instruction stringclasses 1
value | input stringlengths 6 8.98k | output stringlengths 5 3.11k |
|---|---|---|
Generate impression based on findings. | Male 5 days old Reason: where is PICC tip History: PICC placedVIEW: Chest and abdomen AP (two views) 3/17/15 1514 hrs NG tube tip is at the stomach. UVC unchanged. Right upper extremity PCVC terminates at the right external iliac vein.Cardiac silhouette size is normal. Persistent bilateral diffuse lung haziness with no... | Interval placement of right lower extremity PCVC as described.Persistent bilateral diffuse lung haziness. |
Generate impression based on findings. | Female; 66 years old. Reason: eval for disease progression. please compare to previous CT 9/9/14 History: history of GIST, on adjuvant Gleevec CHEST:LUNGS AND PLEURA: Scattered calcified and noncalcified nodules are unchanged. No suspicious pulmonary or masses.MEDIASTINUM AND HILA: No significant abnormality noted.CHES... | No evidence of recurrent of metastatic disease. |
Generate impression based on findings. | The patient is status post endoscopic sinus surgery with bilateral maxillary antrostomy and right partial ethmoidectomy, and middle turbinectomy. Scattered areas of polypoid mucosal thickening in the maxillary sinuses are stable from 2014, and the frontal and sphenoid sinuses are otherwise clear. The ethmoid air cells... | 1.Mild paranasal sinus disease as described above.2.Postoperative changes as described above. |
Generate impression based on findings. | 78-year-old male. Hematuria, painless. ABDOMEN:LUNG BASES: Calcified nodule left lung base consistent with prior infection. Scattered micronodules in the right middle lobe, likely postinflammatory.LIVER, BILIARY TRACT: Small cyst in the right hepatic lobe. Focal 1.6 x 2.1 cm small hypoattenuation in segment 4 of the li... | 1. No renal or ureteral stones. CT urography w/wo contrast may be considered to exclude a mass as a cause of patient's hematuria if clinically warranted.2. 2.1 x 1.6 cm hypoattenuating focus in the liver is incompletely characterized. MRI liver wwo contrast as clinically warranted for further evaluation. |
Generate impression based on findings. | 59 years, Male. Reason: evidence of SBO, stool burden History: re-starting TF, questionable amount of BMs Less than average stool burden. Nonobstructive bowel gas pattern. Right sided tube may be overlying the patient. Note is made of a suprapubic catheter. | Less than average stool burden. |
Generate impression based on findings. | Male; 56 years old. Reason: DH Large Cell NHL History: Evaluate extent of disease CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. Mild bibasilar subsegmental atelectasis.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY T... | 1. Massive conglomerate upper abdominal retroperitoneal lymphadenopathy, which was FDG avid on recent PET scan and compatible with tumor.2. Suspicious right renal lesion. |
Generate impression based on findings. | 20-Year-old with decreased mobility from MVA in January with acute onset shortness of breath and dizziness. PULMONARY ARTERIES: Technically adequate exam for evaluation of pulmonary embolism. No pulmonary embolus is identified. Mild pleural thickening at the bases, right greater than left, may relate to prior trauma/su... | 1.No evidence of pulmonary embolism.2.Incompletely evaluated the inferior right hepatic lobe fluid collection. Differential considerations include biloma versus abscess versus seroma. Correlation with outside imaging is recommended; otherwise dedicated abdominal cross-sectional imaging may be considered if clinically i... |
Generate impression based on findings. | Female, 47 years old. Evaluate for radiopaque foreign object. No unexpected radiopaque foreign object is identified. Towel clips are seen in the right upper and left upper quadrants. Pelvic surgical clips are compatible with patient's recent pelvic surgery. Small amount of pneumoperitoneum is likely post-procedural. Mu... | No unexpected radiopaque foreign object is identified. These findings were discussed by telephone with Dr. Rex Haydon, the attending surgeon, on 3/17/2015 at 1507. |
Generate impression based on findings. | 14-year-old female with history of sickle cell disease, with midline thoracic painVIEWS: Thoracic spine AP, lateral, swimmers (3 views) 3/17/15 The vertebral body heights and disk spaces are maintained. No fracture or subluxation. Surgical clips are noted in the right upper quadrant. | The vertebral body heights and disk spaces are maintained. No fracture or subluxation. |
Generate impression based on findings. | Male 57 years old; Reason: eval for abscess History: delay return of bowel function ABDOMEN:LUNG BASES: Moderate bilateral pleural effusions with compressive atelectasis. The pleural effusions demonstrate scalloping along the atelectatic lung raising the possibility of malignant effusions. Cardiomegaly.LIVER, BILIARY T... | 1.Diffuse bowel dilatation without clear transition point. Favor ileus given the recent surgical procedure however given the degree of persistent bowel dilatation obstruction cannot be completely excluded.2.Loculated fluid collections as detailed above. Continued follow up is recommended as developing infection is not ... |
Generate impression based on findings. | Female 10 days old Reason: Where is PICC tip . Respiratory distress.VIEW: Abdomen and chest AP (two views) 3/17/15 at 1529 hrs ET tube terminates at the thoracic inlet. NG tube tip is at the stomach. UVC terminates at the right atrium. Right lower extremity PCVC tip at the the lower, infrahepatic IVC.Cardiac silhouette... | Interval placement of PCVC as described.Bilateral diffuse lung haziness but no focal opacities. |
Generate impression based on findings. | Female; 30 years old. Reason: fevers No acute fracture or dislocation. All paranasal sinuses are well aerated without air-fluid levels. Enteric tube is partially visualized. | No radiographic evidence of acute sinusitis. |
Generate impression based on findings. | Male; 68 years old. Reason: preop MVR endoscopic History: SOB VESSELS:DESCENDING THORACIC AORTA AT LEVEL OF HIATUS: 2.3 X 2.7 cmSUPRARENAL ABDOMINAL AORTA: 2.1 X 2.1 cmINFRARENAL ABDOMINAL AORTA: 1.4 X 1.8 cmRIGHT COMMON ILIAC ARTERY: 13 X 10 mmRIGHT EXTERNAL ILIAC ARTERY: 11 X 10 mmRIGHT COMMON FEMORAL ARTERY: 11 X 10... | 1. Abdominal aorta and branch vessels are patent as detailed above.2. Prostatomegaly. |
Generate impression based on findings. | Status post lumbar fusion. Assess implants. Again seen are posterior stabilization rods with screws entering the T10 through S1 vertebrae, with an additional screw entering the right ilium. There is no evidence of hardware complication. There is a leftward scoliosis of the lumbar spine with laminectomies. Severe multil... | Post-surgical changes as described above. |
Generate impression based on findings. | The right submandibular gland appears somewhat heterogeneous and displays lobulated contours. In addition, the right submandibular gland appears to be small than the left. There is minimal fat stranding adjacent to the right submandibular gland. There is no evidence of radioattenuating calculi. There is no evidence of... | 1. The right submandibular gland appears somewhat heterogeneous and displays lobulated contours. In addition, the right submandibular gland appears to be small than the left, but no radioattenuating calculi are apparent. The constellation of findings may represent chronic sialadenitis. MRI may be helpful for further ev... |
Generate impression based on findings. | 67-year-old female with history of lung cancer status post chemoradiation . Evaluation of preop for open right lower lobectomy. CHEST:LUNGS AND PLEURA: Redemonstrated spiculated superior segment right lower lobe mass measuring 26 x 19 mm (series 6, 50), previously 31 x 20 mm. New surrounding groundglass opacity may rep... | Spiculated superior segment right lower lobe mass, compatible with known primary lung neoplasm, slightly decreased in size. New surrounding groundglass opacity may represent interval hemorrhage. |
Generate impression based on findings. | Male; 63 years old. Reason: eval for dislocation vs fracture History: right shoulder/AC joint pain s/p trauma; pt has baseline R brachial plexus injury making exam limited. No acute fracture or dislocation identified. Alignment is anatomic. | No acute fracture identified. However, if clinical suspicion persists, CT can be considered for further evaluation. |
Generate impression based on findings. | Female, 17 years old. Abdominal pain, distention. Evaluate for bowel distention, stool burden, free airVIEW: Abdomen AP upright (one view) 3/17/2015, 1525 Right femoral catheter in place.Nonobstructive bowel gas pattern.Small stool burden.No evidence of free air. | No evidence of obstruction or free air. |
Generate impression based on findings. | Status-post CDH repair.VIEWS: Chest AP/lateral (two views) 3/17/15 at 1534 hrs. Cardiac silhouette size is normal. No focal opacities, effusions or pneumothorax. Both diaphragms appears to be intact. | Normal examination. |
Generate impression based on findings. | Female; 39 years old. Presents with left lower extremity pain. No acute fracture or dislocation in the left hip or femur. Alignment is anatomic. | Normal examination. |
Generate impression based on findings. | Female; 82 years old. Reason: loose TEA? History: pain Hardware components of a total elbow arthroplasty device are in near anatomic alignment. The proximal radius has been resected. Lucency along the radial aspect of the humeral component may represent device loosening. Extensive heterotopic ossification is present ab... | 1.Postsurgical changes status post total elbow arthroplasty, with lucency along the radial aspect of the humeral component that may represent hardware loosening. 2.Tubular radiopaque foreign body of unknown etiology projects into the joint space. |
Generate impression based on findings. | Right shoulder pain, acromioclavicular joint. Three views of the right shoulder show no acute fracture or dislocation. The acromioclavicular joint appears normal. There is vacuum disk phenomenon of the glenohumeral joint. | No specific findings to account for the patient's shoulder pain. |
Generate impression based on findings. | Healthy female with left wrist pain for 8 weeks, no improvement with splint/NSAID. Pain at the left wrist, medial anterior ulnar area per urgent care evaluation. Evaluate for fracture or DJD. Three views of the left wrist reveal no acute fracture or malalignment. The bones appear normal. | No specific radiographic findings to account for the patient's pain. |
Generate impression based on findings. | Male; 17 years old. Reason: eval ACJ History: ACJ pain No acute fracture or dislocation. Alignment is anatomic. | Normal examination. |
Generate impression based on findings. | Male; 54 years old. Reason: right hip pain No acute fracture or dislocation. Moderate bilateral degenerative changes are noted. Surgical staples in the superficial soft tissues overlying the proximal right femur. Two orthopedic screws enter the sacrum on the AP view of the pelvis. | Moderate bilateral degenerative changes without acute fracture evident. |
Generate impression based on findings. | Female; 54 years old. Reason: Evaluate for stress fracture at base of 5th metatarsal. History: Right foot pain No acute fracture or dislocation. Alignment is anatomic. Incidental note is made of an accessory navicular and os trigonum. | No acute fracture or dislocation. |
Generate impression based on findings. | Male; 17 years old. Reason: scaphoid fx History: s/p ORIF Headless cannulated screw affixes the scaphoid in near anatomic alignment. There is no evidence of hardware complication or loosening. The fracture line is indistinct, compatible with interval healing. No new fracture is identified. | Healing scaphoid fracture in near anatomic alignment s/p ORIF. |
Generate impression based on findings. | Female, 3 years old. Evaluate stool burden. History: constipation, hx cloacaVIEW: Abdomen AP (one view) 3/17/2015, 1543 Nonobstructive bowel gas pattern.Below-average stool burden, predominantly in the area of the cecum. Decreased from the prior exam.No pneumatosis, portal venous gas, or free air.Abnormal sacral morpho... | Decrease in stool burden. No evidence of obstruction. |
Generate impression based on findings. | Male; 26 years old. Reason: lumbar pain. No acute fracture or malalignment. The vertebral body heights are preserved. No significant degenerative changes. | Normal examination. |
Generate impression based on findings. | 43-year-old female with cavitary lesion on TB therapy. Evaluate cavitary lesion for improvement. LUNGS AND PLEURA: Interval decrease in size of the left lower lobe lesion, measuring 9 x 14 mm from previously 12 x 14 mm. No cavitation is evident. No new areas of consolidation, suspicious nodules, or pleural effusion is ... | 1.Improving left lower lobe lesion.2.Misty mesentery centrally seen at the inferior edge of the field of view, incompletely evaluated. This may be further evaluated with CT chest and abdomen on the next study; however if abdominal symptoms are currently present, CT abdomen could be considered at this time. |
Generate impression based on findings. | 15-year-old male history of fractureVIEWS: Right ankle AP, oblique and lateral (3 views) 3/17/15 Interval removal of screws traversing the distal tibia and fibula. Horizontal lucencies traverse the distal fibula and distal tibia with surrounding sclerosis represent screw tracks. Very small flecks of residual metal are ... | Interval removal of screws traversing the distal tibia and fibula. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: Superior paramediastinal fibrosis likely secondary to radiation. Stable central emphysema.Improved aeration of the lower lobes with only minimal residual scarlike opacity adjacent to calcification in the left lower lobe (6/8... | No evidence of metastatic disease. |
Generate impression based on findings. | 78 year-old female with gradual onset of hoarseness over last 10 years. Evaluate for compression of the recurrent laryngeal nerve. LUNGS AND PLEURA: No focal consolidation, pleural effusion, or suspicious pulmonary nodules.MEDIASTINUM AND HILA: Heart size is normal with no pericardial effusion. No coronary calcificatio... | 1.No mediastinal mass or adenopathy is present.2.There appear to be parapelvic cysts in the left kidney, which is incompletely imaged and therefore mild hydronephrosis cannot be excluded. |
Generate impression based on findings. | Surgery for Blount's disease.VIEWS: Left tibia fibula AP/lateral (two views) 03/17/15 Ilazarov device remains in place. No broken components are seen. Lucency is noted around the second screw in the proximal tibia however this is unchanged in appearance. Alignment at the osteotomy of the proximal tibia is unchanged. Pe... | Continued healing of the tibial osteotomy. |
Generate impression based on findings. | 14-year-old male with newly diagnosed Crohn's disease and history of partial small bowel obstructions, with abdominal pain and feeding intolerance.EXAMINATION: MR enterography without and with IV contrast 3/17/15 ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PAN... | Inflammatory changes of the terminal ileum, consistent with active inflammatory bowel disease, causing stenosis with bowel dilatation. |
Generate impression based on findings. | Reason: head and neck cancer, locally advanced, rule out metastatic disease History: mass at base of tongue LUNGS AND PLEURA: No suspicious nodules or masses. Small micronodule in the right apex, probably a granuloma. No pleural effusion or pneumothorax. Minimal dependent bibasilar atelectasis.MEDIASTINUM AND HILA: Sca... | No evidence of metastatic disease. |
Generate impression based on findings. | 2-year-old female. Evaluate for hip subluxation.VIEWS: Pelvis AP, frog leg (two views) 3/16/2015, 1025 The osseous structures and joint spaces are normal.The femoral head ossification centers are well directed into the acetabula.The right acetabular roof is slightly less horizontal than the left. | No developmental hip dysplasia. |
Generate impression based on findings. | Redemonstrated are postoperative findings related to bilateral frontal craniotomy. The right frontal approach ventricular catheter is in stable position with its tip in the left ambient cistern. The right parietal approach ventriculostomy catheter is also in stable position, with tip just at the right of midline in th... | 1. No acute intracranial hemorrhage.2. No significant interval change in the diffusely dilated shunted ventricular system.3. Redemonstration of premature fusion of calvarial sutures likely related to chronic shunting.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 69 years old Male. Reason: 67 year old man with right renal mass, diagnosed with lymphoma History: 67 year old man with right renal mass, diagnosed with DLBC lymphoma from laprascopic surgery in need of PET scan. RADIOPHARMACEUTICAL: 15.1 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 93 mg/dL. Today's CT p... | 1.New FDG avid mass and lymph nodes in the retroperitoneal cavity, consistent with recurrence of lymphoma.2.Interval near complete resolution of abnormal FDG uptake in the mesentery. |
Generate impression based on findings. | Female; 67 years old. Reason: S/p Lt THA with anterior approach. Postsurgical changes status post left total hip arthroplasty, which is in near anatomic alignment. No acute fracture or dislocation is identified. Gas in the subcutaneous soft tissues and a surgical drain are also noted. Right hip is unremarkable on the A... | Left total hip arthroplasty in near anatomic alignment. |
Generate impression based on findings. | Male, 6 years old. Evaluate for fecal impaction History: encopresisVIEW: Abdomen AP (one view) 3/17/2015, 1621 Moderate stool burden. Moderate stool within a normal sized rectal ampulla. Nonobstructive bowel gas pattern. | Moderate stool burden. No evidence of fecal impaction. |
Generate impression based on findings. | Male; 86 years old. Reason: 86-year-old male with metastatic small cell bladder cancer. History: Abdominal pain and left groin pain. CHEST:LUNGS AND PLEURA: New 4-mm right apical pulmonary nodule, suspicious for metastasis. Additional scattered pulmonary micronodules, some of which are calcified, are stable. Severe emp... | 1. New 4-mm right apical pulmonary nodule, suspicious for metastasis.2. Interval decreased size of mesenteric mass and resolution of left anterior intrapelvic mass, status post radiation treatment.3. Slightly increased lytic appearance of the left superior pubic ramus, likely due to radiation change though underlying i... |
Generate impression based on findings. | Female 58 years old Reason: known lung mets, ? uptake right shoulder on WBS, not confirmed on x-ray, rule out other disease, also WBS suboptimal as pt did not follow low iodine diet as requested History: mild SOBRADIOPHARMACEUTICAL: 13.9 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 81 mg/dL. Today's CT po... | 1.No definite evidence of FDG avid tumor. |
Generate impression based on findings. | 73-year-old male with tonsil cancer CHEST:LUNGS AND PLEURA: Mild centrilobular emphysema. No pleural effusion or pneumothorax.No suspicious nodules or masses. Calcified nodules are unchanged. MEDIASTINUM AND HILA: Reference right paratracheal lymph node is unchanged in size measuring 8 mm (series 4, image 35). Referenc... | Reference left paratracheal lymph node is increased in size as described above, suspicious for a nodal metastasis. Otherwise, no significant interval increase in size of additional mediastinal or hilar lymph nodes. |
Generate impression based on findings. | Female, 7 years old. Blounts disease. Evaluate bone length.VIEWS: Left knee AP (one view) and Mechanical axis/standing lower extremities 3/17/2015, 1624 Again seen are findings of Blount's disease with fragmentation and deformity of the medial epiphysis. There are postsurgical changes of a resection of a bony bridge th... | Stable postsurgical appearance of the left knee. Left genu varus. Left femoral head lower than the right. |
Generate impression based on findings. | 61 year old woman with atypical chest pain, referred to rule out obstructive coronary disease.CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of Valsalva and bifurcates into the left anterior descending and left circumflex coronary arteries. There are no signific... | 1.There are no significant coronary artery stenoses present. 2. No coronary calcification is present. 3. Patent foramen ovale is noted. 4. Mild RV and RA dilation. 5. Moderate burden of epicardial fat noted.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax... |
Generate impression based on findings. | 75 years, Female. Reason: evaluate for free air History: abdominal pain, nausea No radiographic evidence of intraperitoneal free air. No dilated loop of bowel to suggest obstruction. | No radiographic evidence of intraperitoneal free air. |
Generate impression based on findings. | 84 year old female. Abdominal pain. Evaluate for malignancy. Lack of intravenous contrast limits evaluation for solid organ.ABDOMEN:LUNG BASES: Calcified nodule in the right lower lobe consistent with prior infection.LIVER, BILIARY TRACT: Small left hepatic cyst. There is a subcentimeter hypoattenuating hepatic focus, ... | No specific evidence of malignancy or other significant findings to explain the patient's symptoms within limits of noncontrast exam. |
Generate impression based on findings. | Female 88 years old Reason: Evaluate with PET History: Right middle lobe pulmonary noduleRADIOPHARMACEUTICAL: 13.6 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 94 mg/dL. Today's CT portion grossly demonstrates coronary artery calcifications. Splenic artery calcified pseudoaneurysm. Cholecystectomy clips. ... | 1.Findings highly suspicious for primary lung neoplasm with nodal metastases.2.Nonspecific right upper lobe punctate FDG avid foci with no CT correlation. |
Generate impression based on findings. | Ankle injury.VIEWS: Right ankle AP/lateral/oblique (3 views) 03/17/15 Soft tissue swelling laterally has almost completely resolved. No joint effusion is identified. No fracture is seen. | Resolving soft tissue swelling. No bone abnormality. |
Generate impression based on findings. | 66 years, Female. Reason: r/o ileus, colonic distention History: ABD distention There is a Dobbhoff tube with its tip projecting over the antrum of the stomach. Additional enteric tube seen with tip overlying the antrum of the stomach, adjacent to Dobbhoff tube tip. Nonobstructive bowel gas pattern. Nerve stimulator de... | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 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 are scattered punctate and confluent areas of abnormal low attenuation in the periventricular and subcortical white matter, consistent with stable m... | 1. No acute intracranial hemorrhage or mass effect. Please note that CT is insensitive for the detection of acute nonhemorrhagic ischemic event. If there is continued clinical concern and no contraindications, MRI of the brain is recommended. 2. Right cerebellar enhancing lesion presumably representing metastasis bette... |
Generate impression based on findings. | Interspinous fusion device is again seen. There is a similar appearance of bony bridging along the bone graft components. There is slight increased confluence of ossific density to the left of the L4 spinous process, just dorsal to the polygonal shaped bone graft. Lucency remains along the margins of the more anterior... | 1. Interspinous fusion device at L3-L4 with suggestion of stable osseous bridging ventral to the screw, with slight increased confluence of ossific density along the left aspect of the L4 spinous process. Stable trace degenerative grade 1 anterolisthesis at this level.2. Previously described mild to moderate multilevel... |
Generate impression based on findings. | 64 year old female. Metastatic ovarian cancer on IRB 13-1323. Needs reevaluation and comparison to previous. CHEST:LUNGS AND PLEURA: Scattered micronodules, unchanged and favored to be post inflammatory.MEDIASTINUM AND HILA: Scattered small mediastinal lymph nodes, unchanged. No lymphadenopathy.Nonspecific small thyroi... | Stable hepatic lesions suspicious for metastases. New borderline enlarged presacral lymph node. |
Generate impression based on findings. | Evaluation is limited by lack of intravenous contrast and motion artifact. There is a lesion measuring approximately 2.0 x 1.6 cm in the right cingulate gyrus with associated restricted diffusion at its inferior aspect. There is mass effect with downward effacement of the lateral ventricles. There is a moderate amount... | 1. Evaluation is limited by lack of intravenous contrast. There is 2.0 cm mass centered at the right cingulate gyrus with restricted diffusion at the inferior aspect, which may represent a neoplasm. Infection is also a differential consideration although majority of the mass does not have restricted diffusion to sugges... |
Generate impression based on findings. | Female; 64 years old. Reason: bilateral hand, knee, and hip pain. Hips: Mild to moderate degenerative changes noted in the bilateral hips. No acute fracture or dislocation. Alignment is anatomic.Knees: Mild osteoarthritis affects the bilateral knees. No acute fracture or dislocation. No knee joint effusion.Hands: No ac... | Mild degenerative changes without acute fracture evident. |
Generate impression based on findings. | Male; 63 years old. Reason: low back pain; evaluate for DDD History: symptoms of possible spinal stenosis. There is severe degenerative disk disease of the lower lumbar spine with vacuum disk phenomena and marked disk space narrowing. Severe facet joint osteoarthritis is also noted. Slight loss of height of L3 and L4 v... | Stable but severe degenerative disk disease involving the lumbar spine as described above. |
Generate impression based on findings. | 49 year-old female with elevated liver enzymes, right upper quadrant pain. Evaluate vasculature. PORTAL VENOUS: Vein is patent with appropriate hepatopetal flow. Main portal vein peak velocity measures 0.5 m/sec. Left portal vein peak velocity measures 0.2 m/sec. Right portal vein peak velocity measures 0.4 m/sec.HEPAT... | Patent hepatic vasculature. Please refer to ultrasound abdomen exam from same day for additional findings. |
Generate impression based on findings. | Status post corpectomy with fusion Evaluation of the cervicothoracic junction is limited due to overlying anatomy. The patient has undergone C4corpectomy. There is an anterior plate with screws entering the C3 and C5 vertebrae, with spacer devices at C3/4 and C4/5. I see no hardware complications. There is a grade 1 re... | Postoperative changes of corpectomy and fusion as described above. |
Generate impression based on findings. | Recurrent polyarthritis. SLE. Evaluate for erosion/rheumatoid arthritis overlap. Three views of the right hand are provided. Mild osteoarthritis affects the interphalangeal joints. I see no erosions or other specific radiograph features of rheumatoid arthritis. There is a small ossicle dorsal to the carpus that may ref... | Lucency within the tuberosity of the right navicular bone is nonspecific and could represent a cyst, chronic erosion, or postoperative defect. It is unchanged from the prior study. I see no evidence of disease progression. |
Generate impression based on findings. | 68 year old man with mitral regurgitation. Patient referred to assess cardiovascular anatomy prior to "robotic" mitral valve surgery.CPT: 75572 Aortic and Aortic Root. There is a left sided aortic arch with normal brachiocephalic branching pattern. No thoracic aortic dissection or aneurysm is noted. The thoracic aorta ... | 1. Mitral valve prolapse is noted. 2. Mild coronary calcium. 3. Moderate left atrial dilation. 4. Variant left atrial appendage anatomy. 5. Increased left atrial pressure. 6. Moderate thoracic aortic tortuosity.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the t... |
Generate impression based on findings. | Postoperative changes are seen from previous anterior cervical fusion of C5 through C7. An interbody spacer with metallic marker is present at C6-C7, with complete osseous fusion anteriorly. There remains linear lucency along the posterior aspect of the disk space. A ring type interbody spacer/graft is present at C5-C... | 1. Anterior cervical fusion postoperative changes from C5 through C7, without evidence of instrumentation complication or fracture. Osseous fusion visualized at these levels.2. Moderate developmental narrowing of the cervical spinal canal with superimposed minimal spondylotic changes resulting in up to moderate spinal ... |
Generate impression based on findings. | Patient with acute intracranial hemorrhage associated with adjacent aneurysms in posterior circulation.PROCEDURES: 1) cerebral angiogram 2) Embolization of intracranial cerebral aneurysms and right superior cerebellar artery supply to AVM. 3) xpert CT reconstruction Right vertebral artery prior to embolization:The supe... | 1.Quadrigeminal plate cistern arteriovenous malformation. Supply is via superior cerebellar artery branches without anterior circulation supply. There is deep venous drainage.2.Embolization of a dysplastic right vermian artery supply to the AVM with embolization of three aneurysms along its course.3.Findings were discu... |
Generate impression based on findings. | Back pain status post MVA, low mid back. Is there a fracture? I see no fracture or malalignment. Note is made of tiny vertebral body osteophytes. Intervertebral disk spaces are within normal limits. Vertebral body heights are preserved. | No fracture evident. |
Generate impression based on findings. | Reason: Evaluate IVH and possible ischemia There is a 12-mm hematoma present in the right midbrain associated with intraventricular blood involving the third ventricle and to a lesser degree lateral ventricles. The temporal horns of the lateral ventricles are dilated.There is embolic material present in the right ambie... | 1.Right midbrain hematoma associated with intraventricular blood. There is slightly more blood in the lateral ventricles now.2.Status post ventriculostomy tube placement. The lateral ventricles are stable in size.3.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. At this age th... |
Generate impression based on findings. | Clinical question : Evaluate for stroke. Signs and symptoms: AMS Nonenhanced head CT:No detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.There is extensive periventricular and subcortical low attenuation of white matter consistent with advance... | 1.No acute intracranial process.2.Advanced age indeterminate small vessel ischemic strokes. |
Generate impression based on findings. | Clinical question: Evaluate for stroke. Signs and symptoms: Mental status changes similar to prior stroke presentation. Nonenhanced head CT:No detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventr... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Hemorrhage? Signs and symptoms: Possible new seizure. Unenhanced head CT:There is no detectable acute intracranial process. CT however these intensity for early detection of acute nonhemorrhagic ischemic strokes.Examination demonstrates very subtle periventricular low attenuation of white matter and ... | 1.No acute intracranial process.2.Mild age indeterminate small vessel ischemic strokes |
Generate impression based on findings. | Clinical question: Rule out CVA. Signs and symptoms: Headache, history of sickle cell and moyamoya. Nonenhanced head CT:No detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF s... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Evaluate for hemorrhage. Signs and symptoms: Status post fat and head trauma. Nonenhanced head CT:There is no detectable acute posttraumatic intracranial calvarial or soft tissues of the scalp findings.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and gray -- white matt... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: 34-year-old female newly diagnosed bilateral occipital subarachnoid hemorrhage, monitoring. Signs and symptoms: As above. Nonenhanced head CT:Examination demonstrates interval increased subarachnoid hemorrhage and with increased extent. On the current exam hemorrhage is noted in bilateral occipital l... | 1.Interval increased subarachnoid hemorrhage in bilateral occipital lobes and right frontal since prior exam.2.Stable and unremarkable exam otherwise. |
Generate impression based on findings. | Male 8 years old Reason: fall History: swelling and painVIEWS: Left wrist AP, lateral and oblique 3/17/15 (3 views) There is a greenstick fracture of the distal metaphysis of the left radius with minimal palmar and lateral angulation. | Greenstick fracture of the distal radius as described. |
Generate impression based on findings. | Clinical question: Intracranial abnormality. Signs and symptoms: Congestion. Unenhanced head CT:There is menisci acute intracranial hemorrhage, edema, mass effect, midline shift or hydrocephalus.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and gray -- white matter differentiation.Unremar... | 1.Unremarkable nonenhanced head CT.2.Acute on chronic pansinusitis |
Generate impression based on findings. | 8-month-old male history of trauma concern for pneumothorax, fractureVIEWS: Chest and abdomen AP, cervical spine AP and lateral (4 view) 3/17/15 Chest: The aortic arch cardiac apex, and stomach are left-sided. Cardiothymic silhouette is normal. No focal pulmonary opacities. No pneumothorax or pleural effusion.Abdomen: ... | Normal chest. Disorganized bowel gas pattern. C7 is not visualized. |
Generate impression based on findings. | 4-year-old male with worsening cough: Concern for pneumoniaVIEWS: Chest AP/lateral (two views) 3/18/15 The cardiothymic silhouette is normal. Mild bronchial wall thickening consistent with bronchiolitis/reactive airway disease pattern. No pleural effusion or pneumothorax. No pulmonary opacity. | Bronchiolitis/reactive airway disease pattern. |
Generate impression based on findings. | 64-year-old female presents for routine screening mammography. Two standard digital views of both breasts, repeat right MLO view and tomosynthesis were performed 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 susp... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | RFO trigger: R/O RFO RFO trigger: Pregnant and BMI over 50 Suspected RFO location: abdomen Name of suspected RFO: lapAttending Surgeon name/pager: Della torre Body Mass Index (BMI): 51.48 Skin staple line projects over the lower pelvis. Epidural catheter enters the T12-L1 intervertebral space and terminates at the L2-3... | No unexpected radiopaque foreign object identified.These findings were discussed by telephone with Dr. Della Torre, the attending surgeon, on 3/17/2015 at 19:22. |
Generate impression based on findings. | Male 4 months old Reason: ETT placement History: ARDSVIEW: Chest AP (one view) 3/18/15 at 746 hours ET tube terminates thoracic inlet. NG tube tip is at the stomach. Cardiac silhouette size is top normal or mildly enlarged. Right and left upper lobes and bibasilar opacities, likely atelectasis or pneumonia, on a backgr... | Multifocal opacities, likely atelectasis as described. |
Generate impression based on findings. | Male, 10 years old. Evaluate fecal load, appendix, any signs of obstruction History: abd pain, vomiting x2daysVIEW: Abdomen AP (one view) 3/17/2015, 2235 Nonobstructive bowel gas pattern.Small to moderate stool burden. | Below-average stool burden, without evidence of obstruction. |
Generate impression based on findings. | Female, 14 years old. Reason: pain s/p fall History: painVIEWS: Right ribs AP and obliques (4 views total) 3/17/2015, 2327 No acute or healing rib fractures.The aortic arch, cardiac apex, and stomach are left-sided. The cardiothymic silhouette is normal.No focal pulmonary opacities, pleural effusions, or pneumothorax.P... | No rib fractures identified. |
Generate impression based on findings. | Male 4 months old Reason: ETT placement History: Down syndrome, respiratory distress.VIEW: Chest AP (one view) 3/17/15 at 2205 hrs. ET tube tip is below thoracic inlet. Cardiac silhouette size is top normal. Right upper, left upper and bibasilar opacities, likely atelectasis on a background of diffuse lung haziness. No... | ET tube placement.Multifocal opacities as described. |
Generate impression based on findings. | 70 years, Male. Reason: Hx of esophageal cancer History: Bilious vomiting Bilateral nephroureteral stents in place, with distal tips terminating in the distribution of the urinary bladder. There is a generalized absence of bowel gas. Left basilar atelectasis and bilateral pleural effusions are present. | Absence of bowel gas. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of ovarian cancer. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses... | 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. | History of gout in the past. Painful elbow. Question of joint effusion. Four views of the right elbow reveal no acute fracture or malalignment. No joint effusion is identified. An olecranon spur is noted with soft tissue swelling about the olecranon, which is in the region of the olecranon bursa. | 1. No joint effusion.2. Soft tissue swelling in the region of the olecranon bursa may represent bursitis. |
Generate impression based on findings. | Female 18 years old Reason: eval new right PICC History: CF with pulmonary exacerbation, needs IV antibioticsVIEW: Chest AP (one view) 3/17/15 at 1649 hrs. Right upper extremity PICC terminates at the RA/SVC junction. Cardiac silhouette size is normal. Peribronchial thickening and possible upper lobe bronchiectasis. No... | Interval central line placement as described.Persistent lung changes of cystic fibrosis. |
Generate impression based on findings. | Clinical question: Evaluate for hemorrhagic transformation or edema. Known right posterior cerebral artery infarct. Signs and symptoms: Therapeutic heparin drip. Nonenhanced head CT:Examination redemonstrates a subacute nonhemorrhagic in the entire distribution of right PCA. No evidence of hemorrhagic transformation as... | 1.No detectable acute intracranial hemorrhage and in particular no evidence of hemorrhagic transformation of previously known strokes. 2.Subacute nonhemorrhagic ischemic stroke in the entire distribution of right PCA.3.Subacute nonhemorrhagic right superior cerebellar artery territory stroke as detailed.4.Mild age inde... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in her sister at age 36. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern... | Small asymmetry in the right medial breast could represent overlapping tissue, but requires further evaluation with spot compression and possible ultrasound.Given her breast density and family history in a young aged sister, referral to cancer risk clinic could also be considered, as the patient may benefit from screen... |
Generate impression based on findings. | 15-year-old female with fall onto outstretched handVIEWS: Right elbow AP, oblique, lateral; right shoulder internal rotation and external rotation (5 views) 3/17/15 No fracture or malalignment within the elbow. No joint effusion.No fracture or malalignment of the shoulder. The humeral head is well seated in the glenoid... | Normal examinations. |
Generate impression based on findings. | Pain. Question of fracture. Three views of the right hand reveal no acute fracture or malalignment. No soft tissue swelling is seen. The patient is unable to fully extend the fingers. | No acute fracture is evident. |
Generate impression based on findings. | 78 years, Male. Reason: NGT History: NGT Pelvis is not included in field of view and motion artifact limits evaluation. There is a nasogastric tube with its tip projecting over the fundus of the stomach. Nonobstructive bowel gas pattern. | Nasogastric tube with its tip projecting over the fundus of the stomach. |
Generate impression based on findings. | 41-year-old female. GI bleed status post stem cell transplant, evaluate for perforation and infection. CHEST:LUNGS AND PLEURA: Moderate bilateral pleural effusions with adjacent atelectasis.Patchy ground glass opacities and septal lines suggestive of pulmonary edema.Focal area of ground glass nodularity in the left upp... | 1. Bilateral wedge-shaped hypoattenuating foci kidneys suggestive of pyelonephritis.2. Moderate bilateral pleural effusions with pulmonary edema. Findings suggestive of superimposed atypical infection in the left upper lobe.3. Moderate amount of abdominopelvic ascites.Findings were communicated to Dr. Waite-Marin over ... |
Generate impression based on findings. | Male 9 years old Reason: evaluate central line position History: port removal, central line insertionVIEW: Chest AP (one view) 3/17/15 at 1829 hrs Interval feeding tube and Port-A-Cath removal and placement of left upper extremity double-lumen catheter, tip the at the RA/SVC junction.Cardiac silhouette size is normal. ... | Interval Port-A-Cath and feeding tube removal and placement of central line as described. |
Generate impression based on findings. | 78 years, Female. Reason: Is there a partial small bowel obstruction? History: 78 year old woman had total hysterectomy 1-26-13 for endometrial carcinoma followed by radiation therapy. Now she has lower abdominal distention, increased borborygmi and flatus. Moderate/large stool burden distributed throughout the colon. ... | Moderate/large stool burden, with suggestion of possible cecal wall thickening. |
Generate impression based on findings. | Fell on concrete. Generalized pain. Question of fracture. Four views of the right knee reveal no acute fracture or dislocation. | No acute fracture is evident. |
Generate impression based on findings. | 56 years, Male. Reason: Evaluate for obstruction History: No bowel movement; nonspecific pain. Has GT. G-tube projects over the gastric body. Possible Dobbhoff tube tip is seen near the gastroesophageal junction. Nonobstructive bowel gas pattern with greater than average stool burden. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 87 years, Female. Reason: H/o chron's disease with ileostomy, worsening abdominal distension and abdominal pain History: abdominal distension Paucity of bowel gas, scattered air-fluid levels and linearly distributed foci of gas in the right lower quadrant suggestive of possible bowel obstruction. Right midline abdomina... | Findings suggestive of possible bowel obstruction, this could be further evaluated with a dedicated CT examination. |
Generate impression based on findings. | Fall. Evaluate for fracture. Three views of the left hand show no acute fracture or malalignment. | No acute fracture is evident. |
Generate impression based on findings. | 47-year-old female with left shoulder pain status post fall. Three views of the left shoulder demonstrate normal articulation of the glenohumeral joint. No fracture is evident. Chronic left upper lung opacities are better evaluated on recent chest radiograph. | No evidence of fracture or dislocation. Please refer to recent chest radiograph regarding pulmonary findings. |
Generate impression based on findings. | Female 9 years old Reason: pneumonia; h/o rheumatic heart disease History: chest painVIEWS: Chest AP/lateral (two views) 3/18/15 749 hours. Cardiac silhouette size is the normal. Subsegmental atelectasis of the right upper lobe or thickening of the minor fissure is noted no effusions or pneumothorax. | Subsegmental atelectasis on the right upper lobe versus thickening of the minor fissure as described. |
Generate impression based on findings. | 44-year-old female with chest pain, evaluate pulmonary embolism PULMONARY ARTERIES: Pulmonary artery opacification is diagnostic quality with no evidence of pulmonary embolus. The pulmonary artery measures 2.6 cm in diameter which is within the limits of normal. LUNGS AND PLEURA: No pneumothorax. Small pleural effusion... | 1.No evidence of pulmonary embolism.2.Interlobular septal thickening with groundglass opacity in bilateral lower lobes with bronchial wall thickening most compatible with pulmonary edema, possibly noncardiogenic. Mild to moderate centrilobular emphysema.3.Focal opacity in the right middle lobe anteriorly is most sugges... |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.