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Generate impression based on findings. | Fall. Concern for altered mental status.VIEWS: Cervical spine AP/lateral (two views) 01/11/15, 0131100127 Normal examination. Adenoid hypertrophy. | Normal examination. |
Generate impression based on findings. | 25 day old former 25 week gestational age patient with pneumothorax and chest tube placement.VIEWS: Chest AP/lateral (two views) 01/11/15, 0200 and 0202 Endotracheal tube tip is above the carina. Two right chest tubes are in place with their tips located anteriorly. Left upper extremity PICC tip is in superior vena cav... | Small subpulmonic pneumothorax after chest tube placement. |
Generate impression based on findings. | Female 49 years old; Reason: 49 yo with pancreatic abnormality, weight loss, constant n/v. Needs pancreas protocol CT Scan History: abdominal pain, nausea and vomiting ABDOMEN:LUNGS BASES: Incompletely imaged patchy left lower lobe air space disease, not well seen on prior MRI and suspicious for pneumonia.LIVER, BILIAR... | 1. Pancreatic duct stent placement noted, extending into duodenum. Mild prominence of pancreatic duct, measuring up to 3 mm, to level of placement of stent. Visualized pancreatic parenchyma relatively homogeneous. Please refer to outside MRI report for additional findings.2. Incompletely imaged patchy left lower lobe a... |
Generate impression based on findings. | Emesis. Colectomy and multiple bowel resections.VIEW: Abdomen AP upright (one view) 01/11/15, 0216 Several dilated bowel loops are present with air-fluid levels. Other very small air-fluid levels are seen, a string of pearls sign, indicating dilated fluid-filled bowel with small amount of air trapped in the valvulae co... | Bowel obstruction. |
Generate impression based on findings. | Acute bronchiolitis. Respiratory failure. History of prematurity.VIEW: Chest AP (one view) 01/11/15, 0304 Endotracheal tube tip is above carina. Feeding tube has been placed and its tip is in gastric body.Segmental atelectasis is present in right upper and lower lobes. Subsegmental atelectasis is noted in left lung. Lu... | Bronchiolitis with multiple opacities. |
Generate impression based on findings. | Liver transplant and acute kidney failure. Endotracheal tube placement.VIEW: Chest AP (one view) 01/11/15, 0534 Endotracheal tube tip is between thoracic inlet and carina. Left-sided central line has its tip at junction of superior vena cava and right atrium. Feeding tube tip is distal to mid body of stomach and not in... | Decrease in lung opacities. |
Generate impression based on findings. | 63 year old male with syncope. There is no evidence of intracranial hemorrhage. The ventricles and basal cisterns are normal in size and configuration. There is no mass effect or herniation. The imaged paranasal sinuses and mastoid air cells are clear. The skull and extracranial soft tissues are unremarkable. | No evidence of intracranial hemorrhage or mass effect.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | One day old 24 week gestational age patient with respiratory distress.VIEW: Chest AP (one view) 01/11/15, 0503 A large right pneumothorax has developed in the interval. Mediastinum is shifted to the left. Right lung is incompletely collapsed due to surfactant deficiency. Hazy opacities are seen on the left. Cardiac sil... | Large right pneumothorax. |
Generate impression based on findings. | Endotracheal tube placement. Neutropenic sepsis. Stem cell transplant for neuroblastoma.VIEW: Chest AP (one view) 01/11/15, 0236 Endotracheal tube tip is below thoracic inlet. A feeding tube has been placed and its tip is in the gastric antrum. Right jugular line tip is in superior vena cava. Left upper extremity PICC ... | Left lower lobe airspace disease. |
Generate impression based on findings. | Intubated and head trauma.VIEW: Chest AP (one view) 01/11/15, 0542 Endotracheal tube tip is between thoracic inlet and carina. Left-sided central line tip is at junction of brachiocephalic veins. Feeding tube tip is distal to proximal gastric body and not included on image.Cardiothymic silhouette is normal. Multifocal ... | Decrease in left lower lobe opacities. |
Generate impression based on findings. | One day old 24 week gestational age patient with pneumothorax and chest tube placement.VIEWS: Chest AP/lateral (two views) 01/11/15, 0610 and 0615 Endotracheal tube tip is below thoracic inlet. A right chest tube has been placed and its tip is located anteriorly. Umbilical venous line tip is in right atrium. Umbilical ... | Continued large right pneumothorax. |
Generate impression based on findings. | 59-year-old female with chest pain and history of pulmonary embolism PULMONARY ARTERIES: Technically adequate examination. No evidence of pulmonary embolism. The pulmonary artery is borderline enlarged measuring 2.8 cm suggestive of pulmonary artery hypertension.LUNGS AND PLEURA: Minimal bibasilar atelectasis at the lu... | 1.No pulmonary embolism.2.Borderline enlarged pulmonary artery suggestive of pulmonary artery hypertension.PULMONARY EMBOLISM: PE: NoneChronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Imperforate anus. Adjustment of PICC.VIEW: Chest AP (one view) 01/11/15, 0507 Left upper extremity PICC tip is at junction of brachiocephalic veins.Cardiothymic silhouette is normal. No focal lung opacity is present. | PICC tip at junction of brachiocephalic veins. |
Generate impression based on findings. | Female 62 years old; Reason: R femur lesion. Evaluate for primary/mets CHEST:LUNGS AND PLEURA: 2 mm lingula lung nodule, image 50 series 6, nonspecific. Small bibasilar linear atelectasis versus scarring. MEDIASTINUM AND HILA: Mildly heterogeneous thyroid gland with bilateral relatively hypoattenuating nodules measurin... | 1. Breast lesions as described, suspicious for primary breast malignancy (particularly lesion alluded to in left breast) and correlation with patient's clinical history/physical exam and mammography recommended. Mildly enlarged left-sided axillary and subpectoral lymph nodes, suspicious for metastatic adenopathy.2. Sit... |
Generate impression based on findings. | 89 year old male with altered mental status prior to intubation. This exam is mildly degraded by motion artifact. There is no evidence of acute intracranial hemorrhage. There is prominence of the extra-axial CSF spaces along the bilateral convexities which is favored to be related to volume loss and less likely small c... | 1.No evidence of acute intracranial hemorrhage.2.Moderate global volume loss and mild age indeterminate small vessel ischemic disease. There is prominence of the extra-axial CSF spaces along the bilateral convexities which is favored to be related to volume loss and less likely small chronic subdural collections. No as... |
Generate impression based on findings. | Female 43 years old; Reason: Evaluate for acute appendicitis, colitis, free fluid History: periumbilical abdominal pain, +rebound tenderness ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abno... | 1. Findings consistent with small bowel obstruction. Area of transition seen in region of lateral lower left rectus musculature with somewhat tethered appearance of bowel noted, suspicious for underlying adhesive disease as an etiology for the described small bowel obstruction; left groin surgical clips seen. Although ... |
Generate impression based on findings. | 30 year-old female with chest pain, dyspnea on exertion, shortness of breath and tachycardia PULMONARY ARTERIES: Limited study due to patient motion and body habitus. Within these limitations, there is no evidence of pulmonary embolism.LUNGS AND PLEURA: There is a right middle lobe air space opacity/consolidation consi... | 1.Limited examination without evidence of pulmonary embolism.2.Right middle lobe pneumonia. PULMONARY EMBOLISM: PE: None.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | 58 year-old female with HIV/AIDS for evaluation of scarring/atelectasis seen on radiograph LUNGS AND PLEURA: Left lower lobe scarring and/or atelectasis. No focal pulmonary opacities or findings to suggest infection. No pleural effusions.MEDIASTINUM AND HILA: No significant hilar or mediastinal lymphadenopathy. The hea... | Left lower lobe scarring and/or atelectasis. No focal pulmonary opacities to suggest infection. |
Generate impression based on findings. | 61-year-old female with chest pain PULMONARY ARTERIES: Technically adequate examination. No evidence of pulmonary embolism. LUNGS AND PLEURA: Bilateral nodules measuring up to 7 mm (series 10, images 25, 51). Bibasilar subsegmental atelectasis/scarring, right greater than left. Bronchial wall thickening in the lung bas... | 1.No pulmonary embolism.2.Bilateral pulmonary nodules measuring up to 7 mm. Recent guidelines by the Fleischner society (Radiology 2005: 237:395-400) suggest that patients with a low risk for lung cancer who have nodules greater than 6 mm and less than or equal to 8 mm in diameter should have follow up in approximately... |
Generate impression based on findings. | Male 46 years old; Reason: 46yoM new AML on standard induction, neutropenic, persistent fevers, known fungal PNA and sinusitis CHEST:LUNGS AND PLEURA: Interval resolution of previously seen left pleural effusion. Persistent left greater than right patchy ill-defined airspace disease in lungs bilaterally with improved a... | 1. Interval improvement in previously visualized segmental distal transverse colonic wall thickening, liquefied stool seen throughout colon. New small ascites.2. Improved aeration with respect to multifocal airspace disease however with persistent findings noted, as above, likely reflecting patient's reported history o... |
Generate impression based on findings. | Female 23 years old; Reason: Evaluate for acute appendicitis. Comment on gallbladder History: RLQ pain ABDOMEN:LUNGS BASES: Evaluation of incompletely imaged lung fields suboptimal secondary to extensive respiratory motion artifact.LIVER, BILIARY TRACT: Pericholecystic fluid/thick walled gallbladder seen. No radiopaque... | 1. Findings suspicious for acute cholecystitis with marked gallbladder wall thickening seen. Correlation with patient's clinical history/physical exam recommended and please refer to subsequent abdominal sonography performed on January 11, 2015 for additional findings.2. Normal sized appendix.3. Similar to prior exam i... |
Generate impression based on findings. | Female 29 years old Reason: Evaluate for VP shunt-related fluid collection History: pain Survey views of the quadrants of the abdomen unremarkable. No significant ascites or discrete fluid collection delineated. Incidentally visualized portions of gallbladder unremarkable, no intraluminal mobile echogenic foci seen to ... | Unremarkable exam. No sonographic evidence of loculated fluid/discrete fluid collection to suggest CSFoma formation. |
Generate impression based on findings. | Per chart, T2N2b left tonsil SCCA, p16+, s/p CRT finished 8/17/12. Again seen are post-treatment findings in the neck without evidence of mass lesions or significant cervical lymphadenopathy. Unchanged asymmetry of the oropharynx. The thyroid and salivary glands are unchanged including small hypodense bilateral thyroid... | No evidence of locoregional tumor recurrence or significant lymphadenopathy. |
Generate impression based on findings. | Nausea, vomiting, assess for bowel obstruction Nonobstructive bowel gas pattern, small to moderate stool burden. Radiodensities in abdomen, more pronounced on right than on left, may reflect ingested material in the bowel (largest focus seen in right upper quadrant may be intrarenal stone but no stone was present on th... | Nonobstructive gas pattern. |
Generate impression based on findings. | Abdominal pain, location of enteric tube Enteric tube seen with side-port just beyond gastroesophageal junction and further advancing by approximately 8 cm suggested. Right upper quadrant surgical clips related to prior cholecystectomy. Additional retroperitoneal/pelvic surgical clips present. Mild small bowel dilatati... | Enteric tube as above. Partial small bowel obstruction suggested. |
Generate impression based on findings. | Abdominal distention, evaluate for ileus versus obstruction No significant change from prior study. Nonobstructive bowel gas pattern. Percutaneous gastrostomy overlying mid abdomen, in expected region of gastric body. Calcified fibroid uterus. Decreased osseous mineralization and degenerative changes of spine. Deformit... | Stable study as described, nonobstructive bowel gas pattern. |
Generate impression based on findings. | Female, 46 years old, counts were reportedly correct, history of kidney transplant. Right-sided nephroureteral stent. Right pelvic drain and additional catheter overlying lateral aspect of right hemiabdomen, tip kinked or bent, catheter may be overlying patient, correlate with patient's clinical history. No unexpected ... | No unexpected radiopaque foreign body. |
Generate impression based on findings. | Male, 48 years old. Renal transplant, evaluate for radiopaque foreign body Right-sided nephroureteral stent. Right pelvic drain. Multiple surgical clips overlying left femur/in left inguinal area. No unexpected radiopaque foreign body. Please refer to concomitant chest radiography from same day for additional findings.... | No unexpected radiopaque foreign body. |
Generate impression based on findings. | Nausea, vomiting, metastatic SCLC, evaluate for ileus, obstruction or large stool burden Residual contrast and moderate stool seen in right colon. No definitive evidence of bowel obstruction. Degenerative disease of spine. | Residual contrast and moderate stool seen in right colon. |
Generate impression based on findings. | Dobbhoff tube placement Dobbhoff tube with tip beyond gastroesophageal junction in region of gastric fundus. Incompletely imaged abdomen (lower abdomen and lateralmost left abdomen excluded) demonstrates nonobstructive bowel gas pattern. Amorphous radiodensity in region of or just above left iliac crest incompletely im... | Dobbhoff tube as above. |
Generate impression based on findings. | Evaluate ileus and rectal tube position Some redistribution of bowel gas in colon with no significant gross interval change. Rectal tube unchanged in position, coiled in region of descending/sigmoid colon. Enteric tube seen with side-port below level of hemidiaphragms. Dystrophic calcifications in pelvis, may reflect c... | Essentially unchanged as described, with persistent colonic ileus. |
Generate impression based on findings. | Reportedly no bowel movements, evaluate for obstruction Relative paucity of bowel gas, may be seen in setting of fluid containing bowel. No definitive evidence of bowel obstruction seen otherwise. Please refer to concomitant chest radiography from same day for additional findings. Mild hip, spine and symphysis pubis de... | Paucity of bowel gas, no definitive evidence of bowel obstruction. |
Generate impression based on findings. | Female 40 years old; Reason: right back pain, concern for possible kidney stone, also please evaluate stability of left adrenal nodule Evaluation of organs of abdomen and pelvis suboptimal without IV contrast, evaluation of bowel suboptimal without ingested contrast.ABDOMEN:LUNGS BASES: No significant abnormality noted... | Nonobstructing intrarenal nephrolithiasis as described.Left adrenal nodule stable in size. |
Generate impression based on findings. | Female 54 years old; Reason: abdominal pain/hx pancreatitis/hx gallstone CHEST:LUNGS AND PLEURA: Nonspecific micronodules seen bilaterally. For example, 3-mm left perifissural nodule, image 48 series 6. Nonspecific 5-mm pleural-based nodule in right upper lobe, image 29 series 6.MEDIASTINUM AND HILA: Incompletely image... | 1. Improvement in previously seen indistinctness in region of anterior pancreatic head/neck and improved adjacent fat stranding also visualized. 2. Decreased size of left adnexal cystic lesion, may be physiologic, may be further characterized with dedicated pelvic sonography.3. Indeterminant 8 mm soft tissue focus seen... |
Generate impression based on findings. | Female 49 years old; Crohn's disease ABDOMEN:LUNGS BASES: Small left base linear atelectasis or scarring.LIVER, BILIARY TRACT: Mild intrahepatic biliary duct prominence.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: ... | 1. Suboptimal evaluation due to paucity of intraabdominal fat and patient motion artifact. 2. Although somewhat underdistended, extensive moderate degree circumferential colonic wall thickening suggested from approximately level of splenic flexure distally, to region of rectum, suspicious for long segment of inflammato... |
Generate impression based on findings. | Female 66 years old; Reason: unexplained bilateral lower quadrant abdominal pain History: 2-3 weeks of persistent abdominal pain ABDOMEN:LUNGS BASES: Incompletely imaged micronodules, nonspecific but majority of which are calcified, may reflect sequela of prior granulomatous disease.LIVER, BILIARY TRACT: Hepatic steato... | 1. Mild subcutaneous fat induration seen in bilateral lower quadrants with possible mild overlying skin thickening, correlation with patient's clinical history and physical exam recommended to exclude cellulitis or sequela of prior intervention/trauma.2. Moderate to large stool burden. No bowel obstruction. |
Generate impression based on findings. | Female 51 years old; Reason: 50yo female with history of sigmoid colon resection for diverticulitis in 5/13 with recurrent LLQ and RLQ abdominal pain. History: abdominal pain ABDOMEN:LUNGS BASES: Triangular shaped 4-mm nodular focus along minor fissure, nonspecific but may be a lymph node.LIVER, BILIARY TRACT: Scattere... | 1. New from prior exam are supraumbilical and left periumbilical fat-containing hernias as described.2. Scattered colonic diverticulosis. No evidence of acute diverticulitis. |
Generate impression based on findings. | Reason: Evaluate for steno-occlusive disease as etiology of possible stroke History: R sided weakness, expressive aphasia 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 aor... | 1.No evidence for intracranial aneurysm.2.No evidence for cervicocerebral occlusive disease3.A small lesion in posterior limb of the left internal capsule may represent lacunar infarct of indeterminant age or a focus of demyelination from other cause. Please correlate with clinical symptoms. If clinically appropriate f... |
Generate impression based on findings. | 35-year-old female with history of mixed epithelial and stromal tumor status post right partial nephrectomy and history of multiple ectopic pregnancies who presents with right flank pain and diffuse abdominal pain. Evaluate for abscess or renal stone. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY T... | 1.Postoperative changes of partial right nephrectomy without evidence of obstruction or perinephric abscess.2.Mildly changed tubular configuration to the right adnexa which most likely relates to prior ectopic pregnancies --. However, if there is clinical concern for developing hydro-or pyosalpinx, further evaluation w... |
Generate impression based on findings. | Reason: CVA History: CVA The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a small hypodense focus present along the posterior limb of the left internal capsule which is rather subtle. It extends to the left centrum seminale.No abnormal mass lesions are appreciated intracranial... | 1.A small lesion in posterior limb of the left internal capsule may represent lacunar infarct of indeterminant age or a focus of demyelination from other cause. Please correlate with clinical symptoms. If clinically appropriate follow-up exam or MRI of the brain may help further evaluate this.2.No evidence for acute in... |
Generate impression based on findings. | Reason: headache History: headache 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.The visualized portions of the paranasal sinuses are... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.Right-sided orbital floor fracture. This appears chronic. Please correlate with clinical history and clinical exam findings. |
Generate impression based on findings. | The ventricles and sulci are within normal limits. There is no midline shift or mass effect. There is no intracranial hemorrhage. There are no areas of abnormal attenuation. There is no extraaxial fluid collection. Moderate mucosal thickening of the left sphenoid and posterior ethmoid sinuses. The remaining sinuses ar... | No acute intracranial abnormality. Please note that non-enhanced CT is not sensitive for the early detection of acute ischemic stroke and if there is strong clinical concern, an MRI may be considered. |
Generate impression based on findings. | 53-year-old female with pancreatic cyst and cyst gastrostomy in place. Patient with nausea and abdominal pain. Evaluate. ABDOMEN:LUNG BASES: New small left pleural effusion.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: Patient is status post splenectomy and distal pancreatectomy. Again seen are two peri... | 1.Interval placement of a cyst gastrostomy tube with interval decrease in size of the posterior fluid collection and stable anterior fluid collection as above.2.Unchanged wall thickening along greater curvature of the stomach, presumably inflammatory in etiology.3.Small new left pleural effusion. |
Generate impression based on findings. | Reason: r/o bleed History: s/p slip and fall, LOC. states hx of brain tumor 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.The visuali... | 1.No evidence for acute intracranial hemorrhage mass effect or edema. |
Generate impression based on findings. | Fall. No evidence of acute ischemic or hemorrhagic lesion on this scan.Calcified extra axial lesion on the left sylvian fissure likely represent calcified aneurysm, no change since prior exam.Expansile right frontal skull lesion also does not show any interval change since prior exam.Patchy scattered low attenuations o... | 1. No evidence of acute ischemic or hemorrhagic lesion.2. No interval change of left sylvian fissure calcified lesion likely represent calcified aneurysm, chronic ischemic lesion on the right basal ganglia and right frontal skull lesion since prior exam. |
Generate impression based on findings. | Reason: evaluate for cva, ich History: ams post surgical The CSF spaces are appropriate for the patient's stated age with no midline shift. Small subtle hypodense foci are present in the brain stem.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified ... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.Subtle hypodensities in the brainstem are present which could be vascular or related. |
Generate impression based on findings. | Reason: free air History: AMS, abd tenderness. Pelvis excluded from field of view.No evidence of free air given limitations of a single supine view. If there is strong clinical concern, upright or decubitus views may be obtained.Enteric tube tip projects over the gastric body.Non-obstructive bowel gas.Breast calcificat... | No evidence of gross free air. Enteric tube tip in distribution of gastric body. |
Generate impression based on findings. | Reason: follow up contusion/GSW History: s/p GSW There is right occipital depressed skull fracture associated with 4mm depression of the fracture fragment into the calvarium. There is adjacent punctate hyperdensity along the occipital lobe and a 3mm small extra-axial collection associated with some punctate extra-axial... | 1.Right occipital depressed skull fracture associated with adjacent contusion and thin extra-axial hematoma. Since the prior exam the adjacent edema has mildly increased. |
Generate impression based on findings. | History of left mastectomy in 2006 for Paget's disease and DCIS. History of benign right core needle biopsy. No new breast complaints. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchang... | Stable right breast calcifications. 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 M... |
Generate impression based on findings. | 64-year-old male with painless hematuria. Evaluate for bladder cancer. ABDOMEN:LUNG BASES: Mild bilateral basilar atelectasis.LIVER, BILIARY TRACT: No focal hepatic lesion. No intra-or extrahepatic biliary ductal dilatation. SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality noted.ADRENAL GLAN... | 1.Heterogeneously enhancing right renal mass as above highly suspicious for renal cell carcinoma.2.Nonspecific scattered normal sized retroperitoneal and enlarged, enhancing inguinal lymph nodes of uncertain significance. |
Generate impression based on findings. | 10 year old female, intubated.VIEW: Chest AP (one view) 1/12/2015, 05:33 The endotracheal tube tip is between the thoracic inlet and carina. The right internal jugular line tip is at the level of the cavoatrial junction.The cardiothymic silhouette is upper limits of normal in size, unchanged. The bibasilar opacities ar... | Unchanged bibasilar opacities most likely representing atelectasis. |
Generate impression based on findings. | Stable postoperative appearance of right parietal craniotomy with underlying encephalomalacia. There is mild ex vacuo dilatation of the right occipital horn. The ventricles are overall unchanged in size from the prior exam. No significant midline shift or evidence of mass effect. No acute intracranial hemorrhage or ex... | No significant change in right parietal craniotomy with underlying encephalomalacia. |
Generate impression based on findings. | 46-year-old male status post fall, rule out fracture Tibia and fibula: Proximal fibula fracture without significant displacement. There is adjacent soft tissue swelling.Ankle: No ankle fracture or significant soft tissue swelling is evident. | Nondisplaced proximal fibular fracture. |
Generate impression based on findings. | Reason: assess ventricular size History: enlarging ventricles on previous CT Head There are bilateral ventriculostomy tubes coursing through the frontal lobes into the lateral ventricles with tips near the region of the foramen of Monro. The left frontal ventriculostomy tube does not continue extracranially. Additional... | 1.Since the previous exam the lateral ventricles and third ventricle are stable.2.Hyperdense fluid within the lateral ventricles is suspected to represent a small amount of blood which has been previously present and unchanged.3.Status post multiple ventriculostomies.4.A small calcification is present in the left later... |
Generate impression based on findings. | 87 year-old female with abdominal pain. Evaluate for obstruction. ABDOMEN:LUNG BASES: Right lower lobe pulmonary nodule measures 1.4 x 1.0 cm (series 4, image 27), previously measuring 1.3 x 0.9 cm. Left basilar atelectasis/scarring is unchanged.LIVER, BILIARY TRACT: No focal hepatic lesions. Status post cholecystectom... | 1.No specific findings to suggest bowel obstruction.2.Stable right renal mass with mild interval decrease in associated retrocaval lymphadenopathy.3.Stable lytic lesion involving L1 vertebral body. |
Generate impression based on findings. | 2-year-old male, intubated. Evaluate support tubes and lines.VIEW: Chest AP (one view) 1/12/2015, 05:02 Endotracheal tube tip is below the thoracic inlet and above the carina. The feeding tube tip is in the gastric antrum. Right internal jugular line tip is in the superior vena cava. The left upper extremity PICC line ... | Slightly increased left lower lobe airspace opacity, unchanged bibasilar subsegmental atelectasis. |
Generate impression based on findings. | 37-year-old female with history of pain. No acute fracture or malalignment. The soft tissues are unremarkable. | No radiographic findings to account for the patient's pain. |
Generate impression based on findings. | Reason: Patient with multiple episodes emesis s/p total abdominal colectomy POD4, now s/p NGT placement. Please evaluate for possible bowel obstruction and check for proper NGT placement History: nausea and vomiting Time stamp 2:48 hrs.There is marked dilatation of jejunum up to 3.5-cm with air filled distended stomach... | Small bowel obstruction. Enteric tube with tip projecting in the esophagus. Dr. Martin Coronel p3163 was informed at the time of this dictation (1/12/2015 10:00AM). |
Generate impression based on findings. | 27-year-old female with history of pain. There is a small suprapatellar joint effusion. No acute fracture or malalignment. The soft tissues are unremarkable. | Small joint effusion without acute fracture. |
Generate impression based on findings. | 9-year-old male with ARDS.VIEW: Chest AP (one view) 1/12/2015, 05:16 Endotracheal tube tip below the thoracic inlet above the carina. Enteric feeding tube tip is in the antrum of the stomach. Left chest wall Port-A-Cath with tip in the superior vena cava.The cardiothymic silhouette is mildly enlarged. Improved right up... | Pulmonary edema pattern, perhaps slightly increased on the right, with associated unchanged bilateral pleural effusions. |
Generate impression based on findings. | 64 years Female with history of falls, rule out bleed. There is no evidence of intracranial hemorrhage. The ventricles and basal cisterns are normal in size and configuration. There is no mass effect or herniation. The imaged paranasal sinuses and mastoid air cells are clear. The skull and extracranial soft tissues are... | No evidence of intracranial hemorrhage or mass effect. |
Generate impression based on findings. | 97-year-old female with history of pain. The bones are diffusely demineralized suggesting osteoporosis/osteopenia. Left hand: There is a partially imaged chronic deformity of the distal ulnar diaphysis. Mild osteoarthritis affects the DIP, basilar, and triscaphe joints.Left forearm: No acute fracture or malalignment. T... | 1.Acute right both bones forearm fracture.2.Degenerative disease and other findings as above. |
Generate impression based on findings. | The scout lateral view and the sagittal reformatted images demonstrate normal alignment of the cervical spine, with a normal cervical lordosis. The vertebral body and disk space heights are well-maintained.There is no acute fracture.At C1-C2, there is a normal relationship of the dens with the arch of C1.The axial ima... | No evidence of fracture or malalignment. |
Generate impression based on findings. | Respiratory insufficiency.VIEW: Chest AP (one view) 1/11/15 Aortic arch, cardiac apex and stomach are left-sided. Cardiac silhouette is normal in size and shape. Right upper lobe opacity, either atelectasis or pneumonia. No effusions or pneumothorax. | Right upper lobe opacity as described. |
Generate impression based on findings. | 7-week-old former 27 week gestational age patient with chylothorax. Replacement of chest tube.VIEW: Chest AP (one view) 01/12/15, 0548 Endotracheal tube tip is above carina. A feeding tube has been placed and its tip is distal to the GE junction are not included on image. Left upper extremity PICC tip is in left brachi... | Decrease in bilateral pleural effusion. |
Generate impression based on findings. | Male 11 years old Reason: possible fracture History: FOOSHVIEWS: Right forearm AP and lateral 1/11/15 (two views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Reason: fracture dislocation History: see other imaging studies The cervical vertebral bodies are appropriate in overall alignment and height. No fractures are identified in the cervical spine. The osseous structures appear osteopenic. No cervical spine fracture or subluxation is appreciated.At C2-3 there is no signifi... | 1.There are multilevel degenerative changes present in the cervical spine with some narrowing of neural foramina at C5-6. |
Generate impression based on findings. | Reason: eval ileus History: ileus Redemonstration of diffusely distended colon. Stable appearing enteric tube with tip in the region of the gastric body. Right hip prosthesis, right femoral line and rectal tube are again noted. Dystrophic calcifications in pelvis, most reflect coarse calcifications in prostate as seen ... | Stable appearing gaseous distention of the colon. Enteric tube and rectal tube, unchanged. |
Generate impression based on findings. | 15-year-old male with gunshot wound to the right knee, going for washout with orthopedic surgery. As seen on the prior radiograph, an intact bullet is seen within the medial aspect of the proximal tibial metaphysis. There is cortical destruction of the central tibial plateau present just anterior to the tibial spines, ... | Bullet tract extending from the anterior central tibial plateau to the medial tibial metaphysis, where the bullet now resides. Entrance wound seen just lateral to the superior pole of the patella with associated lipohemarthrosis. |
Generate impression based on findings. | 21 year old female status post reduction, history of skiing accident and femur fracture Comminuted spiral fracture of the proximal femur with mild dorsal displacement of the mid fracture fragment appears similar to the prior exam. | Comminuted proximal femur fracture appearing similar to the prior exam. |
Generate impression based on findings. | The ventricles and sulci are within normal limits. There is no midline shift or mass effect. There is no intracranial hemorrhage. There are no areas of abnormal attenuation. There is no extraaxial fluid collection. The visualized portions of the paranasal sinuses and mastoids/middle ears are grossly clear. | No acute intracranial abnormality. Please note that CT is not sensitive for the early detection of acute ischemic stroke and if there is strong clinical concern, an MRI may be considered. |
Generate impression based on findings. | 21-year-old female status post traction pin placement A comminuted spiral fracture of the proximal femur is visualized with mild dorsal displacement of a mid fracture fragment. A traction device is noted on the crosstable lateral view. | Comminuted proximal femur fracture, as above. |
Generate impression based on findings. | 76-year-old female with abdominal pain. Evaluate for abdominal aortic aneurysm leak. CT ANGIOGRAM: Extensive atherosclerotic calcific disease affects the abdominal aorta with an infrarenal abdominal aortic fusiform aneurysm measuring approximately 4.4 x 4 .3 cm, not significantly changed compared to previous CT 10/4/20... | 1.Stable infrarenal abdominal aortic aneurysm without evidence of a leak. 2.Extensive atherosclerotic disease affects the abdominal aorta and its branches as above.3.No specific acute findings to account for patient's abdominal pain. |
Generate impression based on findings. | 72-year-old female with history of breast cancer Hip: There are destructive lesions involving the medial anterior acetabulum, inferior pubic rami and pubic symphysis, consistent with pathologic fractures. The femoral head and neck appear within normal limits.Pelvis: Again seen are destructive lesions and pathologic fra... | Pathologic pelvic fractures of the acetabulum, pubis and ischium as described above. |
Generate impression based on findings. | Fall, evaluate for acute intracranial abnormality Head: Again seen are postsurgical changes from a right frontoparietal craniotomy with underlying encephalomalacia of the frontal parietal lobes and not significantly changed from previous exam. There is associated ex vacuo dilatation of the right lateral ventricle. Ther... | 1. No evidence of acute intracranial hemorrhage or new mass effect. Left parietal subgaleal hematoma without underlying calvarial fracture.2. No acute fracture or subluxation in the cervical spine.3. Extra-axial hyperdense masses along the bilateral convexities and posterior surface of the left petrous temporal bone ar... |
Generate impression based on findings. | Crackles on left lung.VIEWS: Chest AP/lateral (two views) 1/11/15 Aortic arch, cardiac apex and stomach are left-sided. Cardiac silhouette is normal in size and shape. Peribronchial thickening and ill-defined left lingular opacity likely atelectasis. . No effusions or pneumothorax. | Peribronchial thickening and left lingular opacity, likely atelectasis. |
Generate impression based on findings. | No abnormal DWI signal to suggest acute infarct. A few scattered periventricular T2 hyperintensities without corresponding DWI abnormality likely represent mild chronic small vessel ischemic disease. Increased T2 signal within the paramedian pons is also likely vascular related. Enlarged ventricles and prominent sulci... | Mild atrophy and chronic small vessel ischemic disease. Please note that nonenhanced CT is not sensitive for the early detection of acute ischemic stroke and if there is strong clinical concern, an MRI may be obtained. |
Generate impression based on findings. | Reason: retroperitoneal bleed, pneumothorax, rib fracture History: 99yoM fall onto left side earlier today. now complaining of pain with deep inspiration. palpable crepitus on exam over lateral surface of rib 7,8,9. Hypotensive 70s-80s SBP, pall CHEST:LUNGS AND PLEURA: Left lower lobe airspace opacities consistent with... | 1.High grade splenic laceration with associated perisplenic hematoma.2.Mildly displaced left eighth through eleventh rib fractures.3.Left lower lobe aspiration/possible pneumonia.4.1.7-cm right apical lung mass suspicious for neoplasm. Continued follow-up recommended.5.Other findings as described above. |
Generate impression based on findings. | Reason: bleed, fracture History: 99yoM fall onto left side earlier today. now complaining of pain with deep inspiration. palpable crepitus on exam over lateral surface of rib 7,8,9 The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially.... | 1.No evidence for acute intracranial hemorrhage. mass effect or edema.2.CT is insensitive for early detection of nonhemorrhagic CVA. |
Generate impression based on findings. | Abdominal pain. Rule-out appendicitis. ABDOMEN:LUNG BASES: No focal opacity. No pleural effusion.LIVER, BILIARY TRACT: Normal in appearance. Normal opacification of the portal vein.SPLEEN: Normal in appearance.PANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Sy... | Right lower quadrant phlegmon with small bowel obstruction and thickening and cecum/proximal ascending colon. Differential considerations include perforated appendicitis, infectious/inflammatory ileitis and colitis. |
Generate impression based on findings. | 85-year-old female with tenderness to palpation and bilateral pain Right foot: There is marked soft tissue swelling about the foot and ankle as well as the distal Achilles tendon. Heterotopic ossification is noted dorsal to the calcaneus near the Achilles tendon insertion. Vascular calcifications are noted in the soft ... | Marked soft tissue swelling about the foot and distal Achilles tendon as well as degenerative arthritic changes as described above. |
Generate impression based on findings. | 34-year-old female with history of left hip bleed, leukocytosis, assess for abscess or Large soft tissue mass surrounding the hip extending proximally along the ileum with heterogeneously increased signal consistent with subacute blood product. The mass extends extends beneath the gluteal musculature and measures appro... | Large complex collection surrounding the left hip extending beneath the gluteal muscles consistent with a subacute hematoma and/or abscess. |
Generate impression based on findings. | Male 2 days old Reason: Is there evidence of atelaectasis History: Increased WOBVIEW: Chest AP (one view) 1/12/15 at 757 hours ET tube tip is at the thoracic inlet. Umbilical lines unchanged. Right-sided multiple chest tubes (3) are again noted. Cardiac silhouette is non sizable due to an almost complete atelectasis of... | No change in almost complete atelectasis of the left lung, mediastinal shift and residual right-sided pneumothorax. |
Generate impression based on findings. | 39-year-old with history of right mastectomy for IDC. Patient presents for left unilateral follow-up. Three standard views of the left breast were performed digitally 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 ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended annually (although the patient is considering prophylactic mastectomy). Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION... |
Generate impression based on findings. | History of pneumothorax. Worsening ABGsVIEW: Chest AP (one view) 1/11/15 at 2139 hrs ET tube tip is above the carina. UVC terminates at the right atrium. UAC tip is at T6. Three right-sided chest tubes are again noted. Cardiac silhouette is non-sizable due to a left-sided mediastinal shift, almost complete atelectasis ... | Persistent almost complete atelectasis of the left flank and small, residual right-sided pneumothorax. |
Generate impression based on findings. | 7-month-old male in respiratory distress with acute hemoglobin drop and hypotensive. Evaluate for infiltrate or effusion.VIEW: Chest AP (one view) 1/12/2015, 05:09 Endotracheal tube tip below the thoracic inlet and above the carina. Feeding tube tip in the gastric antrum.Right upper, right lower and left lower lobe seg... | Multifocal atelectasis without significant interval change. |
Generate impression based on findings. | Male, 40 years old, with gait disturbance, visual disturbance, left-sided Babinski. Assess for mass. At least 3 parenchymal masses are identified, two in the right frontal lobe and one within the left frontal lobe. They range in size from approximately 1.8 cm in diameter (on the right) to 4.8 cm in diameter (on the lef... | At least 3 parenchymal masses are identified, two in the right frontal lobe and one in the left frontal lobe, compatible with metastases. Further evaluation with contrast-enhanced MRI is recommended. |
Generate impression based on findings. | 76 years Female with Reason: fall, AMS, eval for bleed. No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. There i moderate global parenchymal volume loss commensurate with age. There is prominence of the superior cerebellar cistern. No hydro... | No evidence of intracranial hemorrhage or mass effect. Please note CT is insensitive for the detection of acute non-hemorrhagic infarcts, and MRI should be considered if there is continued clinical suspicion. |
Generate impression based on findings. | Right hemispheric hypoattenuating extra-axial collection is decreased in size measuring 9 mm in thickness (80273/55), previously 15 mm. Dependent hyperdense blood seen on the prior exam is decreased. No evidence of acute interval hemorrhage. No midline shift. Mild mass effect on the adjacent right hemisphere is slight... | 1.Right hemispheric chronic subdural hematoma is decreased in size without evidence of acute hemorrhage.2.Periventricular and subcortical white matter changes are nonspecific. At this age they are most likely vascular related. |
Generate impression based on findings. | Male 20 months old Reason: 20 mo with neuroblastoma, new increased work of breathing, History: retractionsVIEWS: Chest AP/lateral (two views) 1/11/15 at1556 hours. Right IJ venous access terminates at the right atrium. Cardiac silhouette size is normal. Bibasilar atelectasis and right side of her effusion again noted. ... | Persistent right-sided pleural effusion and bibasilar opacities. Right diaphragmatic elevation noted. |
Generate impression based on findings. | 57-year-old male history of metal in eye as welder No radiopaque foreign bodies identified within the orbits. Dental fillings are noted. The osseous structures appear within normal limits. | No radiopaque foreign body. |
Generate impression based on findings. | 47-day-old male with persistent right respiratory support requirements.VIEW: Chest AP (one view) 1/12/2015, 05:57 Enteric feeding tube tip terminates in the fundus of the stomach, with the side port below the GE junction. The cardiothymic silhouette is the upper limits of normal in size. Persistent diffuse hazy pulmona... | Persistent diffuse hazy pulmonary opacities, slightly improved on the right. |
Generate impression based on findings. | Reason: assess intraabdominal processes History: Hep C cirrhosis (on Harvoni) ABDOMEN:LUNG BASES: Small right pleural effusion and bibasilar pulmonary masses. Please see separately dictated chest CT for further description.LIVER, BILIARY TRACT: Cirrhotic liver morphology without discrete focal lesion. Esophageal/spleni... | 1.Right pleural effusion and bibasilar pulmonary masses. Please see separately dictated chest CT for further description of thoracic findings.2.No evidence of metastatic disease in the abdomen/pelvis.3.Cirrhotic liver morphology and findings consistent with portal hypertension. |
Generate impression based on findings. | Female; 66 years old. Reason: patient with chest tightness, SOB, diaphoresis History: chest tightness, SOB, diaphoresis PULMONARY ARTERIES: Technically adequate study. Redemonstration of multiple bilateral partially occlusive pulmonary emboli in the left upper and right middle lobes. Overall, the clot burden is slightl... | 1. Multiple pulmonary emboli with overall clot burden slightly decreased since prior study. No new pulmonary emboli.2. Mild diffuse groundglass opacity and septal thickening, suggestive of mild pulmonary edema.3. Large bilateral pleural effusions with underlying compressive atelectasis/consolidation, slightly improved.... |
Generate impression based on findings. | Reason: r/o malignancy History: weight loss, cough, abnormal ct june 2014 LUNGS AND PLEURA: Airspace opacity in the posterior aspect of the right upper lobe has significantly improved. There are residual small interstitial and groundglass opacities. Patchy right basilar opacities have also improved with scattered areas... | 1. Previously referenced nodular opacity in the left lower lobe measures 6 mm, not significantly changed. Though this is likely an area of scarring, nodules are typically followed to 2 years with CT to confirm stability and exclude the small chance of malignancy.2. Significant interval improvement in right sided opacit... |
Generate impression based on findings. | 21-month-old female with respiratory failure and worsening hypoxemia.VIEW: Chest AP (one view) 1/12/2015, 07:00 Endotracheal tube tip is below the thoracic inlet and above the carina. Left upper extremity PICC line is at the level of the cavoatrial junction. Right-sided central line tip is in the distal superior vena c... | Increased lung volumes with persistent multifocal airspace opacities and small bilateral pleural effusions. |
Generate impression based on findings. | 24 year-old female status post MVC. Evaluate for fracture. There is a nondisplaced fracture of the radial styloid. Alignment is anatomic. Mild soft tissue swelling about the wrist. | Radial styloid fracture as above. |
Generate impression based on findings. | Colectomy and bowel obstruction.VIEWS: Abdomen AP/left lateral decubitus (two views) 01/11/15, 1850, 1851, 1909 Feeding tube tip is at GE junction.Multiple air-fluid levels are again seen. Dilated bowel loops are present. There is no free peritoneal air. A right lower quadrant stoma is present. | Continued bowel obstruction. |
Generate impression based on findings. | 37 years Female with localized swelling on back of head on the right side, concern for lytic lesion History: localized head swelling The skull and extracranial soft tissues appear unremarkable. There is no intracranial mass effect or herniation. There is no evidence of intracranial hemorrhage. The ventricles and basal ... | No intracranial abnormality. No suspicious lesions are seen in the calvarium or scalp. |
Generate impression based on findings. | No abnormal DWI signal to suggest acute infarct. 6-mm left temporal lobe lesion (1302/165) is unchanged in size. Punctate foci of enhancement in the left pons is also unchanged. Enhancing lesions in the frontal lobe along the left cingulate gyrus and anteriorly along the right falx are increased in size from the prior... | 1.Mixed appearance of progression and stability of brain metastases as described in detail above.2.Increased white matter T2 signal which may be treatment related. |
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