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Generate impression based on findings. | 74 year old male. Metastatic renal cell cancer. Repeat imaging please compare to previous. CHEST:LUNGS AND PLEURA: Numerous pulmonary metastases without significant interval change. The reference right upper lobe nodule is 1.5 x 1.4 cm (series 4, image 54) and the reference left lower nodule is 1.8 x 1.7 cm, both uncha... | Slightly increased size of left adrenal metastasis and hepatic lesions. Other reference metastatic lesions are not significantly changed. |
Generate impression based on findings. | Bilateral knee pain. Three views of the left knee show no acute fracture or malalignment. There are tiny osteophytes on the undersurface of the patella indicating minimal osteoarthritis. No joint effusion is identified.Three views of the right knee show no acute fracture or malalignment. There are tiny osteophytes on t... | Minimal osteoarthritis. |
Generate impression based on findings. | Snuffbox tenderness status post fall. Three views of the left hand and two views left wrist reveal no acute fracture or malalignment. No soft tissue swelling is seen. | No acute fracture is evident. |
Generate impression based on findings. | High-risk breast cancer. Left hip pain. Two views of the left hip show no acute fracture or malalignment. No definite osteoblastic or osteolytic lesion is seen within the femur. | No specific findings to account for the patient's pain. |
Generate impression based on findings. | Restaging locally advanced left breast cancer status post modified radical mastectomy and axillary lymph node dissection. Right axillary sentinel lymph nodes were positive for tumor.RADIOPHARMACEUTICAL: 11.0 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 102 mg/dL. Today's CT portion grossly demonstrates bi... | No convincing FDG avid tumor activity currently. Extensive benign postsurgical inflammation and brown fat hypermetabolism is noted. |
Generate impression based on findings. | History of rheumatoid arthritis on prednisone. Patient with left hip/back pain. Two views of the left hip show no acute fracture or malalignment. There is no specific radiographic evidence of avascular necrosis. | No specific radiographic evidence of avascular necrosis. |
Generate impression based on findings. | 40 year old female who was recalled from baseline screening mammogram for left breast asymmetry. An ML view and two spot compression views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | History of figure skating and long-term back pain. No neurological symptoms. Five views of the lumbar spine show no acute fracture. Alignment is anatomic. Vertebral body heights and disk spaces are preserved. A uterine contraceptive device is noted within the pelvis. | No specific findings to account for the patient's symptoms. |
Generate impression based on findings. | 58 year old female status post right lumpectomy in 2008 for IDC with DCIS, presents today for routine follow up. Patient received radiation, chemotherapy, and hormonal therapy (Tamoxifen). No current breast complaints. Family history of breast carcinoma in her paternal aunt and cousin. Three standard views of both brea... | Stable postsurgical changes of the right 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 - Diagno... |
Generate impression based on findings. | Reason: evaluate right upper lobe nodule. SUPER D PROTOCOL. severe COPD. History: dypsnea. LUNGS AND PLEURA: Right upper lobe poorly marginated nodule (image 32 series 6) history interval increase in size now measuring 12 mm x 60 mm previously measuring 8 mm x 13 mm. At this is highly suspicious for primary neoplasm.No... | Interval increase in size of a poorly marginated right upper lobe nodule compatible with a primary neoplasm. |
Generate impression based on findings. | T3N0 laryngeal squamous cell carcinoma status post FHx completed on 10/17/14, as well as radiation therapy, now presenting for follow up. There are post-treatment effects in the larynx with diffuse supraglottic soft tissue swelling. Any residual treated laryngeal mass is not clearly discernible from the treatment effec... | 1. Post-treatment effects in the larynx with diffuse supraglottic soft tissue swelling and perhaps mucositis. Any residual treated laryngeal mass is not clearly discernible from the treatment effects.2. No evidence of significant lymphadenopathy in the neck. |
Generate impression based on findings. | 65 year-old male patient with history of follicular lymphoma previously treated with chemotherapy presents with possible relapse. CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Cardiac size within normal limits without pericardial effusion. Again seen are stable prominent lymph nodes in ... | 1.No significant interval change in the reference mediastinal, axillary, retroperitoneal, and inguinal lymph nodes. No new suspicious lymphadenopathy.2.Multilevel degenerative changes in the thoracolumbar spine, mildly increased compared prior. |
Generate impression based on findings. | An 86 year old female with history of myocardial infarction, s/p coronary artery bypass graft (2002), peripheral artery disease including a stent in the iliac artery, diabetes mellitus, hypertension and severe aortic stenosis. The patient had a balloon valvuloplasty on 7/2014 and now is being evaluated as a candidate f... | 1. Severe aortic valve calcification 2. Thoracic aortic anatomy as described above. Left subclavian artery has a minimal diameter of 4.5cm in the portion of the vessel that is seen. 3. Diffuse subendocardial resting myocardial perfusion defect noted. 4. A prominent sigmoid septum is noted. 5. Extensive coronary artery ... |
Generate impression based on findings. | Elbow pain, evaluate for fracture. Four views of the left elbow show no acute fracture or malalignment. No elbow joint effusion is identified. A small well corticated ossicle adjacent to the medial epicondyle is noted. | No acute fracture is evident. |
Generate impression based on findings. | 4-day-old male with RDS on oscillator.VIEW: Chest AP (one view) 3/23/15 at 1523 Endotracheal tube with tip at the thoracic inlet. Nasogastric tube tip and proximal sidehole are distal to the GE junction. UVC tip at the junction of the IVC and right atrium. Cardiothymic silhouette unable to be assessed due to opacity in... | Decreased right upper lobe opacity. Unchanged left upper and lower lobe opacities. |
Generate impression based on findings. | Female, 4 months old. Reason: is there evidence of osteopenia History: h/o fracturesVIEWS: Left wrist PA, left knee AP (two views) 3/23/15, 1547 No fracture or malalignment.No cupping or fraying of the metaphyses of the distal radius, distal femur, or proximal tibia to suggest rickets. | No evidence of rickets. |
Generate impression based on findings. | Right shoulder pain. Four views of the right shoulder show no acute fracture or malalignment. | No acute fracture is evident. |
Generate impression based on findings. | Pain on the lateral aspect of foot. Three views left foot show no acute fracture or malalignment. No soft tissue swelling is seen. There is mild degenerative change at the first metatarsophalangeal joint. | No acute fracture is evident. |
Generate impression based on findings. | Male, 11 years old. Constipation, Encopresis. Evaluate for fecal impaction.VIEW: Abdomen AP (one view) 3/23/15, 1555 Large amount of stool within the rectum and the dilated sigmoid colon.Moderate stool within the remainder of the colon. Multiple dilated loops of small and large bowel.No pneumatosis, portal venous gas, ... | Large amount of stool within the sigmoid and rectum, compatible with fecal impaction. |
Generate impression based on findings. | Medial foot pain in track runner, flat arches. Question of accessory navicular. Three views of the left foot show no acute fracture or malalignment. No soft tissue swelling seen.Three views of the right foot show no acute fracture or malalignment. No soft tissue swelling seen. | No acute fracture or accessory navicular ossicle is identified. |
Generate impression based on findings. | Male 69 years old; Reason: altered mental status, sepsis - assess for intraabdominal source History: see above Suboptimal exam secondary to patient motion artifact and absence of IV contrast.ABDOMEN:LUNGS BASES: Small right greater than left bibasilar consolidation. Heart borderline in size. Severe calcified coronary a... | 1. Suboptimal exam secondary to patient motion artifact and absence of IV contrast.2. Findings compatible with pancolitis, may be of infectious or inflammatory etiology and ischemic origin not entirely excluded. Correlation with patient's clinical history and laboratory values recommended.3. Small right greater than le... |
Generate impression based on findings. | Male, 16 years old. History of May Thurner's syndrome presenting with RLE swelling. Evaluate for right venous LE abnormality Grayscale, color, and spectral Doppler were performed of the vascular structures.Loss of phasicity is noted in the right common femoral vein and external iliac vein. At the junction of the right ... | Loss of phasicity of flow within the right common femoral and internal/external iliac veins, with narrowing/stenosis at the junction of the right external and internal iliac veins, with local flow acceleration and turbulence. Normal flow of the downstream right common iliac vein. |
Generate impression based on findings. | 24 -year-old male with liver failure. Evaluate for portal vein thrombosis, cirrhosis LIVER: Increased echogenicity of the liver measuring 17.0 cm in length. No focal hepatic lesions. Main portal vein is patent with appropriate directional flow; peak velocity measures 0.2 m/sec.GALLBLADDER, BILIARY TRACT: Normal echogen... | 1. Increased echogenicity of the liver suggestive of parenchymal distortion/infiltration. No focal hepatic lesions. Main portal vein is patent with appropriate directional flow.2. Splenomegaly.3. Right pleural effusion. |
Generate impression based on findings. | 36-year-old male. Left CVA tenderness, pain. Evaluate for stone. Lack of intravenous or oral contrast limits evaluation for solid organ or bowel pathology.ABDOMEN:LUNG BASES: Mild distal esophageal wall thickening, nonspecific, may be artifactual from collapse or represent esophagitis.LIVER, BILIARY TRACT: No significa... | No renal or ureteral stones, no hydronephrosis. Unremarkable study. |
Generate impression based on findings. | Reason: slurred speech and instability of gait History: slurred speech and instability of gait 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 N... | 1.Occlusion of the right vertebral artery at its origin with distal reconstitution via collaterals. The right V4 segment is distally hypoplastic.2.70% stenosis of the left vertebral artery at its origin.3.50% stenosis of the right P2 segment4.Findings are compatible with subacute infarction involving the pons on the ri... |
Generate impression based on findings. | Recent line placement and left leg swelling. Color and spectral Doppler were performed.COMMON ILIAC VEIN: Left lower extremity PICC fills the vein. Blood flow is toward the heart. Wave forms are normal.COMMON FEMORAL VEIN: Left lower extremity PICC fills the vein. Blood flow is toward the heart.OTHER: The ultrasound wi... | Normal examination without thrombosis. |
Generate impression based on findings. | Reason: pulmonary embolism History: hypoxia, tachycardia PULMONARY ARTERIES: Technically adequate examination for the evaluation of pulmonary embolism. No evidence of pulmonary embolus.LUNGS AND PLEURA: Subsegmental atelectasis of bilateral lower lobes and the lingula.MEDIASTINUM AND HILA: There is a small nodule that ... | No pulmonary embolism.PULMONARY EMBOLISM: PE: NoneChronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Reason: evaluate for PE History: dyspnea, chest pain, reported blood tinged sputum PULMONARY ARTERIES: The quality of this examination is markedly limited due to contrast primarily concentrated within the left heart and aorta. Patient was reported to be a tachycardic and experienced vomiting on the table which resulted... | Limited examination as the contrast bolus was concentrated in the left heart and aorta. No large central pulmonary embolus. Localized groundglass within the right upper lobe present on of localized hemorrhage given history of blood tinged sputum. Mild peripheral upper lobe bronchiolectasis. PULMONARY EMBOLISM: PE: No c... |
Generate impression based on findings. | Reason: hx of tongue cancer, prostate cancer, newly diagnosed esophageal cancer and lung cancer here for persistent pneumothorax History: please r/o PE (persistent tachycardia) PULMONARY ARTERIES: Technically adequate examination for the evaluation of pulmonary embolism. No pulmonary embolus is present.LUNGS AND PLEURA... | No pulmonary embolism.Moderate right hydropneumothorax following needle biopsy of spiculated right upper lobe nodule. Decreased hemorrhage associated with recent biopsy. Scattered pulmonary micronodules, the largest in the left upper lobe measures 5 mm. Continued close interval follow-up is recommended.MID to distal es... |
Generate impression based on findings. | Clinical question: Normal hemorrhage. Signs and symptoms: Headache. Nonenhanced head CT:There is 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 spaces and gray -- white... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Rule out ICH. Signs and symptoms: Severe headache. Preeclampsia. Nonenhanced head CT:No detectable acute intracranial process. CT is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and gray -- white ... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Intracranial mass or hemorrhage. Signs and symptoms: History of thymic cancer with brain metastases status post craniotomy. Now presents with bilateral upper extremity weakness. Nonenhanced head CT:Focus of parenchymal low attenuation in the left frontal lobe without convincing evidence of mass-effec... | 1.No evidence of an acute or new finding since prior exam.2.Left anterior frontal craniotomy and underlying parenchymal focus of low attenuation similar to prior study. To exclude residual or recurrence of tumor MRI is recommended.3.Unremarkable and stable study otherwise. |
Generate impression based on findings. | Clinical question: Hemorrhage or fracture. Signs and symptoms: Head injury. Nonenhanced head CT:There is no evidence of acute posttraumatic intracranial, calvarial or soft tissues of the scalp findings.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and gray -- white matter differentiation.... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Is there evidence of shunt malfunction. Signs and symptoms: Headache, emesis, history of VP shunt in 1999 for hydrocephalus. Nonenhanced head CT:Examination demonstrate shunt normal appearing supratentorial and infratentorial ventricular system. A right frontal approach ventricular catheter with the ... | 1.Shunted supratentorial ventricular system and without evidence of hydrocephalus.2.Unremarkable exam otherwise.3.There are no prior exams for comparison. |
Generate impression based on findings. | Clinical question: Left lower extremity weakness. Signs and symptoms: Left lower extremity weakness. Nonenhanced head CT:There is no detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular sys... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Reason: Pulmonary Embolus History: SOB x 2 Days elevated D-Dimer at South Shore PULMONARY ARTERIES: Examination is somewhat limited secondary to patient body habitus and borderline opacification of the pulmonary artery. No pulmonary embolus noted to the segmental level.LUNGS AND PLEURA: No significant abnormality noted... | Limited examination. No pulmonary embolus noted to the segmental level.PULMONARY EMBOLISM: PE: None to the segmental level.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Clinical question: EVD clamped. Signs and symptoms: EVD clamped. Nonenhanced head CT:Images through posterior fossa demonstrate hemorrhage within the normal size fourth ventricle without convincing evidence of change.Images through the supratentorial space demonstrate stable mildly dilated supratentorial ventricular sy... | 1.No evidence of an acute or new finding since prior exam.2.Stable mildly dilated shunt tip supratentorial ventricular system and intraventricular hemorrhage with maintained midline.3.Stable right thalamic acute hematoma, surrounding vasogenic edema and regional mass effect. |
Generate impression based on findings. | Female 34 years old; Reason: r/o SBO, s/p RAVH with extensive LOA. History: SOB/chest pain. CHEST:LUNGS AND PLEURA: Small bilateral pleural effusions and basilar atelectasis; infection cannot be excluded.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. No significant mediastinal or hilar lymphadenop... | Findings compatible with small bowel obstruction at level of probable mesenteric abscess. Bowel leak cannot be excluded. |
Generate impression based on findings. | Tenderness. Third metacarpal head fracture.VIEWS: Right hand PA/lateral/oblique (3 views) 03/23/15 Mild soft tissue swelling is seen at the metacarpophalangeal joints. No fracture is identified. The bones are normal in appearance. | No fracture. |
Generate impression based on findings. | 24 years, Male. Reason: Acute Abdominal Pain History: Acute Abdominal Pain There is diffuse gaseous distention of both large and small bowel, most suggestive of ileus, and not significantly changed from the prior examination. There is no evidence of pneumoperitoneum.Harrington rods in place, with fusion of multiple ver... | Ileus-type gas pattern without evidence of pneumoperitoneum. |
Generate impression based on findings. | RFO trigger: Multiple surgical teams Suspected RFO location: abdomen, pelvic Name of suspected RFO: NA Attending Surgeon name/pager: Dr. Nita Lee No unexpected radiopaque foreign object identified. There is a nonobstructive bowel gas pattern. There is a nasogastric tube with its tip projecting over the body of the stom... | No unexpected radiopaque foreign object identified.These findings were discussed by telephone with Dr. Lee, the attending surgeon, on 3/23/2015 at 17:53. |
Generate impression based on findings. | RFO trigger: Pregnant and BMI over 50 Suspected RFO location: abdomen Name of suspected RFO: unknown Attending Surgeon name/pager: Dade x26639 Body Mass Index (BMI): 55.79 No unexpected radiopaque foreign object identified. Surgical coils project over the abdomen from prior mesh closure. Towel clips are in place. A ski... | No unexpected radiopaque foreign object identified.These findings were discussed by telephone with Dr. Dade, the attending surgeon, on 2/23/2015 at 22:10. |
Generate impression based on findings. | 62 years, Male. Reason: please check Dobbhoff position History: tube repositioned There is a Dobbhoff tube with its tip projecting over the body of the stomach. There is an IVC filter in place. A surgical drain projects over the right upper quadrant. Multilevel vertebroplasty changes are evident. There is a rectal temp... | Dobbhoff tube with its tip projecting over the body of the stomach |
Generate impression based on findings. | Male 52 years old; Reason: eval for primary lesion History: met crani lesions, s/p resection CHEST:LUNGS AND PLEURA: Mild to moderate upper lobe predominant centrilobular emphysema. No focal consolidation or pleural effusion. No suspicious pulmonary nodules. MEDIASTINUM AND HILA: Heart size is normal. No pericardial ef... | No specific findings to indicate a primary neoplasm. |
Generate impression based on findings. | Female, 9 years old. Swelling status post fall 3 days priorVIEWS: Left fifth finger, PA, lateral, oblique (3 views) 3/23/15, 1548 A metaphyseal fragment is located posteriorly within the widened physis of the fifth proximal phalanx.Soft tissue swelling surrounding the metacarpophalangeal joint of the fifth finger.The o... | Salter-Harris type II fracture of the fifth proximal phalanx. |
Generate impression based on findings. | 57 years, Male. Reason: abdominal pain History: see above AICD lead position unchanged. Right femoral central venous catheter tip terminates in the distribution of the right common iliac vein. There are dense atherosclerotic calcifications of the abdominal aorta and its branches. There is an IVC filter in place. Small ... | Nonspecific bowel gas pattern, without definite evidence of small bowel obstruction. |
Generate impression based on findings. | Large wound status post I/O. Evaluate for gas-osteo. Four views of the left knee show a soft tissue defect anterior to the tibial tuberosity with underlying osseous irregularity and cortical destruction. This may related to the interosseous infusion, however cannot exclude osteomyelitis. There is a large joint effusion... | 1. Cortical destruction may be iatrogenic from interosseous infusion, however, cannot exclude superimposed osteomyelitis.2. Large joint effusion with gas may either represent septic arthritis or be iatrogenic in etiology. |
Generate impression based on findings. | Reason: r/o bleed History: fall, head trauma, elderly CT head:The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Periventricular and subco... | 1.No evidence for cervical spine fracture2.No evidence for acute intracranial hemorrhage mass effect or edema.3.There are multilevel degenerative changes present in the cervical spine.4.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular relat... |
Generate impression based on findings. | 16 year old female after fall on outstretched handVIEWS: Left wrist PA oblique and lateral (3 views) 3/23/15 No acute fracture or malalignment. Mild soft tissue swelling is present. The pronator fat pad appears normal. Negative ulnar variance. | No fracture. Negative ulnar variance. |
Generate impression based on findings. | 82 years, Female. Reason: abdominal tenderness and s/p Dobbhoff tube placement; evaluate position of DHT History: abdominal tenderness and s/p Dobbhoff tube placement There is a Dobbhoff tube with its tip in the right mainstem bronchus. Degenerative changes and scoliosis of the thoracolumbar spine. Bilateral hip arthro... | Dobbhoff tube with its tip in the right mainstem bronchus. This tube had been removed at the time of dictation. |
Generate impression based on findings. | Female, 16 years old. Tibial tenderness. Evaluate for fracture.VIEWS: Left knee, AP, lateral, oblique (3 views) 3/23/15, 1829 The osseous structures and joint spaces are normal.No significant joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | HEAD:No acute intracranial hemorrhage is identified. No evidence of intracranial mass, mass-effect, or hydrocephalus. No extra-axial fluid collections. Hypoattenuation of the periventricular and subcortical white matter compatible with age indeterminant small vessel ischemic disease. The imaged paranasal sinuses and m... | 1.No acute intracranial abnormality. Please note CT is not sensitive for detection of acute nonhemorrhagic ischemia and MRI can be considered for further evaluation.2.Unchanged bilateral posterior communicated artery aneurysms that measure up to 2-3 mm.3.Multifocal atherosclerosis of the neck vessels with up to severe ... |
Generate impression based on findings. | Severe right hip pain. Evaluate for dislocation or fracture. Two views of the right hip show no acute fracture or malalignment. Mild osteoarthritis affects the hip. | No acute fracture is evident. |
Generate impression based on findings. | 34 years, Female. Reason: NGT placement History: sbo There is a nasogastric tube with its tip projecting over the fundus of the stomach, appearing kinked. There is a paucity of bowel gas. Dilated loop of small bowel consistent with known small bowel obstruction. | Nasogastric tube with its tip projecting over the fundus of the stomach. Persistent small bowel obstruction. |
Generate impression based on findings. | Female, 7 years old. Pain status post fall. Evaluate for fracture.VIEWS: Right elbow, AP, lateral, oblique. Right forearm, AP, lateral (5 views) 3/23/15, 1948 The osseous structures and joint spaces are normal.No significant joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | 34 years, Female. Reason: NGT adjusted History: above There is a nasogastric tube, which is coiled in the stomach, with the tip projecting over the fundus. There is a paucity of bowel gas. Dilated loop of small bowel consistent with known small bowel obstruction. | Nasogastric tube with its tip projecting over the fundus of the stomach. Persistent small bowel obstruction. |
Generate impression based on findings. | PICC line pulled. Evaluate for retained PICC line. Two views of the left humerus show no evidence of retained PICC tubing. No acute fracture or malalignment is evident. Moderate osteoarthritis affects the left shoulder. | No evidence of retained PICC tubing. |
Generate impression based on findings. | 75 years, Female. Reason: adjusted again NGT History: adjusted NGT There is a nasogastric tube with its tip projecting over the antrum of the stomach, and the side port in the body of the stomach. There atherosclerotic calcifications of the aorta. The small bowel is dilated up to 4 cm with air in the colon, suggestive ... | NG tube with the tip projecting over the antrum of the stomach. Findings suggestive of partial small bowel obstruction. |
Generate impression based on findings. | 75 years, Female. Reason: adjust NGT History: adjust NGT There is a nasogastric tube with its tip projecting over the antrum of the stomach, and the side port in the body of the stomach. There atherosclerotic calcifications of the aorta. The small bowel is dilated with air in the colon, suggestive of a partial small bo... | NG tube with the tip projecting over the antrum of the stomach. Findings suggestive of partial small bowel obstruction. |
Generate impression based on findings. | Six month follow-up for clustered cysts in the right breast. Three standard views of the right breast and spot compression views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. There are multi... | Mammographically benign morphology masses in the right breast corresponding to cysts and an area of fat necrosis on ultrasound. As long as the patient's physical exam remains unremarkable, bilateral diagnostic mammogram in 6 months is recommended. Ultrasound may also be necessary at that time.BIRADS: 3 - Probably benig... |
Generate impression based on findings. | 75 years, Female. Reason: post NGT placement History: post NGT placement There is a nasogastric tube with its tip projecting over gastroesophageal junction. There atherosclerotic calcifications of the aorta. The small bowel is dilated with air in the colon, suggestive of a partial small bowel obstruction. | 1.NG tube with the tip projecting over the gastroesophageal junction. The tube had been repositioned at the time of dictation. 2.Findings suggestive of partial small bowel obstruction. |
Generate impression based on findings. | Pain status-post MVA versus pedestrian. Two views of the left forearm show no acute fracture or malalignment. Mild soft tissue reticulation is noted about the posterior portion of the forearm. | No acute fracture is evident. |
Generate impression based on findings. | 47 years, Male. Reason: s/p NG tube replaced History: NG tube replaced Pacemaker lead position unchanged. There is an LVAD in place. Surgical clips project over the midline lower thorax. Sternotomy wires in place. There is a nasogastric tube with its tip projecting over the body of the stomach. There is a nonobstructiv... | Nasogastric tube with its tip projecting over the body of the stomach. |
Generate impression based on findings. | ICN status post LVAD complicated by right femoral hematoma. Evaluate increase in size, ongoing bleed. CT examination of the right thigh and pelvis reveals a large medial mass consistent with a hematoma which is slightly increased in size from the prior study measuring approximately 8.7 x 7.6 cm, previously 7.0 x 7.0 cm... | Slight interval increase in size of the medial right thigh hematoma. |
Generate impression based on findings. | Female, 93 years old.Reason: Evaluate for PNA, Fragility fracture History: Cough, URI sx, L-sided chest pain, acute Increasing size of right upper lobe pulmonary mass, better characterized on CT chest abdomen and pelvis 1/22/15. Cardiomegaly is unchanged. Suspected subcarinal adenopathy. Severe atherosclerotic disease,... | Increasing right upper lobe mass. No specific evidence of infection or edema. |
Generate impression based on findings. | Female, 7 years old. Wrist pain status post fall. Evaluate for fracture.VIEWS: Right wrist, PA, lateral, oblique (3 views) 3/23/15, 1842 Mild widening of the posterior radial physis is seen. No definite fracture is identified.The other visualized osseous structures and joint spaces are normal.No joint effusion or soft ... | Mild widening of the posterior radial physis in a patient without local swelling or radial tenderness is compatible with normal variant anatomy. Otherwise normal examination. |
Generate impression based on findings. | 4-year-old male with recent pronator fat pad sign. Follow-up for fractureVIEWS: Left elbow AP, oblique, lateral (3 views) 3/24/15 Patient is unable to cooperate fully for the lateral radiograph. Given this limitation, there is no fracture or malalignment. | No fracture is identified. |
Generate impression based on findings. | Male 76 years old Reason: knee pain, evaluate for osteoarthritis History: knee pain Left knee: Metallic look fragments project over the soft tissues along the lateral aspect of the tibia. Sclerotic spiculated medullary region in the distal femur consistent with bone infarct. Osteophyte formation and joint space narrowi... | Osteoarthritic changes and other findings as above. |
Generate impression based on findings. | The ventricles and sulci are slightly prominent for the patient's stated age consistent with mild global volume loss. The cisterns remain patent. There is no midline shift or mass effect. There is suggestion of mild thinning of the pars compacta of the substantia nigra bilaterally, although it remains well delineated,... | No acute intracranial abnormalities on limited preoperative exam. |
Generate impression based on findings. | Reason: evaluate for SAH History: headache; refusing LP 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 significant ... | 1.No evidence for aneurysm.2.No evidence for cervicocerebral occlusive disease.3.New cervical portion of the right internal carotid artery is very tortuous and associated with a mild fusiform dilation. This is an incidental finding a nonspecific one at that. Underlying connective tissue disorder may be one explanation.... |
Generate impression based on findings. | PICC placement. Candida infection.VIEW: Chest AP (one view) 03/23/15, 1920 Left central line has been removed. A lower extremity PICC has been placed and its tip is at the junction of the inferior vena cava and right atrium.Cardiothymic silhouette is normal. Lung volumes are low. Hazy opacities are seen in both lung ba... | Lower extremity PICC tip at junction of IVC and right atrium. |
Generate impression based on findings. | 67 year-old returns for further evaluation of microcalcifications. An ML view and two spot magnification views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. The calcificat... | Calcifications in the left breast are highly likely benign. Without older studies to prove stability, a 6 month follow-up is necessary. Given that she will be almost due for her routine exam of the right breast, a bilateral examination can be performed at that time. The patient will attempt to obtain older mammograms. ... |
Generate impression based on findings. | 6-year-old male with productive cough and feverVIEWS: Chest AP/lateral (two views) 3/24/15 The aortic arch, cardiac apex, and stomach are left-sided. The cardiothymic silhouette is normal. No focal pulmonary opacities. Slightly increased lung volumes and mild bronchial wall thickening suggestive of reactive airway dise... | Mild bronchiolitis/reactive airway disease. |
Generate impression based on findings. | 44 year old with family history of breast cancer in her sister at age 36, presents for annual mammogram. 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... | 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. | Male 63 years old; Reason: evaluate for RP or peritoneal bleed s/p LVP History: drop in Hgb, hypotension, tachycardia - history of cirrhosis, LVP on 3/19 ABDOMEN:LUNGS BASES: Emphysema. Minimal patchy attenuation in the right anterior lung base is nonspecific. Moderate left pleural effusion.LIVER, BILIARY TRACT: Cirrho... | Large left retroperitoneal hematoma with large free collection as well as involvement of the left iliacus, and to a lesser degree, psoas muscles. |
Generate impression based on findings. | 22 year-old female with flank pain. Rule-out stone. Within the limits of a non-IV contrast enhanced examination which limits evaluation of solid parenchymal organs investor structures, the following observations can be made:ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnorma... | 1. Proximal right ureteral stone with mild proximal hydronephrosis. 2. Multiple nonobstructing left kidney calyceal stones. 3. No other abnormalities. |
Generate impression based on findings. | Female 65 years old Reason: neck and shoulder pain on the left- previous rotator cuff issue on the other side History: left sided neck and shoulder pain Left shoulder: Median sternotomy hardware and mediastinal surgical clips are noted. Glenohumeral joint alignment is within normal limits. No evidence of fracture. Cerv... | Degenerative disk disease, and other findings as above. |
Generate impression based on findings. | 12 month old status post cranioplasty October 2014 complicated by resorption, now with left to right craniotomy and cranioplasty, evaluate for hemorrhage. There has been interval left parietal craniotomy with right parietal cranioplasty. There is mixed high attenuation and gas density at the site of the left parietal c... | 1.Expected postoperative findings of left parietal cranioplasty and right parietal calvarial graft without evidence of new hemorrhage.2.Redemonstration and no change of cystic encephalomalacia involving the right parietal lobe.3.Redemonstration and no change in small foci of encephalomalacia in the occipital lobes. |
Generate impression based on findings. | 3-year-old male with fever and coughVIEWS: Chest PA/lateral (two views) 3/24/15 The aortic arch, cardiac apex, and stomach are left-sided. The cardiothymic silhouette is normal. No focal pulmonary opacities. No pleural effusion or pneumothorax. Mild bronchial wall thickening compatible with reactive airway disease/bron... | Mild bronchiolitis/reactive airway disease. |
Generate impression based on findings. | Male, 6 years old. Acute chest syndrome. Evaluate for interval change.VIEW: Chest AP (one view) 3/24/15, 0535 ET tube tip below the thoracic inlet and above the carina. One enteric tube extends below the lower margin of the image. Another enteric tube has its distal side-port below the level of the GE junction.The card... | Improving bilateral pulmonary opacities. |
Generate impression based on findings. | Palpable area of concern in the right breast. Three standard views of both breasts and right spot compression views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. No dominant mass, suspicious microcalcifications or areas of archit... | No mammographic evidence of malignancy. No suspicious finding at the palpable area of concern. Correlation with physical examination is recommended and if physical exam findings are discordant with benign imaging, further evaluation such as referral to breast surgery is recommended. Otherwise, bilateral screening mammo... |
Generate impression based on findings. | 41 day old former 24 week gestational age patient with decreased urine output abnormal blood count and concern for sepsis.VIEWS: Chest and abdomen AP (two views) 03/23/15, 2310 Endotracheal tube tip is below thoracic inlet. Feeding tube tip is at GE junction. Right upper extremity PICC tip is at junction of superior ve... | Persistent hazy lung opacities. Abnormal bowel gas pattern with distention of stomach. |
Generate impression based on findings. | Female; 33 years old. Reason: fistula, abscess, separation of abdominal wall at G-tube site History: abdominal pain and purulent drainage around tube ABDOMEN:LUNG BASES: Mild bibasilar dependent subsegmental atelectasis.LIVER, BILIARY TRACT: Stable mild intrahepatic biliary ductal dilation and prominence of the common ... | 1. G-tube tip in excluded stomach, unchanged since prior small-bowel follow-through on 1/16/15. No contrast leak or free air.2. 5.5-cm length proximal jejunal intussusception without lead point mass evident, likely incidental though clinical correlation is recommended. 3. Stable postsurgical changes of Roux-en-Y gastri... |
Generate impression based on findings. | Male 69 years old Reason: History of AML undergoing chemotherapy and now with new tooth pain Single Panorex view of the mandible demonstrates poor dentition, with few remaining teeth at the midline. No gross bone destruction. | Poor dentition, with no gross bone destruction. |
Generate impression based on findings. | Male 42 years old; Reason: eval for stone History: Abdominal pain ABDOMEN:LUNG BASES: Left lower lobe pulmonary nodule measures 3 mm (image 17/series 4)LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significan... | 1.Mild infiltration of the fat surrounding the right distal ureter possibly represents infectious or inflammatory changes.2.Possible hemorrhage posterior to the left kidney with infiltration of the fat.3.3-mm left lower lobe pulmonary nodule.4.Findings discussed with Dr. Brian Callendar at the time of dictation. |
Generate impression based on findings. | Female, 16 years old. Fifth metatarsal tenderness. Evaluate for fracture.VIEWS: Right ankle, AP, lateral, oblique. Right foot, AP, lateral, oblique (6 views) 3/23/15, 2117 The osseous structures and joint spaces are normal.Possible small ankle joint effusion. No significant soft tissue swelling. | Small ankle joint effusion, without fracture or malalignment. |
Generate impression based on findings. | 13-week-old male post PCVC line changeVIEW: Chest AP (one view) 3/23/15 Mandibular distraction devices are noted along the mandible bilaterally. Nasogastric tube with proximal sidehole near the GE junction and tip in the gastric body. PCVC with tip at the confluence of the brachiocephalic veins. The cardiothymic silhou... | Peripheral catheter with tip at the confluence of the brachiocephalic veins. Proximal sidehole of NG tube near the GE junction. |
Generate impression based on findings. | 28-year-old male with right upper quadrant/flank pain concerning for stone. Within the limits of a non-IV contrast enhanced examination which limits evaluation of solid parenchymal organs and facet structures, the following observations can be made:ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRAC... | 1. No evidence for urinary tract stone disease. 2. No abnormality seen to account for patient's symptomatology. |
Generate impression based on findings. | Female 68 years old Reason: 68F s/p EGD on 3/17 at OSH c/b duodenal perf now s/p laparoscopic primary repair on 3/19; assess for leak History: history of duodenal perforation Scout imaging demonstrated surgical clips projecting over the left and right upper quadrants as well as along the midline thorax. Surgical drain ... | No evidence of contrast extravasation to suggest duodenal leak as clinically questioned. |
Generate impression based on findings. | 3-day-old male post UAC and UVC placementVIEWS: Chest and abdomen AP (two views) 3/23/15, 1900 Endotracheal tube is between the thoracic inlet and the carina. The nasogastric tube tip and proximal sidehole is in the gastric body. UAC is between the level of T5 and T6. The UVC is in the right portal vein.The cardiothymi... | UVC in right portal vein. Persistent mild diffuse granular lung haziness consistent with surfactant deficiency. |
Generate impression based on findings. | Male 36 years old Reason: Evaluate spine alignment History: s/p fusion Two views of the lumbar spine show pedicular screws affixing L4 through S1 vertebral bodies with posterior stabilization rods in anatomic alignment without evidence of hardware complication. Vertebral body heights are maintained. No evidence of acut... | L4 through S1 orthopedic fixation without evidence of hardware complication. |
Generate impression based on findings. | 82 years, Female. Reason: eval Dobbhoff tube re placement History: eval Dobbhoff tube replacement There is a Dobbhoff tube with its tip projecting over the fundus of the stomach, which is folded back upon itself, possibly kinked. There is a nonobstructive bowel gas pattern. Surgical clips project over the right upper q... | Dobbhoff tube with its tip projecting over the fundus of the stomach, which is folded back upon itself, possibly kinked. |
Generate impression based on findings. | Female 53 years old; Reason: eval for obstruction or concern for ischemia History: abdominal pain ABDOMEN:LUNG BASES: Mild basilar emphysema.LIVER, BILIARY TRACT: Liver is diffusely hypoattenuating compatible with fatty infiltration. The hepatic vasculature are patent. No biliary distentionSPLEEN: No significant abnorm... | 1.Findings compatible with a mild acute pancreatitis involving the head and body of the pancreas. (patient has an elevated lipase); Followup is recommended.2.Severe fatty infiltration of the liver.3.Submucosal fat deposition involving the ascending colon most suggestive of a chronic colitis.4.Findings discussed with Dr... |
Generate impression based on findings. | Female 91 years old Reason: Evaluate for fracture History: right leg pain, history of fall Two views of the right tibia-fibula are provided. No acute fracture or malalignment. Four views of the right knee are provided. No acute fracture or malalignment. Chondrocalcinosis is noted.Two views of the right hip show no acut... | No acute fracture or dislocation. |
Generate impression based on findings. | 54 year old with history of right lumpectomy in 2007 for multifocal DCIS, followed by radiation. No new breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Hypodensity in the subcortical white matter of the right frontal lobe, right temporal lobe, and internal capsule is unchanged from the examination on 3/20/2015. Lacunar infarcts in the right cerebellum and left basal ganglia are stable. There is no mass-effect or midline shift. There is no acute intracranial hemorrhag... | Compared to prior exam, the white matter based lesion involving the right frontal lobe, right temporal lobe and the right external and internal capsules has remained stable. |
Generate impression based on findings. | Female 45 years old; Reason: eval for reaccumulation of fluid collection History: LLQ abd pain ABDOMEN:LUNGS BASES: No focal consolidation or pleural effusion.LIVER, BILIARY TRACT: Liver enhances homogeneously without focal lesion. Status post cholecystectomy.SPLEEN: No focal splenic lesion.PANCREAS: No focal pancreati... | 1.Two left-sided pelvic fluid collections; while these both may represent the previously described single left collection, one likely represents physiologic cystic change of the left ovary, with interval decrease in size of a true left pelvic fluid collection.2.Interval resolution of small right pelvic fluid collection... |
Generate impression based on findings. | Reason: Rule out mastoiditis History: rash + posterior ear pain, right V1 dermatome VZV There is preseptal periorbital soft tissue thickening on the right, compatible with right V1 dermatome VZV. Retro-orbital space is unremarkable. The orbits are intact. The bilateral mastoids air cells are hypoplastic but clear. Ther... | 1.Right preseptal periorbital soft tissue thickening compatible with right V1 dermatome VZV. 2.No evidence of mastoiditis as clinically questioned. |
Generate impression based on findings. | 29 year-old female with hematuria. ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Multiple small subcentimeter hypodensities, most likely cysts without other significant abnormality noted in the liver. Patient is status post cholecystectomy without other biliary tract abnormalitySPLEEN: No s... | 1. No evidence for urinary tract stone disease and no source for urinary tract hematuria seen. 2. Increasing size of the uterus with heterogeneous internal and pedunculated lesions. While these most likely are fibroid changes in the uterus, CT cannot characterize uterine soft tissue masses. |
Generate impression based on findings. | Male 57 years old Reason: follow up Three views of the left ankle again show comminuted fracture of the distal fibula in near anatomic alignment. Interval callus formation indicates interval healing. Vascular calcification noted in the posterior soft tissues. Pes planus deformity is present. | Healing distal fibular fracture as above. |
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