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Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are screening mammogram dated February 17, 2015, and right diagnostic mammogram and right breast ultrasound dated February 24, 2015 performed at High Tech Medical Park. For comparison, screening mammograms dated February 11, 2014 and February 5, 2013 ar... | Mildly complicated cyst at the 6 o'clock position of the right breast. Suggest repeat ultrasound for more complete characterization of the cyst. BIRADS: 3 - Probably benign finding.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: Left lower lobe subsegmental atelectasis.No suspicious pulmonary nodule or pleural effusion.MEDIASTINUM AND HILA: There is a bioprosthetic valve in the aortic position. Heart size is normal. No pericardial effusion. Incident... | No evidence of metastatic disease. |
Generate impression based on findings. | GIST CHEST:LUNGS AND PLEURA: Stable biapical scarring.MEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: Stable subcentimeter transiently enhancing focus within segment 6 of the right lobe of the liver.SPLEEN: No significant abnormality notedP... | Stable examination without acute, inflammatory, or metastatic process. |
Generate impression based on findings. | 74 years old Male. Reason: lung cancer workup. History: lung cancer workup. RADIOPHARMACEUTICAL: 10.3 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 103 mg/dL. Today's CT portion grossly demonstrates a new mass in the superior segment of the right lower lobe. Multiple enlarged lymph nodes are seen in the me... | New hypermetabolic mass in the superior segment of the right lower lobe, consistent with the cancer. Retrospective, hypermetabolic focus was seen on prior study in the segmentHypermetabolic lymph nodes in the right hilum and mediastinum at the right paratracheal and precarinal regions.Small focus of increased activity ... |
Generate impression based on findings. | Dizziness and giddiness. Evaluate for lesion/aneurysm. There is no evidence of intracranial hemorrhage or mass effect. There are extensive areas of periventricular and subcortical white matter hypoattenuation, which are unusual in this age group. The ventricles and basal cisterns are normal in size and configuration. T... | 1. No evidence of intracranial hemorrhage or mass effect.2. Extensive areas of periventricular and subcortical white matter attenuation, which are unusual in this age group. Possibilities include vasculopathy, demyelination, and old toxic-metabolic injury, for example. Suggest MRI for further evaluation as clinically i... |
Generate impression based on findings. | Male 55 years old; Reason: 55 yo M hx of wilson's disease and cirrhosis with increasing transaminitis and AFP. Eval for HCC. History: cirrhosis ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Diffuse hypoattenuation of the cirrhotic liver. TIPS shunt in place. 3.6 x 3.8 cm (12:42 and 11:42) v... | 1.Incompletely characterized previously seen sonographic lesion adjacent to the gallbladder. A subtle area of hyperdensity, further described above, may conceivably correlate with the sonographic lesion, but demonstrates no definitive features of HCC. However, further, more definite characterization with MRI is recomme... |
Generate impression based on findings. | Back pain. Degenerative disk disease affecting the spine appears similar to that seen on the prior study. Levoscoliosis of the thoracolumbar spine, as measured from the superior endplate of T12 to the inferior endplate of L3, increases slightly to 25 degrees with bending to the right (compared to 20 degrees on the rout... | Scoliosis as described above. |
Generate impression based on findings. | Pain. Preop. Three views of the right knee are provided. Severe osteoarthritis affects the knee, particularly the lateral compartment where there is near bone on bone apposition. Components of a left total knee arthroplasty device are situated in near anatomic alignment as seen on the frontal view.A mechanical axis rad... | Osteoarthritis and valgus deformity of the knee as above. |
Generate impression based on findings. | Patient had surgery on infected left knee approximately 1 year ago and is having similar pain for the past 2 to 3 days. Increased pain in the left knee. Assess for effusion versus osteomyelitis. Four views of the left knee reveal no acute fracture or malalignment. There is chronic deformity of the patella. No cortical ... | No joint effusion or specific radiographic evidence of osteomyelitis. |
Generate impression based on findings. | Spindle cell neoplasm and obstruction of right ureter.EXAMINATION: Right retrograde pyelogram 03/17/15 41.8 seconds of fluoroscopy time was used.Multiple surgical clips are seen in the right pelvis.Contrast was injected into the right distal ureter. Only a small piece of ureter is visualized. | Obstruction of right ureter to retrograde injection. |
Generate impression based on findings. | Evaluation of the craniocervical junction demonstrates no evidence of tonsillar ectopia or Chiari 1. There is preserved biphasic flow ventrally and dorsally at this foramen magnum. Abnormal T2 signal involving the bilateral cerebellar hemispheres is partially visualized and was present on priorThere is no evidence of ... | 1. Upper thoracic dextroscoliosis, mid-thoracic levoscoliosis, and thoracolumbar dextroscoliosis better assessed on radiographs from 8/21/2014 and progressed since prior MRI from 2011.2. No evidence of Chiari 1, syrinx, tethered cord, or large neurofibromas on this noncontrast study, as clinically questioned. |
Generate impression based on findings. | 68 years old Female. Reason: initial staging, non-small cell lung cancer. History: newly diagnosed adenocarcinoma of lung. For initial staging. RADIOPHARMACEUTICAL: 13.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 110 mg/dL. Today's CT portion grossly demonstrates large right pleural effusion with compre... | 1.Hypermetabolic tumor in the right lower lobe with large right effusion and extensive right pleura metastasis.2.Lymph node metastases in the right lung hilum and mediastinal right paratracheal and subcarinal regions.3.Nonspecific focus of increased activity is seen in the right supra-renal region. |
Generate impression based on findings. | Rib pain after fall. Question of rib fracture. Three views of the ribs show a minimally displaced fracture of the anterior left 4th rib. Median sternotomy hardware is noted. Abdominal surgical clips and vascular calcifications are seen. | Anterior left 4th rib fracture. |
Generate impression based on findings. | 72-year-old male with pleural mesothelioma. CHEST:LUNGS AND PLEURA: Small left pleural effusion, significantly decreased from previous exam; may be partially loculated medially at the level of the pulmonary trunk. Pleurex catheter at the left lung base has been repositioned with tip now in the posterior costophrenic an... | 1.Left pleural thickening has decreased mildly in extent.2.Tumor seeding along the pleurex catheter tract appears mildly decreased in size.3.Stable mediastinal and anterior chest wall tumoral invasion.4.Increased hepatic and left lung metastases, as above.5.Significantly improved left pleural effusion and anasarca. |
Generate impression based on findings. | Female; 72 years old. Reason: 72F s/p cystectomy on 2/5/15 complicated by intra-abdominal abscess, now readmitted with concern for wound infection; please assess for intraabdominal process History: as above ABDOMEN:LUNG BASES: Calcified lung nodules from prior granulomatous disease. Mitral valve annular calcification. ... | 1. Status post cystectomy/hysterectomy with ileal conduit urinary diversion with expected appearance. 2. Interval resolution of pelvic fluid collections. No intra-abdominal or intrapelvic abscess is evident.3. Findings suggestive of cellulitis involving the open anterior abdominal wound, but no evidence of drainable ab... |
Generate impression based on findings. | Male 54 years old Reason: metastatic prostate cancer, evaluation of disease after 6 cycles of investigational therapy. Please complete PCWG2 form History: prostate cancer Numerous foci of increased or decreased uptake consistent with osseous metastases involving the axial and appendicular skeleton, no significant chang... | Diffuse osseous metastatic disease, with no significant interval change. |
Generate impression based on findings. | Clinical question: Status post removal of right maxillary sinus fungal ball. Signs and symptoms: Nasal congestion and discharge. Medtronic fusion sinus CT:The examination demonstrates interval extensive postoperative changes are endoscopic functional sinus surgery with resultant removal of the right ostiomeatal unit an... | 1.Interval postoperative changes on the right as detailed.2.Extensive residual soft tissue density within the right maxillary sinus without high density content to suggest fungus ball.3.Stable right-sided oroantral fistula since prior exam.4.Essentially unremarkable other paranasal sinuses and improvement since prior e... |
Generate impression based on findings. | Male 68 years old Reason: metastatic prostate cancer History: metastatic prostate cancer Degenerative changes are noted in the shoulders, and knees. Large increased area of radiotracer uptake in the thoracic and lumbar spine, with no focal area of increased uptake, likely due to degenerative changes. No convincing evid... | No evidence of bone metastases. |
Generate impression based on findings. | Right wrist bone protrusion. Concern for fracture. Three views of the right wrist reveal no acute fracture or malalignment. There is a small calcification adjacent to the ulnar styloid which is likely chronic in etiology and may represent a small accessory ossicle. There is mild osteoarthritis of the distal radioulnar ... | Degenerative changes without acute fracture. |
Generate impression based on findings. | 39-year-old female, status post ACDF for congenital spinal stenosis and HNP, with neck pain and left upper extremity radiculopathy There is loss of the normal cervical lordosis. The craniocervical junction appears normal. Postoperative changes of C5 through C7 ACDF. There is moderate diffuse congenital spinal canal nar... | 1. Moderate diffuse congenital spinal canal stenosis, with superimposed spondylotic changes worst at C6/7. The cord signal is normal throughout.2. Multilevel uncovertebral joint hypertrophy and neuroforaminal narrowing as described above.3. Moderate right paracentral disk protrusion at C4/5. |
Generate impression based on findings. | Male 58 years old Reason: assess for metastatic disease History: intermediate risk prostate cancer Solitary faint focus of increased radiotracer uptake in the left occipital region, which may represent osseous metastatic lesion, recommend follow-up for further evaluation. | Single focus in the left occipital region, which may represent osseous metastasis. Recommend follow-up examination for further evaluation. |
Generate impression based on findings. | Pain. Three views of the left ankle show a side plate and screw device affixing the distal fibula with a syndesmotic screw and two orthopedic screws affixing the medial malleolus. No evidence of hardware complication. Alignment is anatomic. The fracture lines are not visualized. | Healed orthopedic fixation of bimalleolar fractures. |
Generate impression based on findings. | Injury.VIEWS: Right elbow AP/lateral (two views), right forearm PA/lateral (two views) 03/17/15 The distal humerus is broadened and the olecranon fossa appears to be shallow. The posterior aspect of the capitellum is slightly irregular. | Posttraumatic changes with probable shallow olecranon fossa. |
Generate impression based on findings. | Follow-up. Three views of the right ankle show a side plate and screw device affixing the distal fibula. An orthopedic screw affixes the medial malleolus. No evidence of hardware complication. The fracture lines are indistinct consistent with healing. | Orthopedic fixation of bimalleolar fractures. |
Generate impression based on findings. | Female; 81 years old. Reason: assess for progression of OA in shoulder History: pain and decreased ROM. Increased subchondral cysts, joint space narrowing, and glenohumeral osteophytes, compatible with mild interval progression of osteoarthritis. No acute fracture or dislocation. | Mild interval progression of glenohumeral osteoarthritis. |
Generate impression based on findings. | 59-year-old with history of right mastectomy for ILC. On Tamoxifen. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No dominant mass, suspicious microca... | 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: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Female; 66 years old. Reason: knee pain after fall 2 months ago. r/o bony path History: pain in the right knee. No acute fracture or dislocation. Scattered tricompartmental osteophytes and joint space narrowing compatible with mild osteoarthritis, most pronounced in the patellofemoral compartment. | Mild osteoarthritis without fracture. |
Generate impression based on findings. | Male 53 years old; Reason: Pre-kidney transplant evaluation. Assess vasculature to support kidney transplant. History: Pre-transplant evaluation. The absence of intravenous and oral contrast limits evaluation of the solid organs and of the bowels. Given these limitations, the following observations were made:ABDOMEN:LU... | 1.Iliac artery calcification as detailed above. |
Generate impression based on findings. | Female; 47 years old. Reason: eval primary, new brain lesion History: new brain lesion CHEST:LUNGS AND PLEURA: Mixed cavitary and solid, spiculated mass in the left apex measuring up to 3.7 x 2.3 cm in greatest axial dimension (series 4/20), suspicious for lung cancer. Abutment of the mass along the posterior left apic... | Left apical mass, suspicious for lung cancer though tuberculosis or atypical mycobacterial infection could have a similar appearance.Results discussed with Dr. Ardelt at 3:08 p.m. on 3/17/15. |
Generate impression based on findings. | Male; 49 years old. Reason: Dysphagia and shortness of breath. Cervical spine is visualized to the top of C6 on the lateral view. No acute fracture or malalignment. Vertebral body heights are preserved. The prevertebral soft tissues and epiglottis are within normal limits. | No acute osseous or soft tissue abnormality identified. |
Generate impression based on findings. | Female 11 years old Reason: assess for constipation, obstruction, ileus History: RLQ pain, no BM x4dVIEWS: Abdomen AP supine and upright 3/17/15 (two views) Mild fecal loading. Normal abdomen gas pattern. No evidence of obstruction or free air. | Normal abdomen. |
Generate impression based on findings. | Female; 87 years old. Reason: history metastatic renal cancer, on no therapy, assess for progression History: none CHEST:LUNGS AND PLEURA: Reference right lower lobe pulmonary nodule measures 1.4 x 1 cm, unchanged since prior study on 1/11/15 when it measured 1.4 x 1 cm (series 5/84). Reference right middle lobe nodule... | 1. Mild increase in left chest wall index lesion. Other index lesions are not significantly changed. No new sites of disease.2. Stable appearance of lytic L1 vertebral body lesion causing severe central canal stenosis. MRI would be more sensitive for cord pathology if clinically indicated. |
Generate impression based on findings. | Male 13 years old Partial physeal arrest. Status post surgeryVIEWS: Left wrist AP and lateral 3/17/15 (two views) Cast material obscures fine bone detail. Round lucency over the medial distal physis of the left radius is related to postsurgical changes. Alignment is anatomic. Distal physis of the left radius and ulna a... | Postsurgical changes as described. |
Generate impression based on findings. | Right hydronephrosis.EXAMINATION: Right and left retrograde pyelogram 03/17/15 Lower pole right ureter was injected. The lower pole ureter is normal in caliber. There is a transition between the lower pole ureter and the renal pelvis which is dilated. The calyces are dilated. The right upper pole ureter was injected an... | Right duplicated ureters with lower pole UPJ obstruction. |
Generate impression based on findings. | History of osteoradionecrosis of the mandible, with left-sided jaw swelling after tooth extraction. He is on nearly completed 6 weeks of Augmentin therapy with no progression. No new swelling and no new pain. Panorex was done on December 30, 2014. He is status post chemoradiation for T3N2b left oral tongue cancer. Comp... | 1. No evidence of recurrent disease or cervical lymphadenopathy. 2. Again seen are findings suggestive of osteoradionecrosis of the left hemimandible. Compared to prior, there is mild increase in associated lucency, including linear lucency involving the cortex which is suspicious for fracture. No fluid collections in ... |
Generate impression based on findings. | Male, 7 years old. Abdominal pain. ABDOMEN:LUNG BASES: No focal pulmonary opacities. No pleural effusions.LIVER, BILIARY TRACT: No focal liver lesions. No intrahepatic or extrahepatic biliary ductal dilatation. The gallbladder is normal.SPLEEN: Not enlarged.PANCREAS: Normal in appearance.ADRENAL GLANDS: No significant ... | Normal examination. |
Generate impression based on findings. | 52 year old female status post right lumpectomy in 2012 for invasive ductal carcinoma, presents today for routine follow up. Patient received neoadjuvant chemotherapy, radiation, and Herceptin. No current breast complaints. No family history of breast cancer. Three standard views of both breasts, and a laterally exagge... | 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. | Female; 88 years old. Reason: left hip pain. Orthopedic plate and dynamic screws affix the left proximal femur in near anatomic alignment. No evidence of hardware complication or loosening. No acute fracture or dislocation. Mild degenerative changes affect the left hip. Mild degenerative changes are also seen in the ri... | Postsurgical and degenerative changes as described above. |
Generate impression based on findings. | Male 9 years old Reason: post-op . Status-post hardware removal.VIEWS: Right ankle AP, lateral and oblique 3/17/15 (3 views) Interval removal of right tibial distal epiphyseal screw. No evidence of complications related to the procedure. Healed fracture is in anatomic alignment. | Healed fracture in anatomic alignment, after hardware removal. |
Generate impression based on findings. | 58 year old female. Evaluate for progression of disease. Ovarian cancer. CHEST:LUNGS AND PLEURA: Right lower lobe micronodule, unchanged, likely postinflammatory.MEDIASTINUM AND HILA: Scattered small mediastinal lymph nodes. No lymphadenopathy.Normal heart size without pericardial effusion. Mild coronary artery calcifi... | Significant decrease in extensive peritoneal metastatic disease. Interval resolution of right cardiophrenic lymphadenopathy and decreased size of a perigastric lymph node. Another perigastric lymph node is mildly increased in size, of unclear clinical significance. |
Generate impression based on findings. | 64 years, Female. Reason: s/p NGT placement History: s/p NGT placement Limited study, pelvis is excluded from field of view. There is a nasogastric tube with its tip projecting over the fundus of the stomach. Again seen are multiple dilated loops of small bowel measuring up to 4.5 cm in diameter, compatible with patien... | Nasogastric tube with its tip projecting over the fundus of the stomach. |
Generate impression based on findings. | There are no masses, mass effect or midline shift. There is no evidence for intracranial hemorrhage or diffusion-weighted abnormalities. There are no extraaxial fluid collections. The ventricles and sulci are normal in size. Sulcation appears normal. There is normal myelination. Midline structures including the corpus... | MRI of the brain appears within normal limits. Specifically, no structural abnormalities within the basal ganglia are seen as clinically questioned. |
Generate impression based on findings. | Male, 3 years old. Evaluate stool burden, colonic distension History: Imperforate anus, constipation, now with pain with stoolingVIEW: Abdomen AP (one view) 3/17/20 15, 1353 Gastrostomy tube in place in the left upper quadrant. Redemonstration of surgical changes in left upper quadrant. Ascending colonic enema catheter... | Moderate to large stool burden, predominantly in the descending colon. |
Generate impression based on findings. | Female; 88 years old. Reason: osteoarthritis History: knee pain and swelling Left knee: No acute fracture or dislocation. Moderate medial and patellofemoral compartment joint space narrowing and small joint effusion.Right knee: No acute fracture or dislocation. Mild medial and patellofemoral compartment joint space nar... | Bilateral osteoarthritis, left greater than right. No acute fracture is evident. |
Generate impression based on findings. | Male 83 years old; Reason: 83 year old with a history of urothelial cancer. please assess for disease progression **CT UROGRAM, DELAYED VIEWS 3D VIEW RECONSTRUCTION* History: urothelial cancer The images are somewhat limited by motion artifact.CHEST:LUNGS AND PLEURA: Left apical lung nodule measures 1.5 x 1.5 cm (serie... | 1.Stable left apical lung lesion. As has been mentioned previously, this demonstrates interval growth compared to remote studies and a primary lung cancer is not excluded.2.No evidence of metastatic disease. |
Generate impression based on findings. | 59 year old female who was recalled from screening mammogram for technical repeat of the left MLO view for skinfold versus architectural distortion. Additional history was obtained at the time of examination of remote injury in the left axillary region. On physical examination, a scar is present in the lower left axill... | Scar formation in the left axillary region accounting for the finding on prior mammogram. 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: 2 - Be... |
Generate impression based on findings. | Female 61 years old Reason: evaluate for esophageal stricture History: solid food dysphagia. Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions.Double contrast evaluation of the esophagus and gastric cardia/fundus revealed no morphologic abnormalities of the... | 1. Small hiatal hernia nonobstructive to barium pill. 2. Trace amount of spontaneous reflux with rapid clearance. |
Generate impression based on findings. | 68-year-old asymptomatic female presents for diagnostic mammogram. Personally history of laryngeal squamous cell carcinoma. Family history of breast carcinoma in her sister at unknown age, and a paternal aunt at age 52. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.... | 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. | 70 year-old male with hypoechoic right testicular lesion, follow-up ultrasound. RIGHT TESTIS: Measures 2.5 cm x 1.8 cm x 3.9 cm and is slightly heterogeneous in echotexture. Hypoechoic lesion is again seen measuring 9 mm x 8 mm x 6 mm unchanged.LEFT TESTIS: 3.0 cm x 2.2 cm x 4.5 cm. Normal echotexture with no focal les... | Heterogeneous echotexture of the right testicle with a focal hypoechoic lesion unchanged. Findings are suspicious for neoplastic etiology and less likely infectious given stability in size and appearance of the lesion. Another consideration is a focal infarct, however this is also less likely given stability in size of... |
Generate impression based on findings. | Status post fracture.VIEWS: Right forearm AP and lateral 3/17/15 (two views) Cast material obscures fine bone detail. Healing fracture of both forearm bones with periosteal reaction , callus formation and palmar angulation, is unchanged in alignment. | Healing both forearm bones fractures, unchanged in alignment. |
Generate impression based on findings. | 82-year-old male with history of head and neck cancer and chemoradiation therapy. Compared to previous. LUNGS AND PLEURA: Moderate to severe centrilobular and paraseptal emphysema. Scattered bilateral pulmonary micronodules, some calcified, stable in size and number. Right middle lobe and lingular scarring again noted.... | No evidence of metastatic disease. |
Generate impression based on findings. | Reason: evaluate ILD History: cough shortness of breath, fibrosis LUNGS AND PLEURA: Scattered reticular opacities with peripheral groundglass predominantly in the lung bases. No honeycombing is present. No pleural effusion or pneumothorax. Mild mosaic attenuation on expiratory sequence is compatible with air trapping. ... | Interstitial reticular opacities with groundglass predominantly in the lung bases are most compatible with fibrosing NSIP, although atypical UIP related to connective tissue disease may be considered in the correct clinical context.. |
Generate impression based on findings. | 15 year-old male with cerebral palsy and concern for hip subluxationEXAMINATION: Pelvis AP and frog leg 3/17/15 The femoral heads are well seated within the acetabula bilaterally. No fracture. Plate and screw device affix the lateral aspect of the left proximal femoral metadiaphysis. Right coxa valga deformity. | The femoral heads are well seated within the well formed acetabula without evidence of subluxation. |
Generate impression based on findings. | Reason: h/o tonsil and thyroid ca, h/o CRT, compare to previous, measurements pls History: none. CHEST:LUNGS AND PLEURA: Mild centrilobular emphysema. Few scattered micronodules, some of which are calcified. No suspicious pulmonary nodules. No focal consolidation or pleural effusion.MEDIASTINUM AND HILA: Heart size is ... | No evidence of metastatic disease. |
Generate impression based on findings. | Clinical question: 84-year-old male with AMS, evaluate for bleed. Signs and symptoms: A mass, respiratory failure, nonverbal. Nonenhanced head CT:There is no detectable acute intracranial process. CT however is insensitive for early detection of acute non-hemorrhagic ischemic strokes.Prominence of the cortical sulci, C... | 1.No acute intracranial process.2.Very minimal findings suggestive of age indeterminate small vessel ischemic strokes. |
Generate impression based on findings. | 50 year old female status post right lumpectomy in 2010 for DCIS, and left lumpectomy in 2012 for invasive ductal carcinoma, presents today for routine follow up. Patient received radiation in 2010, and radiation and chemotherapy in 2012. No current breast complaints. No family history of breast cancer. Three standard ... | Stable postsurgical changes in both breasts. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Additionally, given the patient's history and breast density, annual screening MRI may be considered. Results and rec... |
Generate impression based on findings. | Male 75 years old Reason: Does this man have a Zenker's diverticulum? History: Pharyngoesophageal dysphagia in a 75 year old man. Some times the pills he swallowed come back up. Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions.Single contrast evaluation of... | 1. Small volume silent aspiration. 2. Esophageal dysmotility as described above.3. Barium pill remained in hypopharynx. A oropharyngeal motility study is recommended for further evaluation. |
Generate impression based on findings. | 8-year-old male with history of fall, pain and swellingVIEWS: Right ankle AP, oblique lateral (3 views) 3/17/15 Significantly increased space between the talus and calcaneus with adjacent soft tissue swelling and joint effusion is suggestive of a ligamentous injury. The posterior aspect of the talocalcaneal joint is me... | Significant separation of the talocalcaneal joint with adjacent soft tissue swelling and effusion is suggestive of subtalar ligamentous injury. |
Generate impression based on findings. | Female; 48 years old. Reason: TSA evaluation, bilateral wrist pain. Right shoulder: Reverse ball socket total shoulder arthroplasty is again noted and in near anatomic alignment. No evidence of hardware complication or loosening. No acute fracture or dislocation. Heterotopic bone formation under the AC joint is unchang... | 1.Bilateral negative ulnar variance and sclerosis of the left lunate, suggestive of Kienbock's malacia. 2.First left carpometacarpal joint dislocation which appears chronic. 3.Total right shoulder arthroplasty in near anatomic alignment. |
Generate impression based on findings. | Right shoulder pain, no injury. Patient complains of popping with external rotation of shoulder. The bones of the shoulder appear normal. No acute fracture is evident. Glenohumeral alignment is within normal limits. No large joint effusion is present. The rotator cuff muscle bulk appears to be within normal limits. The... | No specific CT findings to explain the patient's symptoms. If there is continued concern for rotator cuff or labral injury, MRI may be considered for further evaluation. |
Generate impression based on findings. | There is minimal grade 1 anterolisthesis of C4 on C5 measuring 2 mm. The cervical spine is otherwise in normal alignment, with mild reversal of the normal cervical lordosis centered at C4-C5. There is moderate narrowing of the C5-C6 disk C6-C7 disk, with diffuse disk desiccation throughout the cervical spine. The rema... | 1. Overall, moderate spondylotic changes most prominent at C5-C6 where there is moderate-severe central spinal stenosis as well as severe left and moderate-severe right foraminal narrowing.2. Cord signal abnormality just caudal to this level with suggestion of volume loss at least on the left side. Findings likely repr... |
Generate impression based on findings. | Female 45 years old Reason: Please evaluate the transplanted kidney for size, echogenicity and hydronephrosis History: History of kidney transplant. Decline in renal function and pain at the kidney transplant site TRANSPLANTED KIDNEY: The kidney measures 11.2 cm. No shadowing calculi or hydronephrosis is present. Renal... | Increased velocity at level of anastomosis, measuring 219 to 246 cm/sec (but improved from 1/2013 ultrasound study when measured 440 cm/sec) and gradient across anastomosis measures 2.1 to 2.4, assessment however was suboptimal due to vessel tortuosity at this level and these values are equivocal. While underlying anas... |
Generate impression based on findings. | Male 84 years old; Reason: lung mass History: lung mass ABDOMEN:LUNG BASES: Please see report of CT chest same date.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: Exophytic nodule closely related to the pancreatic tail. This mass has similar attenuation to the ... | 1.Nonspecific adrenal nodular thickening which is indeterminate particularly given the presence of a lung mass.2.Exophytic nodule off the pancreatic tail with similar enhancement characteristics to spleen, may represent accessory splenic tissue. |
Generate impression based on findings. | Pain and inability to bear weight. Question of intertrochanteric fracture. No acute fracture of the left femur is identified. There is irregularity of the greater trochanter which is likely related to sequela of a previously noted fracture in this region. Mild to moderate osteoarthritis affects the left hip with small ... | No evidence of an acute femur fracture. |
Generate impression based on findings. | ACL repair. MCL repair Two views of the left knee reveal a screw in the medial condyle consistent with ligament repair. There is an additional small sideplate on the lateral femoral condyle. Two additional bone defects caused by orthopedic hardware are seen in the proximal tibia. No change from previous exam of Februar... | Intact hardware from ligamentous repair. No acute abnormalities. |
Generate impression based on findings. | 46 year old female. History of hemangioendothelioma of vertebrae and liver and bilateral pelvic pain. Measure using recist criteria. CHEST:LUNGS AND PLEURA: Mild interstitial thickening in the anterior aspect of the left anterior lobe, unchanged.Nodular soft tissue thickening along the left major fissure and multiple n... | Stable examination with no new sites of disease. |
Generate impression based on findings. | Male 79 years old History: History of lung cancer, re-stageRADIOPHARMACEUTICAL: 9.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 109 mg/dL. Today's CT portion grossly demonstrates right lower lobe consolidation, with pleural thickening. Postradiation fibrotic changes are again noted. Previously identified... | 1.Diffusely increased activity in right lower lobe consolidation, which most likely represents post treatment changes.2.Two focal areas of increased activity adjacent to post treatment changes in right lower lobe with SUV of 7.1. Residual/recurrent tumor cannot be excluded.3.Cystic right renal lesion with peripheral FD... |
Generate impression based on findings. | 69-year-old asymptomatic female presents for diagnostic examination. History of abnormal mammogram. Family history of breast carcinoma in her maternal aunt at age 60. 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 fib... | 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: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Pain after ski injury. Three views of the left shoulder reveal no acute fracture or dislocation. There is sclerosis along the superior cortex of the humeral head, best seen on the grayshee view, which may be degenerative but is unusual for the patient's age. | Sclerosis about the superior cortex of the humeral head may be degenerative but is unusual for the patient's age; MRI of the shoulder is recommended to evaluate for internal derangement. |
Generate impression based on findings. | Lung CA follow-up CHEST:LUNGS AND PLEURA: Left upper lobe solid spiculated nodule slightly decreased in size, measuring 18 x 23 mm, previously 20 x 26 mm (5/43). There is a new small component of subsegmental atelectasis laterally.Emphysema. No pleural fluid or pneumothorax. No new nodules.MEDIASTINUM AND HILA: Low lef... | Minimal decrease in size measurements of left upper lobe spiculated nodule compatible with malignancy. Low left paratracheal lymphadenopathy not significantly changed. Subtle increase in size and nodular appearance of the anterior distal gastric wall of unclear etiology; an underlying lesion cannot be excluded in the a... |
Generate impression based on findings. | Pressure ulcers. Evaluate for osteomyelitis. Three views of the right ankle show a soft tissue defect at the lateral malleolus. There is cortical irregularity and periosteal reaction of the lateral and inferior distal fibular tip underlying the soft tissue defect, best seen on the oblique view. No acute fracture is evi... | Osteomyelitis of the distal fibular tip. |
Generate impression based on findings. | Status-post resection of thyroid gland and left neck dissection. No abnormal enhancement or soft tissue mass. Reference submandibular lymph nodes measuring 6 mm bilaterally, stable from prior study (series 6 image 31). Small right 3-4 mm level 3 lymph node is also unchanged. The parotid and submandibular glands are un... | No evidence of locoregional tumor recurrence in the neck. No significant cervical lymphadenopathy. |
Generate impression based on findings. | Right total knee arthroplasty pain. Four views of the right knee show a total knee arthroplasty device with resection of the proximal tibial plateau. There is lucency around the cement-bone interface of both the femoral and tibial components of the prosthesis, most predominately of the medial femoral component; compari... | Lucency surrounding the bone-cement interface of the right total knee arthroplasty raises the question of loosening; comparison to prior radiographs would be helpful if available. |
Generate impression based on findings. | 84-year-old male with lung mass. LUNGS AND PLEURA: Large , heterogeneously enhancing, centrally necrotic subpleural mass in the posterior segment of the right upper lobe measures 6.2 x 6.2 cm (series 20359, image 42). Extension is seen to the right posterior fifth and sixth ribs, evidenced by osseous destruction. No ot... | 1.Large right upper lobe subpleural mass with invasion of the fifth and sixth ribs is highly suspicious for malignancy.2.Left adrenal nodularity, suspicious for metastasis. |
Generate impression based on findings. | Female; 79 years old. Reason: S/p Left TKA Postsurgical changes status post total knee arthroplasty which is in near anatomic alignment. No acute fracture or dislocation. Midline surgical staples. | Total knee arthroplasty hardware in near anatomic alignment. |
Generate impression based on findings. | Female 44 years old Reason: rule out tracheoesophageal fistula History: vomiting/coughing. not tolerating any po. Scout radiograph of the chest was obtained. Please refer to same day chest radiograph for complete thoracic findings.Limited study as patient had small volume swallows. Water-soluble contrast evaluation did... | 1. No tracheo-esophageal fistula, mass, or sinus tract in this limited study.2. Possible nonobstructive anterior cervical web. |
Generate impression based on findings. | Reason: f/u LUL nodules, tobacco use history, COPD History: lung nodule LUNGS AND PLEURA: No pleural effusion or pneumothorax. Central airways are patent. Minimal left basilar atelectasis. Mild centrilobular emphysema. Slight interval decrease in left apical nodules suggestive of resolving post inflammatory changes. Ad... | 1. Interval decrease in left upper lobe cluster of micronodules. Stable unchanged micronodules. No suspicious nodules. 2. Fatty infiltration of the liver and deposition of intrathoracic and intra-abdominal fat disproportionate to degree of subcutaneous fat, correlate for hypercortisolism. |
Generate impression based on findings. | The patient submitted outside mammogram dated 1/11/12, 3/11/13. Submitted outside study was compared to the current mammogram dated 3/4/15. Right axillary lymph nodes are not visualized on the prior studies, and one of left axillary lymph nodes is partially visualized on the study of 1/11/12. No suspicious masses, micr... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Male; 23 years old. Reason: right ankle pain Diffuse soft tissue swelling is noted about the ankle. No acute fracture or dislocation is identified. However, slight widening of the medial tibiotalar gutter is noted on the stress view compared to unstressed views. | Soft tissue swelling and slight widening of the medial tibiotalar joint space on the stress view. No acute fracture identified. |
Generate impression based on findings. | Caroli's disease and renal failure. Kidney transplant. Pre-kidney and liver transplant evaluation for line placement during surgery. Color and spectral Doppler were performed.INTERNAL JUGULAR VEINS: Internal jugular veins have normal waveforms. Blood flow is in the direction of the heart. The veins are compressible.SUB... | Normal examination without thrombosis. |
Generate impression based on findings. | 17-day-old male with distended abdomen and emesisVIEW: Abdomen AP (one view) 3/17/15 Nasogastric tube tip and proximal sidehole within the gastric body. Nonobstructive bowel gas pattern. No pneumatosis, free air, or portal venous gas. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Female; 72 years old. Reason: please eval knee for signs of OA . please include skyline view to assess posterior patella History: clinical signs of patellofemoral syndrome and OA. No acute fracture or dislocation. Mild osteoarthritis is noted about the right knee. Vascular calcifications are seen in the posterior soft ... | Mild osteoarthritis without fracture. |
Generate impression based on findings. | Male 16 years old Reason: Evaluate for further tumor spread History: Newly diagnosed sarcomaRADIOPHARMACEUTICAL: 6.9 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 89 mg/dL. Today's CT portion grossly demonstrates postsurgical changes of laminectomy involving the cervical and upper thoracic spine. Vertebral... | 1.Postsurgical changes in the cervical spine and upper thoracic spine, as well as the sternum and anterior mediastinum.2.Left paraspinal mass with heterogeneous FDG uptake, suggest surveillance imaging with MR if clinically indicated because of lower level of uptake. |
Generate impression based on findings. | The patient submitted outside mammogram dated 1/11/12, 3/11/13. Submitted outside study was compared to the current mammogram dated 3/4/15. Right axillary lymph nodes are not visualized on the prior studies, and one of left axillary lymph nodes is partially visualized on the study of 1/11/12. No suspicious masses, micr... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Female; 61 years old. Reason: Evaluate for evidence of spinal stenosis and assess degree of degenerative disc disease History: worsening back pain. No acute fracture or malalignment. Small anterior osteophytes are noted in the lower lumbar spine, but the vertebral body heights and disk spaces are preserved. Sclerosis o... | Mild degenerative changes as described above, without acute superimposed abnormality. |
Generate impression based on findings. | 65 year old man with hypertension, hyperlipidemia presenting with atypical chest pain but limited exercise capacity.CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of Valsalva and goes onto form the left anterior descending artery. There are no significant stenos... | 1. There are no severe coronary artery stenoses present. 2. There are stenoses of intermediate severity (50-70%) in the proximal and mid left anterior descending artery. 3. The left circumflex arises anomalously from the right coronary artery with a retro-aortic course. 4. Mild left ventricular hypertrophy with evidenc... |
Generate impression based on findings. | Female, 6 years old. Post-op bilateral Achilles' tendon lengthening and talectomy on 1/29/2015VIEWS: Right foot lateral and left foot lateral (two views) 3/17/20 15, 1454 Overlying casting material obscures fine osseous detail.Redemonstration of postsurgical changes, with two K wires in the left foot and 3 K wires in t... | Stable postsurgical changes as detailed above. |
Generate impression based on findings. | Reason: osteosarcoma with lung mets compare to last CT and measure using RECIST criteria 1.1 History: pre chemo. LUNGS AND PLEURA: Numerous bilateral masses, nodules, and micronodules, some partially ossified. Some are increased in size, though no definite new lesions are identified. For example, a medial lingular nodu... | Numerous bilateral pulmonary osteosarcoma metastases, some increased in size. |
Generate impression based on findings. | 76-year-old female. Unexplained weight loss. History of multiple myeloma and GIST tumor. Refusing therapy for GIST. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Three scattered subcentimeter arterially enhancing foci in the liver, too small to characterize, may be THADs; special attention o... | 1. No significant change in known gastric GIST. 2. Three subcentimeter arterially hyperenhancing foci in the liver, too small to characterize, may be perfusion abnormalities; special attention on follow-up scans.3. Extensive osseous changes of multiple myeloma with stable lumbar compression deformities. |
Generate impression based on findings. | Male; 50 years old. Reason: s/p MVA with possible left acromion fracture. Need axillary, ap, scapular Y view (3 views) There is no acute fracture or dislocation. Alignment is anatomic. No significant degenerative changes are noted. | No acute fracture or dislocation. |
Generate impression based on findings. | The ventricles and sulci are within normal limits. The basal cisterns remain patent. There is no midline shift or mass effect. There are scattered foci of abnormal T2/FLAIR hyperintensity within the periventricular and subcortical white matter as well as in the pons, which are nonspecific. There is no diffusion abnorm... | 1. Moderate amount of abnormal T2/FLAIR hyperintense signal within the periventricular and subcortical white matter, which is nonspecific, but favored to represent chronic small vessel ischemic disease and/or vasculopathy related to lupus. No large infarcts.2. Diffuse opacification of the right maxillary sinus. |
Generate impression based on findings. | Male 57 years old Reason: 57yo M w/ duodenitis, concerning for duodenal perf History: rule out duodenal perforation. Limited study was performed, and reduces sensitivity of mucosal masses or lesions. Additionally, retained contrast in the colon from prior study limits the study. However, within these limitations, singl... | 1. Esophageal dysmotility as described above. 2. No evidence of duodenal perforation, scarring, or chronic peptic ulcerative disease. |
Generate impression based on findings. | 73 years, Female. Reason: 73 yo female with abdominal pain and constipation. Please assess for signs of constipation. History: upper abdominal pain, constipation Nonobstructive bowel gas pattern with a slightly greater than average stool burden. | Slightly greater than average stool burden. |
Generate impression based on findings. | Female 2 years old Reason: fracture/post-op VIEWS: Left elbow AP and lateral 3/17/15 (two views) Cast material obscures fine bone detail. Three K wires are affixing a healing supracondylar fracture to near-anatomic alignment. | Healing fracture, in near anatomic alignment after pinning and casting. |
Generate impression based on findings. | 79 years, Male. Reason: 79 yom abdominal pain, eval obstruction, perforation History: abdominal pain. The pelvis is excluded from the field of view. There is a Dobbhoff tube with its tip projecting over the antropyloric region of the stomach. Nonobstructive bowel gas pattern. However, pneumoperitoneum cannot be entirel... | Nonobstructive bowel gas pattern. However, pneumoperitoneum cannot be entirely excluded in a supine study. |
Generate impression based on findings. | 54 year old female status post right mastectomy in 2012 for IDC and DCIS, presents today for routine follow up. Patient is currently on tamoxifen. History of benign left breast excisional biopsy, and more recent left breast core needle biopsy. No current breast complaints. Family history of breast carcinoma in her pate... | 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: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | There is unchanged encephalomalacia of the left middle frontal gyrus, likely representing prior infarct. The ventricles and sulci are prominent, consistent with mild age-related volume loss. There is no midline shift or mass effect. There is no intracranial hemorrhage. There is mild progression of scattered punctate a... | 1. No acute intracranial hemorrhage. 2. Mild age-indeterminate small vessel ischemic changes. Chronic left frontal infarct. Please note that CT is insensitive for the detection of acute nonhemorrhagic ischemic event. If there is continued clinical concern and there are no contraindications, MRI of the brain is recommen... |
Generate impression based on findings. | 77-year-old with history of left breast cancer status post mastectomy. No current complaints. Three standard 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. No domina... | 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: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Male 68 years old; Reason: hx of bladder cancer s/p radical cystectomy with ileal conduit urinary diversion, evaluate for metastatic disease with delayed imaging History: see above ABDOMEN: LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnorma... | 1.No evidence of metastatic disease. |
Generate impression based on findings. | Male 74 years old Reason: history of metastatic prostate cancer, on enzalutamide, PSA rising assess extent of disease History: none Numerous osseous metastases in the cervical spine, thoracic spine, lumbar spine, pelvis and ribs appear similar to prior examination. No new focal osseous lesions are identified. | Extensive osseous metastatic disease, with no significant interval change, and no evidence of new osseous lesions. |
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