. | Prior lumbar surgery. Evaluate for spondylolisthesis. Severe degenerative disk disease affects L5/S1. Relatively mild degenerative disk disease affects L3/4 and L4/5. I see no spondylolisthesis or frank instability between the flexion, neutral, and extension views. Vertebral body heights are preserved.There is a 3-cm r... | 1.Degenerative disk disease without evidence of spinal instability2.Findings suggestive of an ingested foreign body/bodies in the lower midabdomen. This was relayed to Dr. Mok at the time of dictation. |
Generate impression based on findings. | 66 year old female status post left lumpectomy in 2007 for invasive lobular carcinoma, 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 re... | Stable 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 annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Male 73 years old Reason: prostate cancer with rising PSA on therapy. History: prostate cancer Scattered foci of increased radiotracer uptake in the spine, right ribs and right SI joint are again unchanged. No abnormal osseous foci are identified to indicate metastatic disease. | No evidence of bone metastases, with no significant interval change. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements CHEST:LUNGS AND PLEURA: Apical pleuroparenchymal scarring unchanged.Minimal centrilobular emphysema. No interval suspicious pulmonary nodules or pleural effusion.MEDIASTINUM AND HILA: Heart size is unchanged. Moderate coronary artery calcification. No mediastina... | No evidence of metastatic disease. |
Generate impression based on findings. | There are postoperative changes of bilateral antrostomy, partial ethmoidectomy, and sphenoidotomy. Right antrostomy is patent. Additionally, there are questionable findings of partial bilateral middle turbinectomy. There is near complete opacification of bilateral maxillary and frontal sinuses with moderate-to-severe,... | 1.Moderate to severe scattered opacification and mucosal thickening of the paranasal sinuses, similar to the prior examination.2.Extensive postoperative changes. |
Generate impression based on findings. | Pain Mild osteoarthritis affects the ankle. Additionally, there is irregularity of the medial articular surface of the talar dome with small foci of depression of the subchondral bone plate and underlying sclerosis that I suspect represents an old osteochondral injury. A tiny density overlying the posterior recess of t... | Osteoarthritis and findings compatible with an old talar dome osteochondral injury as described above. |
Generate impression based on findings. | Female 48 years old; Reason: rule out renal recurrence History: hx or renal cell carcinoma, sp partial nephrectomy ABDOMEN:LUNG BASES: Granulomatous changes of the right lung including calcified hilar lymph nodes and scattered granulomas.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abno... | 1.Status post partial nephrectomy and likely cystectomy of the right kidney as described above. No definite evidence of recurrence. |
Generate impression based on findings. | 69 year old female with left breast mass 9:00. Left ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a mixed echogenicity mass measuring 25 x 14 mm at the 9 o’clock position with increased vascularity, 12 cm from the nipple. The lesion was readily visible.PROCEDURE: The procedure and ... | Successful ultrasound-guided core biopsy of the left breast lesion and clip placement. This is most likely a malignancy. Pathology is pending at this time.BIRADS: 5 - Highly suggestive of malignancy.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Reason: enlarged goiter. need to rule out narrowing of trachea History: none Respiratory motion degrades exam quality.LUNGS AND PLEURA: Persistent lingular linear atelectasis. No pleural effusion or pneumothorax. Scattered nonspecific micronodules. No suspicious nodules or masses.MEDIASTINUM AND HILA: No significant in... | No significant change in size of goiter with stable narrowing and anterior displacement of the trachea. |
Generate impression based on findings. | Renal cell carcinoma CHEST:LUNGS AND PLEURA: Mild cardiomegaly.MEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: AbsentPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormalit... | Stable examination without evidence for acute, inflammatory, or metastatic process. |
Generate impression based on findings. | Reason: Cerebral AVM surgery. It is not known if there is residual AVM present. The patient being anticoagulated Left vertebral artery: There is opacification of the basilar artery and both posterior cerebral arteries. There is a reverse filling of the posterior communicating arteries - left is larger than the right. T... | 1.No evidence for residual AVM. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: There has been interval resolution of the previous right middle lobe pneumonia. Several nodules were previously obscured by the pneumonia and are slightly more prominent compared to 8/1/14. One measures 5 mm (1/23), as compa... | Interval resolution of right middle lobe pneumonia. Residual scarring in this location is noted, along with centrilobular nodules of likely mild bronchiolitis.Two peripheral right middle lobe micronodules have increased in size when compared to 8/2014. These are suspicious for metastases. Attention to these on subseque... |
Generate impression based on findings. | Spinal stenosis, lumbar region, with neurogenic claudication. There is severe degenerative disk disease as well as facet joint osteoarthritis throughout the lumbar spine. There is a slight leftward curvature of the lumbar spine. There is a grade 1 retrolisthesis of T12 and L1 and a grade 1 anterolisthesis of L4. Modera... | Severe degenerative arthritic changes as described above. |
Generate impression based on findings. | Female, 76 years old, history of tonsil cancer status post CRT. Post treatment changes are again seen including volume loss along the left tongue base as well as infiltration of the fat planes of the neck. No mucosal lesions are seen.No pathologic adenopathy is detected by size criteria. A left level 2 reference lymph ... | Redemonstration of treatment related findings with no evidence to suggest local disease recurrence or pathologic adenopathy. |
Generate impression based on findings. | Male; 49 years old. Reason: Pancreas cancer currently on vaccine study please assess and compare to previous scan and provide index lesion measurements for RECIST History: As above CHEST:LUNGS AND PLEURA: Stable calcified and noncalcified pulmonary micronodules stable. No suspicious pulmonary nodules or masses. No pleu... | No significant interval change in index lesions. No new sites of disease. |
Generate impression based on findings. | Legs giving way. Assess implants. Again seen are posterior rods with screws entering the L1, L2, L4, and L5 vertebrae. There is straightening of the lumbar spine. The posterior components of the left L1 and L2 pedicle screws, as well as one of the L5 pedicle screws, have dislodged, but this appears similar to that seen... | Postoperative and arthritic changes of the spine as described above. |
Generate impression based on findings. | History bladder carcinoma status post radical cystectomy with Indiana pouch ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Subcentimeter low attenuation left lobe hepatic focusSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abno... | Bilateral pelvic masses worrisome for metastatic adenopathy.Incompletely characterized low-attenuation focus within the right kidney; would recommend correlation with ultrasound.Abdominal aortic aneurysm with maximal AP diameter 4.6 cm. |
Generate impression based on findings. | Evaluate for renal artery stenosis, history of hypertension RIGHT KIDNEY: Measures 10.8 cm. Increased renal cortical echogenicity. No shadowing intrarenal echogenic focus seen to suggest underlying nephrolithiasis. No hydronephrosis. No perinephric free fluid. Upper pole cystic focus, measuring 1.4 x 1.2 x 0.9 cm.LEFT ... | No sonographic evidence of renal artery stenosis. Echogenic kidneys, compatible with medical renal disease. |
Generate impression based on findings. | Bilateral hip pain. Three views of the right hip, three views of the left hip, and AP view of the pelvis reveal no acute fracture or dislocation. The bilateral hip joints and sacroiliac joints appear normal. | No acute fracture is evident. |
Generate impression based on findings. | Female 14 years old Reason: location of sitz marks (day 5) History: pica; feculent emesisVIEW: Abdomen AP (one view) 3/17/15 Eight Sitz markers are located in the right hemiabdomen and a right one in the left. No evidence of obstruction or free air. | Sitzmarks location as described. |
Generate impression based on findings. | Clinical question: Rule out hemorrhage. Signs and symptoms: 55 year old female with headache, known brain metastases, recent start on anti-coagulation. Unenhanced head CT:There is no detectable acute intracranial findings. CT however is insensitive for the early detection of an acute nonhemorrhagic ischemic stroke.Prev... | Unremarkable exam. |
Generate impression based on findings. | 18 years, Female. Reason: stent placement History: L ureteral stent placed at OSH Nonobstructive bowel gas pattern. Average stool burden. Left nephroureteral stent in expected position. | Left nephroureteral stent in expected position. Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 52 year old male hx of abdominal surgery with 4 weeks of abdominal pain, nausea, vomiting. Please evaluate for obstruction. History: Intractable nausea and vomiting. Nonobstructive bowel gas pattern. No free air on upright view. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 64 yo F s/p AAA repair History: abd pain Interval placement of lower abdominal aortic stent graft, in expected position. Multiple additional surgical clips unchanged. Nonobstructive bowel gas pattern. Right nephroureteral stent and peritoneal shunt tubing unchanged. | Interval placement of lower abdominal aortic stent graft without complication. |
Generate impression based on findings. | Pain. Injury. Two views of the left hip and an AP view of the pelvis are provided. The bones appear demineralized. There is mild irregularity of the margin of the greater trochanter superiorly which could conceivably represent an acute fracture, although this is also the site of a previous fracture sustained in April 2... | Slight irregularity of the superior aspect of the greater trochanter could conceivably represent an acute fracture, but may reflect old injury (i.e., a healed fracture at this location sustained last year). If further imaging evaluation is clinically warranted CT may be considered. I personally reviewed the Images and/... |
Generate impression based on findings. | Clinical question: Evaluate sinuses. Signs and symptoms: Chronic sinusitis and nasal polyposis. Medtronic fusion sinus CT:There is extensive to near complete opacification of all paranasal sinuses consistent with pansinusitis. Uniformly the contents of the sinuses along the inner walls of the sinuses are low in density... | 1.Extensive chronic pansinusitis with occluded bilateral ostiomeatal units and sphenoethmoidal recesses.2.Increased soft tissue within the nasal passage likely representing clinically suspected polyposis.3.Slightly higher density of the contents of the sinuses likely indicating long-standing chronic sinus disease. Poss... |
Generate impression based on findings. | 61 year old female status post left lumpectomy June 2013 for invasive ductal carcinoma with DCIS, presents today for routine follow up. Patient received radiation and hormonal therapy. No current breast complaints. Family history of breast carcinoma in her maternal cousin. Three standard views of both breasts, and 2 ma... | Stable 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 annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Male, 56 years old, history of T2N2BM0 left base of tongue p16+ cancer, status post CRT. Post-treatment findings are redemonstrated with reticulation of the subcutaneous fat and supraglottic mucosal thickening, unchanged. No evidence to suggest recurrent tumor is seen.No pathologic adenopathy is detected by size criter... | No evidence of local disease recurrence or pathologic adenopathy. |
Generate impression based on findings. | Female; 51 years old. Reason: Hx of diverticular disease History: hx diverticulitis, pre-op exam. The scout film showed proper positioning of the rectal tube and balloon. Barium flowed freely from the rectum to the cecum. The exam demonstrated moderate diverticulosis of the sigmoid colon as well as scattered diverticul... | Moderate sigmoid diverticulosis without acute colonic abnormality. FLUORO TIME: 6 minutes 42 seconds. |
Generate impression based on findings. | GIST 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: No significant abnormality notedRETROPERITONEUM, LYMPH NODES:... | Slight interval decrease in size of mesenteric masses. |
Generate impression based on findings. | Sarcoma/MFH, evaluate for progression. LUNGS AND PLEURA: Postsurgical volume loss on the left from wedge resection. Left upper lobe collapse; previously seen short segment of the aerated bronchus is now unopacified caudal to the level of the suture line towards the hilum. Reference central measurement is 16-mm (4/32), ... | Slight increase in pleural fluid and pleural thickening in the left hemithorax with ipsilateral intercostal lymph node enlargement suspicious for indolent metastatic disease or infection the pleural space, further evaluation recommended. Left cardiophrenic soft tissue nodule likely result of localized extension of pleu... |
Generate impression based on findings. | Male 74 years old; Reason: history of metastatic prostate cancer, rising PSA, assess for disease extent CHEST:LUNGS AND PLEURA: Biapical pleural nodularity/scarring. Again seen are scattered calcified and noncalcified micronodules. Reference left upper lobe lung nodule stable, measuring 4 mm, image 65 series 4. Increas... | 1. New and enlarging lung micronodules as described, nonspecific but suspicious for metastatic disease.2. Enlarging osseous metastatic disease. Please note that bone scintigraphy is more sensitive for evaluation, please refer to concomitant nuclear medicine bone scan from same day for additional findings.3. Indetermina... |
Generate impression based on findings. | There is an interspinous fusion device between L4 and L5 spinous processes. Bone graft material is identified just anteriorly without no definite bony bridging identified to the adjacent native bone, although margins are slightly indistinct. There is stable grade 1 anterolisthesis of L4 on L5 measuring 6 mm. The scout... | 1. Degenerative grade 1 anterolisthesis of L4 on L5 with evidence of posterior interspinous fusion device. Associated bone graft maternal is identified with no definite bony bridging at this time, although there is suggestion of ill-defined superior and inferior margins.2. At least moderate central canal stenosis at L4... |
Generate impression based on findings. | Six-months postop Again seen are postsurgical changes of partial C2 as well as total C3 and C4 laminectomy as well as posterior spinal fusion seen from C2 to C4. Lateral screws and rods are intact and appear well-positioned. There is mild periscrew lucency on the left at C4. Interval decrease in lucency at the left C3-... | 1. Postsurgical changes of C2 to C4 laminectomy and posterior spinal fusion. Hardware is intact and well positioned. There is mild periscrew lucency at C4 on the left. There is interval decrease in lucency at the left C3-C4 facet joint which may suggest mild progression of fusion.2. Degenerative changes as seen previou... |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.