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Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. 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. Benign calcifications in both breasts are stabl... | 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. | 56 years, Male. Reason: assess NGT position History: s/p NGT There is a nasogastric tube with its tip projecting over the body of the stomach. There is nonspecific gaseous distention of the stomach. | NG tube with tip projecting over the body of the stomach. Nonspecific gaseous distention of the stomach. |
Generate impression based on findings. | 62 years, Male. Reason: Abdominal distension, evaluate for ileus History: abdominal distension There is diffuse gaseous distention of both large and small bowel with gas seen in the rectum, most consistent with ileus although obstruction at the level of the of anal canal cannot be excluded. Moderate degenerative change... | Diffuse gaseous distention of both large and small bowel most consistent with ileus, although distal obstruction not excluded. |
Generate impression based on findings. | Male 60 years old; Reason: evaluate for sternal dehiscence, evaluate sternal wires, plates, fluid collection History: s/p CABG, known sternal drainage, unstable sternum LUNGS AND PLEURA: Moderate left pleural effusion with underlying left lower lobe segmental atelectasis. No specific evidence of pneumonia or interstiti... | 1. Status post CABG with sternotomy. Attenuation and foci of gas in the surrounding subcutaneous and anterior mediastinal soft tissues may represent, in part, post-surgical changes such as hematoma or seroma. However, given the persistence of these findings 10 days after surgery, a developing cellulitis remains on the ... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Patient reports weight loss since last mammogram. Two standard digital views of both breasts, additional left MLO view, and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in p... | 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: NSA - Screening Mammogram. |
Generate impression based on findings. | Desaturations and intubated. Hyperthermia protocol.VIEWS: Chest and abdomen AP (two views) 03/20/15, 0655 Endotracheal tube tip is at thoracic inlet. Feeding tube tip is in proximal stomach. Esophageal temperature probe tip is in mid esophagus. Umbilical venous line tip is at level of left hepatic vein or ductus venosu... | Development of soft tissue edema. Streaky opacities in lung bases may be subsegmental atelectasis. |
Generate impression based on findings. | 56-year-old male with two week history of back pain. Two views of the thoracic spine demonstrate multilevel mild degenerative disease of the thoracic and lower cervical spine, including mild disk space narrowing. The body heights are grossly preserved. Alignment is anatomic.Four views of the lumbar spine demonstrate mi... | Scattered multilevel degenerative disease of the spine as above. No evidence of acute fracture or malalignment. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and additional right MLO and CC views were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. Scattered benign calcifications ... | 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: NSA - Screening Mammogram. |
Generate impression based on findings. | 62 year old female with history of left breast cysts. No current breast complaints. No family history of breast cancer. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and d... | Stable left breast asymmetries. 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. | Supracondylar fracture.VIEWS: Left elbow AP/lateral/oblique (3 views) 03/20/15 K wires have been removed. Callus formation around the distal humeral fracture is again seen. Alignment is near-anatomic. | Healing supracondylar fracture. Removal of K wires. |
Generate impression based on findings. | Left thumb injury. Needs surgery.VIEWS: Left hand PA left thumb PA/lateral (3 views) 03/20/15 The soft tissues of the lateral aspect of the index finger at the level of the proximal phalanx and proximal interphalangeal joint, and the soft tissues surrounding the thumb, especially posteriorly at the level of the phalang... | Abnormal soft tissues, abnormal bone contours raise the possibility of vascular malformation, lymphangioma, Proteus syndrome, and others. |
Generate impression based on findings. | Ataxia. Tremors. There is mild parenchymal volume loss. There is no evidence of acute intracranial hemorrhage or mass effect. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The imaged paranasal sinuses and mastoid air cells are clear. There is a partiall... | 1. No evidence of acute intracranial hemorrhage or mass effect. 2. Findings of Chiari one malformation. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. 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. Circular skin markers were placed over both axillae. Partially obscured mass in the ri... | Partially obscured mass in the right medial central breast, mid depth for which additional views including spot compression views and possible ultrasound are recommended.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EB - Additional Mammo/Ultrasound Workup Required. |
Generate impression based on findings. | Male 74 years old; Reason: Eval for obstruction History: Vomiting There is gaseous distention of the small bowel compatible with an ileus. Scattered gas is noted within the colon. There is some enteric contrast in the left upper abdomen likely within the stomach.Degenerative changes affects the hips and lumbar spine. | 1.Ileus |
Generate impression based on findings. | Female 67 years old; Reason: Evaluate for distension, bowel wall abnormalities, free air History: Pain, unable to verbalize site; diarrhea, NG feedings Bilateral double nephroureteral stents. These originates in the region of the renal pelvis and terminate in the region of the urinary bladder.The descending colon has a... | 1.Abnormal radiograph for the mottled appearance of the descending colon differential considerations include a colitis or colonic pneumatosis. Follow up CT scan is recommended.Findings discussed with Dr.ARDELT at the time of dictation |
Generate impression based on findings. | Female; 56 years old. Reason: Pt with h/o peripancreatic edema possible pseudocyst. Last scan was December 2014. Needs to be revaluated in March, 2015. History: Left sided abdominal pain ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Focal fatty sparing along the falciform ligament. Interval ... | Decreased peripancreatic fluid collections. |
Generate impression based on findings. | 63-year-old male with renal failure. ULTRASOUND KIDNEYSRIGHT KIDNEY: The right kidney measures approximately 15 cm in length. There is severe hydronephrosis with marked parenchymal loss involving the right kidney with dilatation of the visualized proximal ureterLEFT KIDNEY: The left kidney measures approximately 16.4 c... | Bladder outlet obstruction with severe, bilateral hydronephrosis and parenchymal loss involving the kidneys.Debris within urinary bladder.No evidence for renal artery stenosis.Discussed with Dr. Toback, Gerber and the Emergency Room. Patient to be admitted to the emergency room with Foley catheter placement and electro... |
Generate impression based on findings. | ESRD patient with stent, sudden worsening of vision. Evaluate for hemorrhage or large hypodensity. There is no evidence of intracranial hemorrhage or mass effect. There are bilateral patchy areas of white matter hypoattenuation including the frontal periventricular white matter, right internal capsule, and coronaradiat... | 1.No evidence of acute intracranial hemorrhage or mass effect. Patchy white matter hypoattenuation, which is compatible with chronic small vessel ischemic disease. Please note that CT is insensitive for the detection of acute nonhemorrhagic ischemic event. If there is continued clinical concern and no contraindications... |
Generate impression based on findings. | Female 48 years old; Reason: evaluate for abnormal lung parenchyma History: hypoxia at rest. LUNGS AND PLEURA: Minimal basilar scarring/subsegmental atelectasis. No specific evidence of infection or edema. No pleural effusions. MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy.Normal-sized heart without per... | No specific findings to account for the patient's symptoms. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Prior surgical biopsy right axilla 2006 with benign findings. Family history of breast cancer in two maternal aunts. Two standard digital views of both breasts on a total of 10 images were performed and reviewed with the aid of R2 CAD 9.3. The breast paren... | 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: NSA - Screening Mammogram. |
Generate impression based on findings. | 15-year-old female suspect right fifth metacarpal fracture.VIEWS: Right hand PA, oblique, lateral (3 views) 3/20/15 Overlying cast material obscures fine bone detail. No fracture or sclerotic line to suggest a healing fracture is identified. | No fracture or healing fractures identified. |
Generate impression based on findings. | Hodgkin lymphoma status post chemotherapy and radiation. There are postoperative findings related to excisional biopsy in the right supraclavicular region. There is extensive bilateral cervical, supraclavicular, and partially imaged mediastinal lymphadenopathy. The suprahyoid lymph nodes appear to be slightly larger, w... | Slight interval increase in size of suprahyoid lymph nodes, which is nonspecific. Otherwise, the lower cervical, supraclavicular, and partially imaged mediastinal lymphadenopathy appear to be stable to slightly smaller. |
Generate impression based on findings. | Male, 13 years old. Reason: s/p chemotherapy for osteosarcoma History: see above LUNGS AND PLEURA: Scattered micronodules are unchanged. No new suspicious pulmonary nodules or masses. No focal consolidation. No pleural effusions.MEDIASTINUM AND HILA: The heart is normal in size, without pericardial effusion.No mediasti... | No evidence of metastatic disease to the chest. |
Generate impression based on findings. | Male 57 years old; Reason: 57M hx ampullary stenosis s/p ERCP with PD stent placement. Need to assess PD stent passage History: s/p ERCP The bowel gas pattern is nonobstructive. Multiple clips are noted in the right upper abdomen. No definite free intraperitoneal air. Previously placed pancreatic duct stent is not evid... | 1.Nonobstructive bowel gas pattern.2.No evident pancreatic duct stent. |
Generate impression based on findings. | Humeral fracture.VIEWS: Left humerus AP and lateral 3/20/15 (number of views views) There is a posterior, distal metaphyseal fracture of the left humerus. Alignment is near anatomic. Cast material obscures fine bone detail. | Left humeral fracture as described. |
Generate impression based on findings. | Male 73 years old; Reason: assess for intraabdominal pathology, OGT placement History: firm abdomen Bowel gas pattern is nonobstructive. A right central venous catheter projects over the chest.Enteric tube projects over the level of the fundus.Bilateral iliac stents are noted in the sitting of calcific arteriosclerotic... | 1.Enteric tube terminates in the region of the gastric fundus. |
Generate impression based on findings. | SDH with resolution. Evaluate for recurrence or abnormality: headaches There are postoperative findings related to right calvarial burr hole subdural collection drainage. The bilateral cerebral convexity subdural hematomas have nearly resolved with minimal residual low attenuation extra-axial fluid. There is no signifi... | Postoperative findings with near interval resolution of the bilateral cerebral convexity subdural collections and no evidence of acute intracranial hemorrhage. |
Generate impression based on findings. | Male; 61 years old. Reason: Hx of Follicular NHL History: Chemo complete 5/2012; compare to previous CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. A prominent right hilar lymph node is not significantly changed sinc... | Stable appearance of the chest, abdomen, and pelvis. No new findings. |
Generate impression based on findings. | Male 60 years old; Reason: obstr History: pain There is persistent mild gaseous distention of the small bowel. Oral contrast has reached the descending colon over a two day period.No free intraperitoneal air.There is left lower lobe atelectasis. | 1.ileus |
Generate impression based on findings. | Male 53 years old; Reason: OG placement History: OG placement Enteric tube terminates in the region of the gastric body. Upper abdominal small bowel pattern is nonobstructive.Air bronchograms are noted in the left lower lobe representing either atelectasis and/or consolidation. | 1.Enteric tube is in the region of the gastric body. |
Generate impression based on findings. | 60 year old female status post left mastectomy in 1993 in the Philippines for recurrent cystic change, as per patient, presents today for routine follow up. No current breast complaints. No family history of breast cancer. Three standard views of the right breast were performed digitally and reviewed with the aid of R2... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Female 40 years old Reason: 40 yr old patient with peritoneal cancer s/p 2 cycles of Doxil compare to 1-7-15 scan. 8-14-14 had TAH/BSO, colon resection, ileocecel resection and appy. History: none CHEST:LUNGS AND PLEURA: No suspicious pleural nodules or masses identified.MEDIASTINUM AND HILA: The heart size is normal a... | Interval regression of disease with reference measurements given above. |
Generate impression based on findings. | 10-year-old male with Hodgkin lymphoma CHEST:LUNGS AND PLEURA: No focal lung opacities. No pleural effusion or pneumothorax. Mild scarring adjacent to the right upper mediastinal mass likely secondary to radiation. No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: The heart size is normal without pericard... | 1. Slight interval decrease in superior right mediastinal mass.2. No significant change in mild prominence of mediastinal lymph nodes. |
Generate impression based on findings. | Female; 73 years old. Reason: Patient with pancreatic NET on sunitinib. Disease surveillance. History: ascites Lack of intravenous contrast limits sensitivity for solid organ pathology.CHEST:LUNGS AND PLEURA: Scattered subcentimeter pulmonary nodules are unchanged. No new suspicious pulmonary nodules or masses. No pleu... | No significant interval change in index lesions. No new sites of disease. |
Generate impression based on findings. | Male 19 months old Reason: Follow-up scan History: Left UPJ S/P pyeloplasty; hydronephrosis The posterior abdominal radionuclide angiogram demonstrates prompt, symmetrical perfusion of the kidneys. Sequential renal images show the kidneys to be of normal size and morphology. There is prompt uptake and excretion of the ... | Normal symmetric renal parenchymal function. No evidence of current collecting system obstruction. Previous suspected left sided obstruction has resolved. |
Generate impression based on findings. | RIGHT TEMPORAL BONE: The inner ear structures are unremarkable. The external auditory canal is patent, however, there is cerumen. The middle ear and mastoid air cells are well-pneumatized and clear. The ossicular chain is intact. The facial nerve describes a normal course.LEFT TEMPORAL BONE: The inner ear structures a... | 1.No evidence of bony inner ear abnormalities. 2.Cerumen within the bilateral external auditory canals. |
Generate impression based on findings. | Proximal humerus fracture. Evaluate healing.VIEWS: Left shoulder AP/Grashey/Y (3 views) 03/20/15 Fracture of the proximal humeral diaphysis is again seen. Lateral angulation of the distal fracture fragment is seen. Callus formation has developed in the interval and surrounds the fracture. The humeral head is well direc... | Healing proximal humeral fracture. |
Generate impression based on findings. | 93 year old female status post left lumpectomy in 2013 for invasive mammary carcinoma with mixed ductal and lobular features, presents today for routine follow up. Patient received radiation therapy and hormonal therapy. No current breast complaints. Family history of breast carcinoma in her sister, daughter, and a mat... | Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | 63 year old female status post heart transplant experiencing aphasia. The ventricles and sulci are unchanged in size or shape without evidence of hydrocephalus. There are no masses, mass effect or midline shift. Gray/white interfaces are maintained. There is no evidence for intracranial hemorrhage or acute cerebral or ... | No CT evidence of acute intracranial process. If there is continued clinical concern for acute ischemia, MRI would be recommended. |
Generate impression based on findings. | Reason: lung cancer sp chemo radiation, has CKI no contrast History: cough CHEST:LUNGS AND PLEURA: Index right paramediastinal mass is not clearly visualized to lack of IV contrast. Within these limitations, the approximate measurements are 3.1 x 2.6 cm, previously 3.5 x 3.0 cm (series 4, image 21). Right upper lobe in... | Interval decrease in size of right paramediastinal mass provided differences in technique. No significant change in surrounding radiation change. Interval resolution of bilateral pleural effusions. Small interval increase in size of hypodense pancreatic lesion presumed to be an IPMN. |
Generate impression based on findings. | Sacral decubitus ulcer. History of chronic osteomyelitis. Evaluate for evolution of osteomyelitis. There is redemonstration of destruction/absence and sclerosis of the left superior and inferior pubic rami along with the left ischium, appearing similar to the prior examination. Overlying soft tissue inflammatory change... | 1. Left ischial decubitus ulcer with sclerosis of the remaining left pubic rami and ischium appearing similar to the prior study. 2. Stable right sacral cortical destruction with overlying soft tissue inflammatory change without discrete fluid collection.3. Foci of gas in or adjacent to the urethra is concerning for a ... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. 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. Partially obscured masses in the right upper breast.No suspicious microcalcif... | Partially obscured masses in the right breast, for which additional views including spot compression views and possible ultrasound are recommended.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EC - Additional Mammo/Ultrasound Workup Required. |
Generate impression based on findings. | Left forearm osteotomyVIEWS: Left forearm AP/lateral (two views) 03/20/15 Compression plate and screws device along the radial diaphysis is intact. Ulnar fracture and radial osteotomy have healed. Alignment is anatomic. | Anatomic alignment of the forearm. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts 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. Stable bilateral benign intra... | 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; 68 years old. Reason: Evaluate for disease recurrence s/p distal pancreatectomy, splenectomy, and cholecystectomy for pancreatic islet cell tumor History: follow-up ABDOMEN:LUNG BASES: No significant abnormality.LIVER, BILIARY TRACT: No focal hepatic lesions. Minimal intrahepatic biliary ductal prominence is st... | 1.Postsurgical changes of distal pancreatectomy/splenectomy. Residual pancreas enhances homogenously. 2.Stable borderline enlarged peripancreatic and periportal lymph nodes. 3.Three intraperitoneal soft-tissue attenuation nodules have decreased in size and may represent post-surgical changes/fat necrosis but continued ... |
Generate impression based on findings. | Thyromegaly and calcified structure external to thyroid gland. The thyroid gland is not particularly enlarged, but there is a subcentimeter nodules in the left lobe. There is no evidence of abnormal calcifications in the neck. There is no evidence of measurable mass lesions or significant cervical lymphadenopathy based... | The thyroid gland is not particularly enlarged and there is no evidence of abnormal calcifications in the neck. |
Generate impression based on findings. | Distal radius fracture, need to evaluate multiple fragments. Pain. There is a comminuted, slightly impacted fracture of the distal radial metaphysis. There is slight volar angulation of the distal fracture fragment. The articular surface is intact with normal positioning of the radiocarpal joint and distal radioulnar j... | Slightly impacted, comminuted fracture of the distal radial metaphysis without intraarticular extension. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and additional left MLO view 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. Circular skin mark... | 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. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts, additional left 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. Circular skin marker was placed over the ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually. Mammography is optimally performed when prior studies are available to detect changes. If the patient's prior mammograms can be submitted, then an addendum to this r... |
Generate impression based on findings. | 72-year-old male with esophageal cancer status post chemoradiation CHEST:LUNGS AND PLEURA: Apical scarring/atelectasis is not significantly changed.No pleural effusion or pneumothorax. No focal consolidation. Multiple scattered nonspecific calcified and noncalcified micronodules. No new nodules.MEDIASTINUM AND HILA: Mi... | Circumferential thickening of the distal esophagus reflecting patient's known malignancy is unchanged the prior exam. Slight interval decrease in size of anterior mediastinal soft tissue mass. No significant interval change in size of scattered mediastinal and hilar lymph nodes. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts 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 suspicious masses, microca... | 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. | Asymptomatic female presents for routine screening mammography. History of benign right breast biopsy approximately 40 years ago. Family history of breast cancer diagnosed in sister in her 60s. Two standard digital views of both breasts were performed for a total of 8 images and reviewed with the aid of R2 CAD 9.3. The... | 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. | Asymptomatic female presents for routine screening mammography. History of benign left breast biopsy in 1973. Two standard digital views and cleavage view 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 a... | 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. | 82 year old female status post right lumpectomy in 2012 for DCIS, presents today for routine follow up. Patient received chemotherapy. No current breast complaints. No family history breast carcinoma. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast paren... | Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | 78-year-old male with intraventricular hemorrhage and possible ischemia Redemonstrated is a hemorrhage within the right midbrain which is unchanged. Associated intraventricular blood has redistributed. Ventricular sizes are unchanged. There is no interval hemorrhage.As before, there is embolic material present in the r... | 1.Stable right midbrain hematoma. Intraventricular hemorrhage has redistributed. There is no interval new hemorrhage.2.The ventricles are stable in size. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts 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. Scattered bilateral benign ca... | 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. | Puncture wound. Question of foreign body. Pulse oximeter over the right second digit along with IV tubing obscures evaluation of the underlying soft tissues.No acute fracture is evident. No radiopaque foreign object is identified. Vascular calcifications are noted. | No radiopaque foreign object is identified. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is extremely dense, which lowers the sensitivity of mammography, unchanged in pattern and distribution. Benign calcif... | 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: NSD - Screening Mammogram. |
Generate impression based on findings. | Reason: eval for vessel stenosis History: L weakness, dysarthria Neck CTA: There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is no sig... | 1.Findings a raise a question of a small aneurysm versus infundibulum at the origin of the right posterior communicating artery.2.No evidence for cervicocerebral occlusive disease. |
Generate impression based on findings. | Mild diffuse cerebral volume loss without a lobar specific pattern. Hypoattenuation of the periventricular and subcortical white matter compatible with age indeterminant small vessel ischemic disease. No acute intracranial hemorrhage is identified. No evidence of intracranial mass, mass-effect, or hydrocephalus. No ex... | 1.No evidence for acute intracranial abnormality. Please note CT is not sensitive for detection of acute nonhemorrhagic ischemia and MRI can be considered for further evaluation, if clinically indicated.2.Mild diffuse cerebral volume loss. |
Generate impression based on findings. | Male; 75 years old. Reason: choledocholithiasis s/p ERCP with dilation of ampulla and cystic duct. now with rigidity on abdominal exam History: see above ABDOMEN:LUNG BASES: New small pleural effusions with underlying bibasilar dependent subsegmental atelectasis. Cardiomegaly.LIVER, BILIARY TRACT: New moderate amount o... | Findings most compatible with acute cholecystitis with new moderate inflammatory changes in the porta hepatis. Adjacent duodenal wall thickening is also seen, but there is no free air or contrast leak.Findings discussed with the medicine resident caring for the patient (pager 2702) at 11 a.m. on 3/20/15. |
Generate impression based on findings. | Status post distal radius fracture. Status post reduction and casting. Cast material obscures evaluation of fine bone detail. Interval reduction of a distal radius fracture which appears in gross anatomic alignment. | Interval casting and reduction of a distal radius fracture. |
Generate impression based on findings. | 68-year-old male with history of NSCLC status post therapy CHEST:LUNGS AND PLEURA: Left paramediastinal and perihilar radiation reaction is not significantly changed since the prior exam.Mild subpleural reticulonodular opacities in the lingula and anterior left lower lobe compatible with bronchiolitis and scarring, unc... | No specific evidence of metastatic disease, status post lung cancer treatment. |
Generate impression based on findings. | 60 year-old female preop bone length study. Views of the right leg demonstrate severe osteoarthritis of the right knee with bone on bone apposition and subchondral sclerosis as well as osteophytosis; mild osteoarthritis affects the right hip. Mechanical axis radiographs reveal approximately 7 degrees of varus alignment... | Osteoarthritis and varus deformity as detailed above. |
Generate impression based on findings. | 72-year-old female with a strong family history of breast and ovarian cancer. No current breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distributio... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Reason: eval for vessel stenosis History: L weakness, dysarthria Neck CTA: There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is no sig... | 1.Findings a raise a question of a small aneurysm versus infundibulum at the origin of the right posterior communicating artery.2.No evidence for cervicocerebral occlusive disease. |
Generate impression based on findings. | Reason: 63 year old female with bilateral episcleral vessel dilation, left-sided hemi-retinal vein occlusion, significantly elevated left eye pressure; with clinical concern for C-C or low-flow dural fistula History: 63 year old female with bilateral episcleral vessel dilation, left-sided hemi-retinal vein occlusion, s... | 1.No evidence for a cavernous carotid fistula. Both the superior opthalmic veins to drain towards the cavernous sinus.2.Findings were discussed with Dr Ksiazek at the time of this dictation. |
Generate impression based on findings. | 54 years, Female. Reason: Toxic Megacolon? History: Diarrhea, sepsis Distended transverse colon measuring up to 11 cm in maximal diameter, which could reflect toxic megacolon in the appropriate clinical setting. | Distended transverse colon measuring up to 11 cm in maximal diameter, which could reflect toxic megacolon in the appropriate clinical setting. |
Generate impression based on findings. | 58-year-old female with right breast cyst presents for aspiration. The lesion to be aspirated is a circumscribed, anechoic cyst at the 3 o'clock position of the right breast, 2 cm from the nipple.The procedure, risks including bleeding, infection, mistargeting, and benefits of ultrasound guided cyst aspiration were dis... | Successful fine needle aspiration of a cyst in the right breast, with complete resolution on mammogram and ultrasound. No cytology sample was sent, as no appreciable fluid was aspirated as a result of the cyst dissipating upon contact of the needle with the cyst wall. As long as the patient's physical examination is un... |
Generate impression based on findings. | 52 years, Male. Reason: assess OGT placement History: s/p OGT There is a nasogastric tube with its tip projecting over the body of the stomach. There is a nonobstructive bowel gas pattern. Pleural drain projects over the left upper quadrant. Bibasilar atelectasis and pleural effusion. | Nasogastric tube with its tip projecting over the body of the stomach. |
Generate impression based on findings. | Male; 93 years old. Reason: prostate cancer with rising PSA. reeval History: prostate cancer ABDOMEN:LUNG BASES: Minimal bibasilar subsegmental atelectasis and/or scarring. No suspicious pulmonary nodules or masses in the visualized lung bases.LIVER, BILIARY TRACT: No suspicious hepatic lesions. Stable punctate calcifi... | No evidence of a residual or recurrent disease. No evidence of metastatic disease. Please follow-up final report for bone scan, which will be more sensitive for bony metastases. |
Generate impression based on findings. | Left ankle fracture status post ORIF. Evaluate fracture. Three views of the left ankle with weight-bearing show a side plate and screw device affixing a distal fibular fracture with two syndesmotic screws and two orthopedic screws affixing the medial malleolus. The fracture lines appear less distinct suggestive of heal... | Orthopedic fixation of distal fibula and tibia fractures. |
Generate impression based on findings. | Male 49 years old Reason: determine recurrence HL extent and staging History: Monitor lymphoma stagingRADIOPHARMACEUTICAL: 15.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 104 mg/dL. Today's CT portion grossly demonstrates left chest port with tip in the SVC. Bilateral groundglass opacities most likely i... | 1.Significant metabolic response to therapy with near complete to complete resolution of previous tumor activity. Single decreased but residual subcentimeter left obturator lymph node activity may represent inflammation or possibly small residual tumor activity. No new FDG avid lesion.2.New left renal parenchymal dysfu... |
Generate impression based on findings. | 37-year-old male with left knee pain. Four views of the left knee demonstrate suture anchors projecting over the lateral femoral condyle. Mild osteoarthritis affects the knees, left greater than right, including mild joint space narrowing of the medial compartment, sharpening of the tibial spines, and osteophytosis. Th... | No evidence of acute fracture or malalignment. Mild bilateral osteoarthritis. |
Generate impression based on findings. | Male, 2 months old. Elbow injury. Evaluate for fracture.VIEWS: Left elbow, AP and lateral (two views) 3/20/2015, 1055 A posterior fat pad is present from a joint effusion.Callus formation encircles the distal humerus, more prominent on the ulnar aspect, compatible with a fracture as previously questioned. | Healing corner fracture of the distal humerus. |
Generate impression based on findings. | Left hip pain. AP view of the pelvis and single view of the left hip show sclerosis of the superior acetabulum of the bilateral hips. There is no flattening of the femoral heads. No acute fracture is evident. | Early mild osteoarthritis of the bilateral hips. |
Generate impression based on findings. | Status post ROH. Evaluate clavicle fracture. Two views of the right clavicle show interval removal of an intramedullary rod affixing a mid-clavicular fracture. The fracture line is less distinct with increased callus formation compatible with healing. Alignment is grossly anatomic. | Healing right clavicle fracture. |
Generate impression based on findings. | Pain, cracking. Three views of the left ankle show no acute fracture or malalignment. The ankle mortise is intact. No ankle joint effusion or soft tissue swelling is seen. There is pes planus deformity.Three views of the right ankle show no acute fracture or malalignment. The ankle mortise is intact. No ankle joint eff... | Bilateral pes planus deformity. |
Generate impression based on findings. | 1-year-old male with history of thin liquid aspirationEXAMINATION: Oropharyngeal motility study 3/20/15 Dana Sussman, speech and language therapist, supervised the examination.92 seconds of fluoroscopy was used.Oral deficits were present including positive premature spillage into the hypopharynx and increased oral tran... | Trace aspiration of thin liquids without cough.Please see the speech and language therapist's report for feeding recommendations. |
Generate impression based on findings. | 82-year-old male status post right hip hemiarthroplasty. Two views of the right hip demonstrate hardware components of a right hip hemiarthroplasty, in near-anatomic alignment. There is no evidence of hardware complication. Ossific densities superolateral to the greater trochanter and inferolateral to the acetabulum li... | Status post right hip hemiarthroplasty as above. |
Generate impression based on findings. | Shoulder pain. Four views of the right shoulder show a reverse ball-and-socket right total shoulder arthroplasty in anatomic alignment without evidence of hardware complication. No acute fracture is evident. A small amount of heterotopic bone is noted along the lateral aspect of the joint.A vascular stent is noted. | Reverse total shoulder arthroplasty. |
Generate impression based on findings. | Knee pain. Left hip pain. Four views of the left knee show no acute fracture or malalignment. There are tiny patellar osteophytes indicating minimal osteoarthritis, unchanged. No large joint effusion is identified.AP view of the pelvis and two views of the left hip show small osteophyte formation of the bilateral hips,... | Minor degenerative changes as above. |
Generate impression based on findings. | Right hip pain and limited range of motion. Evaluate position of prosthesis and evaluate for infection. Two views of the right hip show a right hip bipolar hemiarthroplasty device situated in anatomic alignment without evidence of hardware complication. No acute fracture is evident. Minimal lucency about the acetabular... | Right hip bipolar hemiarthroplasty device without evidence of complication. Minimal lucency surrounding the acetabular component of the prosthesis is unchanged from the immediate postop radiograph, however, continued normal surveillance is recommended. |
Generate impression based on findings. | 24-year-old male with diffuse large B-cell lymphoma status post chemotherapy. Recent PET last month question residual disease in left pelvis. Restaging exam.RADIOPHARMACEUTICAL: 15.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 99 mg/dL. Today's CT portion of the neck demonstrates no significant pathology... | 1.Progression of hypermetabolic tumor in the left pelvis and possibly also in the superior mediastinum.Diagnostic CTs of the chest, abdomen, and pelvis also performed at today's visit will be reported separately. |
Generate impression based on findings. | With thyroid thyroid cancer. Evaluate for recurrent disease. RIGHT LOBE MEASUREMENTS: Post thyroidectomyLEFT LOBE MEASUREMENTS: Post thyroidectomyISTHMUS MEASUREMENTS: Post thyroidectomyRIGHT LOBE: No massLEFT LOBE: No massISTHMUS: No massPARATHYROID GLANDS: No significant abnormality noted.LYMPH NODES: No significant ... | No evidence for recurrent disease. No change. |
Generate impression based on findings. | 53-year-old male with pain and swelling of the right elbow. Two views of the right elbow demonstrate mild osteoarthritis affecting the elbow joint. There is no significant joint effusion, acute fracture or malalignment within this limited study. | There is no acute fracture or malalignment. |
Generate impression based on findings. | Male, 2 months old. Reason: Interval Skeletal Survey History: Interval changes to fracturesEXAMINATION: Thoracolumbar spine AP, right humerus AP, left humerus AP, right forearm AP, left forearm AP, right hand PA, left hand PA, chest AP, ribs right oblique/left oblique, pelvis AP, right femur AP, left femur AP, right ti... | Healing fractures of the posterior ribs as detailed above. A left distal humerus fracture has significant new callus formation, compatible with acute presentation on 3/4/2015. Periosteal reaction along the left tibia is similar to the prior exam. |
Generate impression based on findings. | Three-month status post posterior spinal fixation. Evaluate implant position. Three views lumbar spine show screws in the pedicles of L4 and L5 with posterior stabilization rods and interposed disk spacer material. No acute fracture is evident. Alignment is anatomic. No definite bony fusion is observed. | Lower lumbar posterior spinal fixation as above. |
Generate impression based on findings. | Chronic and decreased range of motion of the bilateral shoulders. Pain, popping sensation at the left shoulder with lifting a box. Three views of the right shoulder show no acute fracture or malalignment. Mild osteoarthritis affects the acromioclavicular glenohumeral joints.Three views of the left shoulder show no acut... | Mild osteoarthritis as above. |
Generate impression based on findings. | Male 69 years old Reason: History laryngeal cancer sp laryngectomy with peristomal recurrence, concern for metastasesRADIOPHARMACEUTICAL: 15.3 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 70 mg/dL. Today's CT portion grossly demonstrates extensive postoperative changes in the neck. Scattered solid and gro... | 1.Large hypermetabolic anterior midline neck mass consistent with peristomal recurrence. No additional suspicious lesions in the neck.2.Scattered, multifocal hypermetabolic lung activity corresponding to ground glass opacities, as well as bilateral axillary hypermetabolic nodes. Most appear inflammatory, however superi... |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are ultrasound images (3/13/15) performed at Northshore University Healthcare System Per outside radiology report, the patient with history of bilateral mastectomies had a palpable lump in the left medial chest wall. There are two mixed hypo/iso-echoic ... | Two mixed hypo/iso-echoic masses in the left medial chest wall. Fat necrosis is likely diagnosis, but malignancy cannot be ruled out. Needle biopsy for both masses is recommended.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | T1N1 oral tongue squamous cell carcinoma initially treated in 2008 followed by recurrence with lung metastases and left chest wall mass in May 2014, treated with chemotherapy. Neck: There are stable post-treatment findings, including absence of the right submandibular gland. There is no evidence of mass lesions or sign... | 1.No evidence of locoregional tumor recurrence or significant lymphadenopathy in the neck.2.No evidence of intracranial metastases.3. A lytic lesion in the right frontal calvarium may represent a metastasis. 4. Multiple lesions in the partially imaged lungs. Please refer to the separate chest CT report for additional d... |
Generate impression based on findings. | Female 57 years old; Reason: follow up for RCC History: hx of RCC CHEST:LUNGS AND PLEURA: Visualized lung fields unchanged in appearance, including 2 mm right apical micronodules. No suspicious lung nodule. No pleural effusion. Scattered pleural blebs/bullae. MEDIASTINUM AND HILA: Evaluation of thyroid gland demonstrat... | 1. Stable nonspecific nodularity in superior aspect of left nephrectomy bed (likely primarily reflecting left crus of diaphragm), as described.2. Unchanged right thyroid nodularity, may be further assessed with dedicated sonography if clinically desired.3. Interval resolution of ventral abdominal wall fluid collection ... |
Generate impression based on findings. | Headache. There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. There appears to be a small amount of fluid in the left maxillary sinus. The mastoid air cell... | 1. No evidence of acute intracranial hemorrhage, mass, or ventriulomegaly.2. Suggestion of acute sinusitis. |
Generate impression based on findings. | Female, 8 years old. Reason: adenoid hypertrophy History: mouth breathingVIEWS: Neck soft tissue, lateral (one view) 3/20/20 pain, 1111 Mild to moderate enlargement of the adenoids, without obstruction of the posterior nasopharynx.The palatine tonsils are markedly enlarged, extending to the level of the epiglottis.The ... | Mild to moderate adenoid hypertrophy and marked hypertrophy of the palatine tonsils. |
Generate impression based on findings. | Female 73 years old Reason: r/o aspiration and stricture. Hx: esophageal webbing and irritation History: vomiting, feels like food is getting stuck Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions. Right neck catheter terminates at the cavoatrial junction.... | Unremarkable single contrast esophagram. |
Generate impression based on findings. | Female 64 years old; Reason: Had CT concern for SBO. Now having some flatus, observe for improvement in SBO/ileus History: As above Enteric tube terminates in the left upper abdomen in the region of the gastric body. There multiple dilated loops of small bowel with air-fluid levels compatible with a developing obstruct... | 1.Findings suspicious for a developing small bowel obstruction. |
Generate impression based on findings. | Epilepsy, with seizure today with possible fall: agitation, headache. There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. The imaged paranasal sinuses and ... | Possible small supraorbital scalp contusion, but no evidence of acute intracranial hemorrhage or skull fracture. |
Generate impression based on findings. | Immunocompromised due to myelofibrosis status post SCT with right C5 pain radiating to left paraspinal and fevers. The images are degraded by patient motion. Head: There is no evidence of acute intracranial hemorrhage or mass. There is a hypoattenuating area in the right posterior frontal lobe. The ventricles are norma... | 1. A hypoattenuating area in the right posterior frontal lobe may represent an infarct of indeterminate age. No evidence of acute intracranial hemorrhage or mass. However, non-contrast CT is insensitive for the detection of non-hemorrhagic acute infarct and intracranial infection.2. No definite fluid collection in the ... |
Generate impression based on findings. | Metacarpal fracture.VIEWS: Right hand PA/lateral/obluique (three views) 03/20/15 The K wires have been removed. A cast has been applied. Callus formation surrounds the little finger distal metacarpal. Anterior angulation of the distal fracture fragment is again seen. | Healing fracture of little finger metacarpal. |
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