instruction stringclasses 1
value | input stringlengths 6 8.98k | output stringlengths 5 3.11k |
|---|---|---|
Generate impression based on findings. | Motor vehicle collision. Evaluate for bleed. There is no evidence of intracranial hemorrhage or mass effect. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The imaged paranasal sinuses and mastoid air cells are clear. The skull and extracranial soft tiss... | No evidence of intracranial hemorrhage or mass effect. No calvarial fracture.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Altered mental status. Evaluate for bleed. There is no evidence of acute intracranial hemorrhage or mass effect. The ventricles and sulci are mildly prominent, consistent with mild age-related volume loss. There are scattered punctate and confluent areas of abnormal low attenuation in the periventricular and subcortica... | 1. No evidence of acute intracranial hemorrhage or mass effect.2. Age-indeterminate small vessel ischemic changes. However, non-contrast CT is insensitive for the detection of non-hemorrhagic acute infarct.3. Nonspecific 8mm lytic lesion in the left parietal bone with mild soft tissue/scalp component. Nonspecific super... |
Generate impression based on findings. | Headache and blurred vision. Evaluate for bleed. There is no evidence of acute intracranial hemorrhage or mass effect. There is prominence of the ventricles, slightly out of proportion to the prominent sulci. There are scattered punctate and confluent areas of abnormal low attenuation in the periventricular and subcort... | 1. No evidence of acute intracranial hemorrhage or mass effect.2. Ventriculomegaly, which is largely related to parenchymal volume loss; however, a component of communicating hydrocephalus/NPH is not excluded and can be correlated with clinical findings.3. Nonspecific scattered hypoattenuating areas of the periventricu... |
Generate impression based on findings. | Anti-coagulated with altered mental status, right-sided weakness and aphasia. Evaluate for new left frontal hemorrhage. There is interval development of an intraparenchymal hemorrhage centered predominantly in the left posterior frontal lobe with a smaller component in the anterior parietal region, measuring up to 60 m... | Interval development of acute large intraparenchymal hematoma in the left posterior frontal and anterior parietal lobes, measuring up to 60 mm, with intraventricular extension. Hematocrit effect noted within the hematoma which can be seen with coagulopathy and active bleeding. There is adjacent subarachnoid hemorrhage ... |
Generate impression based on findings. | 59-year-old female with COPD, respiratory failure, concern for pulmonary embolism PULMONARY ARTERIES: Suboptimal study due to respiratory motion. Within these limitations, there is no evidence of pulmonary embolism.The main pulmonary artery caliber is within normal limits.LUNGS AND PLEURA: Evaluation is limited due to ... | 1.No evidence of pulmonary embolism.2.Irregularly shaped right middle lobe nodule. Given the presence of atelectasis at this site on prior CT, postinflammatory etiology is favored although a follow-up in 3-6 months is recommended to confirm stability or resolution. 3.Severe apical predominant centrilobular emphysema wi... |
Generate impression based on findings. | Reason: Evaluate DHT placement History: as above Dobbhoff tube tip projects over the gastric body. Bilateral nephrograms, likely from recent CT. Left pleural effusion. | Dobbhoff tube placement as above. |
Generate impression based on findings. | Female, 26 years old. Cesarean section. No unexpected radiopaque foreign body. | No unexpected radiopaque foreign body. Findings discussed with Dr. Boyle at 2100 on 3/27/2015. |
Generate impression based on findings. | Reason: s/p NGT placement History: s/p NGT placement NG tube tip projects over the gastric antrum. Two likely drainage catheters are seen projecting over the right abdomen. Surgical clips and staples are noted. Residual contrast in the colon limits evaluation. Lucencies in the right midabdomen, likely related to pocket... | Line and tube placement as above. |
Generate impression based on findings. | Reason: NG History: NG NG tube tip projects over the gastric fundus. Mild gaseous distention of loops of small and large bowel in a nonobstructive pattern. Foley catheter tip projects over the expected location of the urinary bladder. | Line and tube placement as above. |
Generate impression based on findings. | Head trauma (pushed in wall corner), no loss of consciousness, 2 lacerations. Evaluate for fracture. CT head: There is no evidence of intracranial hemorrhage or mass effect. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. There is mild mucosal thickening ... | 1. No evidence of intracranial hemorrhage or mass effect. Right occipital and left frontal scalp lacerations without underlying calvarial fracture. 2. Minimal retrolisthesis of C5 on C6, likely degenerative in nature. No acute fracture of the cervical spine.3. Mild degenerative changes without significant spinal canal ... |
Generate impression based on findings. | Reason: OG tube placement History: None OG tube tip projects over the gastric fundus. Study limited by motion. | Limited study by motion. OG tube tip projects over the gastric fundus. |
Generate impression based on findings. | Opsoclonus - myoclonus. Evaluate for neuroblastoma. CHEST:LUNGS AND PLEURA: Dependent atelectasis is present bilaterally right greater than left.MEDIASTINUM AND HILA: Heart size is normal. Branching pattern of the great vessels is normal. The thymus is normal in appearance.CHEST WALL: No paraspinal mass is identified.A... | Normal examination. No neuroblastoma identified. |
Generate impression based on findings. | Syncope, head trauma. Evaluate for subdural hemorrhage. There is no evidence of acute intracranial hemorrhage or mass effect. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The imaged paranasal sinuses and mastoid air cells are clear. The skull and extra... | No evidence of acute 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. | Reason: colitis? History: fever, likely c diff Cardiomegaly. Sternotomy wires. Epicardial pacemaker leads unchanged. Patchy pulmonary opacities. Partially visualized central line tip projects over the cavoatrial junction. Please see chest radiograph report from 3/28/2015. Feeding tube tip projects over the gastric antr... | Line and tube placement as above. Nonobstructive gas pattern. Please see chest radiograph report from 3/28/2015 for thoracic findings. |
Generate impression based on findings. | 33-year-old male patient with abdominal pain. Evaluate for intra-abdominal infection. Limited exam due to patient body habitus. Note that the scan was delayed due to patient motion during intravenous contrast administration. Additionally, the delayed phase images are limited by patient motion. Given these significant l... | Significantly limited examination without acute intra-abdominal abnormalities to account for patient's symptoms. |
Generate impression based on findings. | Reason: NG History: NG Nasogastric tube tip projects over the stomach. Nonobstructive gas pattern. Unchanged basilar atelectasis/consolidation. | Line and tube placement as above. |
Generate impression based on findings. | Reason: r/o obstruction vs ileus History: post op day 8 from lap sbr Oral contrast seen within loops of bowel. Nasogastric tube tip projects over the stomach. Overall, significant improvement in gaseous distention and dilatation of previously seen small and large bowel loops, with most gas seen within the colon. No pne... | Interval improvement of bowel dilatation as described above. |
Generate impression based on findings. | Reason: h/o partial SBO, evaluate for movement of PO contrast History: h/o partial SBO, evaluate for movement of PO contrast Oral contrast seen within the small bowel, and colon limits evaluation. Overall, no significant change in prominent/mildly dilated loops of central small bowel compared to the scout image from re... | Findings unchanged from recent CT, and still suspicious for at least partial small bowel obstruction. |
Generate impression based on findings. | 56 year old male patient with a left flank pain and vomiting. Exam is not sensitive for detecting lesions in the bowel and solid organs due to the lack of oral and intravenous contrast. Given those limitations, the following observations are made:ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT... | Two obstructive renal calculi in the distal left ureter, largest of which measures 4 mm. No significant hydronephrosis. |
Generate impression based on findings. | 37 week gestational age patient with line placement.VIEWS: Chest and abdomen AP (two views) 03/27/15, 2009 A fracture of the right clavicle is identified at the junction of the medial and lateral thirds.Umbilical venous line tip is in left atrium. Umbilical arterial line has its tip at T2.Cardiothymic silhouette is nor... | Right clavicle fracture. No focal lung opacity. Disorganized bowel gas pattern. |
Generate impression based on findings. | Male, 3 months old. Left humeral fracture. Evaluate for other injuryEXAMINATION: Skull AP/lateral, cervical spine AP/lateral, thoracolumbar spine AP/lateral, right humerus AP, right forearm AP, right hand PA, left hand PA, chest AP, ribs right oblique/left oblique, pelvis AP, right femur AP, left femur AP, right tibia ... | Aside from the previously described left humeral fracture, no other fracture is identified. |
Generate impression based on findings. | Reason: 24F s/p MVA with seatbelt sign, ?vascular injury History: 24F s/p MVA with seatbelt sign, ?vascular injury CHEST:LUNGS AND PLEURA: No pneumothorax, pleural effusion, or consolidation.MEDIASTINUM AND HILA: No aortic dissection or evidence of injury.CORONARY ARTERY CALCIFICATION: None.CHEST WALL: No rib fractures... | No evidence of traumatic injury to the aorta. |
Generate impression based on findings. | No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift, or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hydrocephalus.There is partial opacification of the left maxill... | 1. No intracranial hemorrhage or venous sinus thrombosis.2. Paranasal sinus opacification as above. |
Generate impression based on findings. | 60 year-old female patient with history of pancreatic cancer status post ex lap with liver wedge resection presents with abdominal pain. Evaluate for liver abscess or other cause of right upper quadrant pain. ABDOMEN:LUNG BASES: Pectus excavatum deformity noted.LIVER, BILIARY TRACT: Along the superior aspect of the rem... | 1.New intra-and extrahepatic biliary ductal dilatation. Fluid collection noted along the superior margin of the left lobe of the liver. Cannot exclude early abscess formation.2.No significant interval change in large pancreatic head primary tumor. Direct invasion into the SMV and bowel cannot be excluded. |
Generate impression based on findings. | Male 61 years old; Reason: evaluate bladder mass History: hematuria; bladder mass noted on ultrasound ABDOMEN:LUNG BASES: Calcified granuloma right lower lobe..LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: Mild ... | 1.Large predominantly intravesicular bladder mass, likely neoplasm, with difficulty in separating the prostate gland, and right seminal vesicle, further described above. Couple prominent pelvic lymph nodes are not enlarged by size criteria, further described above.2.Indeterminant 1.9cm left adrenal enhancing lesion. |
Generate impression based on findings. | There is straightening of the cervical spine. The vertebral bodies, dens, lateral masses, pedicles, lamina, facets, and posterior elements are intact with no evidence of fracture or subluxation. Mild degenerative disk disease affects the lower cervical spine including prominent facet arthropathy at the C7-T1 level. Wi... | 1. No evidence of acute cervical spine fracture or subluxation.2. 15x12 mm linear soft tissue nodule involving the left upper posterior neck skin and subcutaneous tissues at the C1-2 level. Correlate with direct visualization. |
Generate impression based on findings. | 44-year-old male with headache, rule out bleed No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are prominent for age without evidence of hydrocephalus. No extra-axial collectio... | 1. 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 clinical suspicion.2. Hypoattenuation in the periventricular and subcortical white matter is nonspecific but favored to represent chronic ... |
Generate impression based on findings. | There is a new hematoma centered in the right cerebellum with subdural and subarachnoid extension and mild associated vasogenic edema. Hematoma measures up to 17x42 mm in the axial dimension and up to 27 mm in the craniocaudal dimension. There is associated mass effect on the fourth ventricle and minimal prominence of... | 1. New posterior fossa intraparenchymal hematoma involving the cerebellum with small subdural and subarachnoid components and minimal mass effect on the fourth ventricle. No clear hydrocephalus.2. Scattered areas of hypoattenuation in the periventricular and subcortical white matter which are nonspecific but favored to... |
Generate impression based on findings. | Female, 7 months old. Follow-up pneumothoraxVIEW: Chest AP (one view) 3/27/15, 1954 ET tube tip below thoracic inlet and above carina. Enteric tube with tip at the level of the GE junction. Lower extremity PICC, tip in the IVC.Cardiac silhouette size is normal.Moderate left pneumothorax, stable from the prior exam, wit... | Increasing pneumomediastinum and subcutaneous emphysema, with a stable moderate left pneumothorax. |
Generate impression based on findings. | 27-year-old male patient with left lower quadrant pain and history of Crohn's disease. ABDOMEN:LUNG BASES: Basilar atelectasis.LIVER, BILIARY TRACT: Foci of air within the biliary tree noted.SPLEEN: Multiple hypoattenuating splenic lesions appear similar compared to prior MRCP. Larger lesion is incompletely characteriz... | 1.Findings compatible with acute inflammatory changes in the terminal ileum and colon.2.Air within the biliary tree and gallbladder may be iatrogenic from prior ERCP and dilation. However, given the length of time from the procedure, cholangitis cannot be excluded.3.Incompletely characterized and indeterminate splenic ... |
Generate impression based on findings. | Female, 7 months old. Reason: 7 mo F submersion injury, intubated. Eval ETT tube and lung fields. History: submersionVIEW: Chest AP (one view) 3/28/15, 0327 ET tube tip below the thoracic inlet and above the carina. Enteric tube with tip at the level of the GE junction. Lower extremity PICC, tip in the IVC.The cardiac ... | Increasing left pneumothorax, with persistent pneumomediastinum and subcutaneous emphysema. |
Generate impression based on findings. | Female, 7 months old. Pigtail catheter placement. Evaluate pneumothorax.VIEW: Chest AP (one view) 3/28/15, 0904 Interval placement of left pigtail chest tube, terminating inferior to the left hilum. ET tube tip below the thoracic inlet and above the carina. Enteric tube with tip at the level of the GE junction. Lower e... | Left chest tube placement, with significant decrease in size of the left pneumothorax. Persistent large pneumomediastinum and subcutaneous emphysema. |
Generate impression based on findings. | Reason: Ct scan per living kidney donor protocol History: kidney donor LOWER THORAX: No significant abnormality.ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URE... | Renal measurements and arterial anatomy as above. Subcentimeter left renal hypodensities are too small to characterize, likely cysts. No other abdominal or pelvic pathology, given limitations in evaluation as described above. |
Generate impression based on findings. | Female, 1 day old. Evaluate UVC UAC palcementVIEWS: Chest and abdomen AP (two views) 3/27/2015 The cardiac apex and stomach a right-sided. The liver is left-sided.The umbilical artery catheter is adjacent to the right pedicle of T9.The umbilical venous catheter is at the junction of the IVC and the left-sided right atr... | Situs inversus and lumbosacral spinal abnormalities as detailed above. |
Generate impression based on findings. | 56 year old female patient with altered mental status and brain lesion. Evaluate for primary neoplasm. CHEST:LUNGS AND PLEURA: Nonspecific debris/septation in the trachea. Biapical scarring and azygous lobe noted. Moderate to severe centrilobular emphysema. No suspicious pulmonary lesions. Left basilar scarring.MEDIAST... | 1.No radiographic evidence of intrathoracic or intra-abdominal malignancy.2.Moderate to severe emphysema.3.Nonspecific tracheal debris/septation noted. |
Generate impression based on findings. | Female 45 years old Reason: evaluate hepatic artery, celiac artery, portal system and TIPS History: evaluate hepatic artery, celiac artery, portal system and TIPS LIVER DOPPLER:TIPS: Patent.PORTAL VEINS: Patent.HEPATIC ARTERIES: Difficult to visualize, but arterial waveform seen within the right and left hepatic arteri... | 1.Difficult to visualize hepatic arteries. CTA with venous phase can be performed if there is a rise in LFTs to assess the hepatic arteries. |
Generate impression based on findings. | 28-year-old female patient with metastatic cervical cancer. Evaluate for progression of disease. Per clinic notes: Patient has history of bilateral ovarian resection and lymph node dissection. ABDOMEN:LUNG BASES: Scattered subcentimeter solid pulmonary micronodules are nonspecific. Reference left lower lobe nodule meas... | Interval right hydronephrosis from obstructing right pelvic lesion. Metastatic disease in the pelvis, as described above.Findings communicated to Dr. Luke via EPIC message on 3/28/2015 at 11:52 AM. |
Generate impression based on findings. | Reason: evaluate for ischemic lesion/changes History: abdominal pain and abnormal CT ABDOMEN:LIVER, BILIARY TRACT: Geographic area of hypoattenuation is likely perfusional, related to the abnormalities described below.SPLEEN: Stable cystic lesion.PANCREAS: Unchanged 1.3 similar hypodense focus in the uncinate process, ... | Unchanged appearance of the vasculature related to vasculitis and likely associated infarct, as described above. |
Generate impression based on findings. | 53-year-old male with supraglottic cancer status post chemoradiation CHEST:LUNGS AND PLEURA: Persistent subtle basilar groundglass opacities suggestive of chronic aspiration. No new suspicious nodules. No focal consolidation. No pleural effusion or pneumothorax. The central airways are patent.MEDIASTINUM AND HILA: Thym... | No evidence of metastatic disease. No significant interval change since prior exam. |
Generate impression based on findings. | Pain after fall.EXAMINATION: Left forearm AP/lateral (two views) 03/27/15 The bones are normal in appearance no fracture is present. | Normal examination. |
Generate impression based on findings. | Pain after fall.EXAMINATION: Left wrist PA/lateral/oblique (3 views) 03/27/15 No joint effusion is present. The soft tissues are normal. A fracture is not seen. | Normal examination. |
Generate impression based on findings. | Back pain.VIEWS: Thoracic spine AP/lateral/swimmers (3 views) 03/28/15 Vertebral body heights and disk spaces are maintained. No fracture is identified. No paraspinal mass is seen. | Normal examination. |
Generate impression based on findings. | Back pain.VIEWS: Lumbar spine AP/lateral/lumbosacral junction lateral (3 views) 03/28/15 Vertebral body heights and disk spaces are maintained. No spondylolysis is seen. No fracture is identified. | Normal examination. |
Generate impression based on findings. | Headache status post craniotomy for right frontal AVM. There are postoperative findings related to right sided craniotomy for resection of a right frontal lobe arteriovenous malformation and hematoma evacuation. There is interval increase in size of a right parietal subgaleal collection. There is interval decrease in p... | 1. Postoperative findings related to resection of a right frontal lobe arteriovenous malformation and hematoma evacuation with minimal subjacent blood products, edema, and local mass effect. No midline shift or herniation. 2. Mild increase in right parietal subgaleal collection.I personally reviewed the Images and/or p... |
Generate impression based on findings. | Male, 16 years old. Fever, cough. Neutropenic patient.VIEWS: Chest AP/lateral (two views) /28/15, 1119 Median sternotomy wires, and cervical spine plates and screws, unchanged. Mediastinal clips, unchanged. Lower extremity PICC tip at the junction of the IVC and right atrium. Right atrial line has been removed.The card... | Bronchiolitis pattern, unchanged. |
Generate impression based on findings. | Recurrent squamous cell carcinoma in the right infratemporal fossa, tumor progressing on chemo/RT based on radiation resimulation. There are postoperative findings related to partial right mandibulectomy with graft reconstruction. Although incompletely imaged, there has been interval increase in size of the ill-defined... | 1. Although partially-imaged, the recurrent tumor centered in the right infratemporal fossa with associated perineural spread appears to have increased in size. 2. New fluid collection in the right masseter muscle and retromolar trigone region with associated demineralization of the right mandible and formation of peri... |
Generate impression based on findings. | ICH. Per chart, past medical history of seizures controlled on Tegretol presented to outside hospital on 3/23/15 with a posterior headache, slurred speech and decreasing responsiveness. He was then taken to the OSH where CT brain revealed "a large hemorrhage in the pons extending into the brain and extending and effaci... | 1. No significant interval change in intraparenchymal hemorrhage centered in the pons as well as in the third ventricle, allowing for differences in technique. New trace layering blood products in the right occipital horn compatible with redistribution. No significant interval change in minimal subarachnoid blood produ... |
Generate impression based on findings. | 59-year-old male with history of prior stroke and balance problem There is no evidence of acute intracranial hemorrhage. There is mild periventricular and subcortical white matter hypoattenuation. The gray-white differentiation otherwise appears to be preserved. The basal cisterns are patent. No midline shift or mass e... | 1. No evidence of acute intracranial hemorrhage.2. Mild age indeterminate small vessel ischemic disease. Please note that CT is insensitive for the detection of acute nonhemorrhagic infarction. An MRI may be obtained if clinically warranted and there is no contraindication.3. Deficiency of the left mandibular condyle a... |
Generate impression based on findings. | Status post AVM resection. Altered mental status. There are evolving postsurgical changes related to resection of previously seen arteriovenous malformation involving the inferior parietal lobule near the left parieto-temporo-occipital junction. There is a small resection cavity with surgical clips, air and blood produ... | Evolving postsurgical changes of left parietal craniotomy for resection of previously seen AVM. Slight evolution of 1.6 x 1.0 cm hematoma in the left posterior temporal gyrus adjacent to the surgical clips. No significant mass-effect is appreciated. I personally reviewed the Images and/or procedure with the Resident/Fe... |
Generate impression based on findings. | Altered mental status. Dementia, concern for intracranial abnormalities No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are within normal limits for age without evidence of hyd... | 1. 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 clinical suspicion.2. Chronic small vessel ischemic changes. |
Generate impression based on findings. | 74-year-old male with end-stage renal disease, history of stroke and worsening dementia Motion degraded exam. No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are within normal ... | 1. 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.2. Moderate chronic small vessel ischemic disease similar to prior. |
Generate impression based on findings. | Dance injury. Medial condyle tenderness.VIEWS: Left knee AP/lateral/oblique (3 views) 03/28/15 A joint effusion is not present. The bones are normal in appearance. Fracture is not identified. | Normal examination. |
Generate impression based on findings. | Rule out interval increase in bleed in patient with subarachnoid hemorrhage altered mental status, worsened. History of neuroblastoma status post SCT, thrombocytopenia Compared to CT dated 3/22/2015, there has been evolution of previously seen intra-parenchymal hematoma in the right frontal lobe with residual surroundi... | 1. Compared to 3/22/2015, there is no evidence of new hemorrhage or worsening mass-effect. 2. There is been interval evolution of the large right frontal intraparenchymal hematoma, small bilateral parieto-occipital subarachnoid hemorrhage, and intraventricular hemorrhage. 3. There is interval decrease in size of the ve... |
Generate impression based on findings. | Newly diagnosed cervical esophageal cancer. There is mid-esophageal wall thickening. The trachea appears to be grossly intact. There is no evidence of significant cervical lymphadenopathy based on size criteria. However, there is a prominent pretracheal lymph node at the thoracic inlet that measures 9 mm in short axis.... | Mid-esophageal wall thickening is compatible with the known cancer, which is otherwise better depicted on endoscopy. No evidence of gross trachea invasion or significant cervical lymphadenopathy. However, a prominent pretracheal lymph node at the thoracic inlet may be involved by metastatic disease. PET is useful for f... |
Generate impression based on findings. | Head: No intracranial hemorrhage or skull fracture is identified. No intracranial mass or evidence of mass-effect. No midline shift, or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hydrocephalus. Right phthisis bulbi.Rig... | 1. No acute intracranial hemorrhage, mass effect or skull fracture.2. No cervical spine fracture or malalignment. |
Generate impression based on findings. | 37-year-old female with headaches, question of pseudotumor cerebri. No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift, or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence... | 1. No evidence of acute intracranial hemorrhage or mass effect. 2. Partially empty sella, which may be incidental, although this can also be seen with intracranial hypertension. |
Generate impression based on findings. | 55-year-old male with history of colon adenocarcinoma. Passing out. No intracranial hemorrhage is identified. No intracranial mass, evidence of mass-effect or abnormal contrast enhancement. No midline shift, or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within... | No evidence of acute intracranial hemorrhage, mass effect, or abnormal contrast enhancement. Please note MRI with contrast would be more sensitive for metastatic disease and can be considered if clinically indicated. |
Generate impression based on findings. | Altered mental status after injury. Head: There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. The imaged paranasal sinuses and mastoid air cells are clear.... | 1. No evidence of acute intracranial hemorrhage or skull fracture.2. No evidence of cervical spine fracture.3. Nonspecific opacification of the partially-imaged lungs. |
Generate impression based on findings. | 53-year-old male with history of SGL carcinoma and CRT. There is redemonstration of diffuse supraglottic mucosal edema, resulting in mild narrowing of the airway, but improved from the prior exam. There is no discrete mass lesion seen in the supraglottic area.Scattered small cervical lymph nodes are identified. No lymp... | 1. No discrete mass or significant cervical lymphadenopathy2. Supraglottic mucosal edema, likely related to treatment, is slightly improved from the prior exam. 3. Redemonstration of multilevel ossification of the posterior longitudinal ligament with severe associated spinal canal stenosis. |
Generate impression based on findings. | Right base of tongue T2N2b squamous cell carcinoma status post induction. There is interval decrease in size of the right cervical lymphadenopathy. For example, a right level 2A lymph node now measures 11 x 12 mm, previously 30 x 35 mm. There is also marked interval decrease in size of the tongue base mass that may mea... | Marked interval decrease in size of the tongue base tumor and right cervical lymphadenopathy. |
Generate impression based on findings. | There is no evidence of fracture. There is mild anterolisthesis of C7 on T1 of 3 mm. There is anterior spinal fusion at C6-C7 with intervertebral disc spacer and wide decompressive laminectomies at C3-C7. There is a fracture of the C6 screw as correlated with prior radiographs. There may some bony bridging at C6-C7; h... | 1. Status post anterior C6-C7 fusion with wide decompressive laminectomies from C3 to C7. There is a fracture of the C6 screw as correlated with prior radiographs. 2. Degenerative changes of the cervical spine with large posterior osteophytes at C3-C4 and C6-C7. There is mild impression on the ventral cord at the left ... |
Generate impression based on findings. | 44-year-old male with respiratory failure and chronic pancreatitis with posterior head wound. Evaluate for hemorrhage or fluid collection No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift, or uncal herniation. Gray-white differentiation is maintained. No extra-a... | 1. No evidence of acute intracranial hemorrhage or mass effect. 2. A small focal defect in the skin is noted along the posterior scalp without associated fluid collection or significant underlying inflammatory changes. |
Generate impression based on findings. | Shortness of breath. Multiple surgeries for esophageal atresia.VIEW: Chest AP (one view) 03/28/15, 1321 Postoperative changes in the right chest continue. Lower extremity central line tip is at junction of inferior vena cava and right atrium. Air filled structures in right upper and overlying the spine and left upper l... | Continued left lung opacities. |
Generate impression based on findings. | Anti-coagulated with altered mental status, right-sided weakness and aphasia. Evaluate for intracranial hemorrhage. There is interval increase in size of an intraparenchymal hemorrhage centered predominantly in the left posterior frontal lobe with a smaller component in the anterior parietal region, measuring 67 x 55 m... | 1. Slight increase in size of large acute intraparenchymal hematoma in the left posterior frontal and anterior parietal lobes, measuring up to 67 mm, with intraventricular extension. There is adjacent subarachnoid hemorrhage along the left fronto-parietal convexity. There is worsening mass effect with increased left to... |
Generate impression based on findings. | Reason: r/o fx History: pain Irregular contour about the waist of the scaphoid may reflect old trauma. No evidence of acute fracture or necrosis is identified. The bones remain in normal anatomic alignment. | Suggestion of chronic scaphoid injury. No acute fracture is identified. If there strong clinical suspicion for acute fracture, repeat radiographs may be obtained in 7 days. |
Generate impression based on findings. | Reason: s/p fall with pain. assess for fx History: as above No evidence of acute fracture or malalignment. There is no significant joint effusion or soft tissue swelling. Sharpening of the tibial spines suggests mild osteoarthritis. | No evidence of acute fracture, malalignment, or joint effusion. |
Generate impression based on findings. | Reason: eval for AC separation vs clav fx History: shoulder deformity The acromioclavicular joint is mildly widened, measuring 9 mm, with slight elevation of the clavicle with respect to the acromion. The coracoclavicular distance is upper limits of normal, measuring 14 mm. Glenohumeral joint is in anatomic alignment, ... | Findings suggestive type II acromioclavicular separation. Comparison radiographs of the contralateral shoulder may be considered. |
Generate impression based on findings. | Three month old, blunt trauma No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hydrocephalus.The visualized portio... | No evidence of intracranial hemorrhage or skull fracture. |
Generate impression based on findings. | 23 month old status post trauma No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hydrocephalus.There is diffuse op... | 1. No evidence of intracranial hemorrhage or skull fracture.2. Diffuse opacification of the paranasal sinuses, bilateral middle ears, and bilateral mastoid air cells. |
Generate impression based on findings. | Reason: r/o fracture History: pain Mild/moderate soft tissue swelling and a small joint effusion, without evidence of acute fracture or malalignment. A plantar heel spur is present. Punctate calcification along the medial aspect of the first MTP joint is unchanged when compared to prior, and likely related to remote tr... | Small joint effusion and soft tissue swelling without evidence of acute fracture or malalignment. |
Generate impression based on findings. | Reason: r/o fracture History: pain Joint effusion is soft tissue swelling associated with a comminuted, minimally displaced fracture of the coronoid process. The radial head is intact. A punctate radiopaque density in the radiohumeral articulation represents an additional fracture fragment, better evaluated on subseque... | Type III coronoid fracture as above. |
Generate impression based on findings. | Reason: fracture History: right elbow and forearm pain Irregular, well corticated, bony excrescences project from the medial lateral humeral epicondyles, as well as the posterior olecranon, likely relating to chronic trauma. Ossific density within the joint space may represent chondrocalcinosis. No elbow joint effusion... | Findings suggestive of chronic right elbow injury as above. No evidence of acute fracture or malalignment. No significant joint effusion or soft tissue swelling. |
Generate impression based on findings. | Altered mental status No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hydrocephalus.The visualized portions of th... | No evidence of acute intracranial hemorrhage or mass effect. |
Generate impression based on findings. | Intracranial hemorrhage, encephalopathy. Redemonstrated is hemorrhage within the left lateral ventricle, with a left to right midline shift of approximately 12 mm, previously 11 mm. Redemonstrated is a hematoma centered within the left posterior parietal lobe, which is grossly stable. There is extensive right hemispher... | 1. Stable left posterior parietal hematoma and extensive intraventricular hemorrhage.2. Stable enlarged ventricular system and right frontal approach ventricular catheter.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Reason: r/o fx History: knee pain s/p fall Partially visualized intra-nodular rod with multiple transverse screws fix is the distal femur. Metallic projectile fragments about the distal femoral diaphysis are compatible with a previous ballistic injury. There is no evidence of acute fracture or malalignment. No radiogra... | Orthopedic hardware and metallic ballistic fragments as above. No radiographic evidence of acute fracture, malalignment, or hardware complication. |
Generate impression based on findings. | 3-month old with lethargy. Found unresponsive and given CPR. No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift, or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hyd... | 1. No evidence of acute intracranial hemorrhage, mass effect, or cerebral edema. 2. There is apparent hyperdensity involving the cerebellum which is of uncertain significance given otherwise preserved attenuation and gray-white differentiation supratentorially. Please note CT is insensitive for the detection of acute i... |
Generate impression based on findings. | Reason: eval for fx History: joint effusion Moderate soft tissue swelling about the medial and lateral aspects of the left ankle, without evidence of underlying fracture or malalignment. A small joint effusion is likely. | Soft tissue swelling and small joint effusion without evidence of acute fracture or malalignment. |
Generate impression based on findings. | Reason: Evaluate for Fx/retained bullet fragments History: S/p gunshot to Left knee Incomplete/chip fracture along the medial aspect of the medial femoral condyle, measuring 1.3 cm. Subcutaneous foci of gas corresponds to known recent ballistic injury. A moderate joint effusion is present. No unexpected radiopaque fore... | Medial femoral condylar fracture as above. |
Generate impression based on findings. | Reason: evaluate for fracture History: s/p trauma w/MVC Mild/moderate osteoarthritis affects the right hip. The remainder of the femur is unremarkable. Mild osteoarthritis affects the right knee. There is mild to moderate soft tissue swelling without evidence of joint effusion. Diffuse subcutaneous edema about the lowe... | Diffuse soft tissue swelling/subcutaneous edema and degenerative changes as above, without evidence of acute fracture or malalignment. |
Generate impression based on findings. | Altered mental status. Evaluate status post hematoma evacuation. There is interval placement of a left frontal approach ventricular catheter with the tip terminating adjacent to the right frontal horn. There are postoperative changes related to a left parietal craniectomy for hematoma evacuation. There is expected pneu... | 1. Postoperative changes related to a left parietal craniectomy for decompression and hematoma evacuation with residual blood products and pneumocephalus. Improved left to right midline shift now measuring 8 mm. Mild subarachnoid blood products along the left frontoparietal convexity and residual intraventricular blood... |
Generate impression based on findings. | Reason: eval for fracture History: s/p fall with left hip pain Moderate/severe osteoarthritis affects the bilateral hips, with joint space narrowing, subchondral sclerosis, and extensive osteophytosis. Degenerative changes affect the sacroiliac joints, right greater than left. There is soft tissue swelling about the le... | Degenerative arthritic changes as above, without evidence of acute fracture or malalignment. |
Generate impression based on findings. | Suspected sepsis. History of chronic lung disease and renal failure.VIEW: Chest AP (one view) 03/28/15, 1547 Left port tip is in superior vena cava. Septal occluder device is again seen. Gastrojejunostomy tube is present. Small amounts of barium in the peritoneum are noted. A tiny streak of barium is seen overlying T4.... | No pneumonia. |
Generate impression based on findings. | Syncope, supratherapeutic INR No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are within normal limits for age without evidence of hydrocephalus. No extra-axial collections. Th... | No evidence of intracranial hemorrhage or mass effect. |
Generate impression based on findings. | Reason: surgical pin dislodgement History: s/p surgery for hammer toes presents with toe pain Postoperative changes of distal osteotomies of the second, third, and fourth proximal phalanges, with K-wires affixing the phalanges of all 3 toes. No radiographic evidence of hardware complication. There is no definite osteol... | No radiographic evidence of hardware complication or surgical pin dislodgment. |
Generate impression based on findings. | Trauma.VIEWS: Cervical spine AP/lateral (two views) 03/28/15, 1650 and 1655 Pseudosubluxation of C2 on C3 is present, normal variant anatomy. No fracture or dislocation is seen. No prevertebral soft tissue swelling is present. | No fracture or dislocation. |
Generate impression based on findings. | Reason: evaluate for fracture or dislocation History: pain on palpation s/p fall The bones appear diffusely demineralized. Mild osteoarthritis affects the right hip. Extensive vascular calcifications are present in the right thigh and leg. There is no evidence of acute fracture or malalignment. A well corticated ossicl... | Degenerative arthritic changes as above, without evidence of acute fracture or malalignment. |
Generate impression based on findings. | Trauma.VIEW: Pelvis AP (one view) 03/28/15, 1656 Femoral head epiphyses are well directed into normally formed acetabula. No fractures identified.A moderate amount of feces is present in the rectosigmoid. | Normal examination. |
Generate impression based on findings. | Status post fall with loss of consciousness, cervical spine tenderness Head: No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are within normal limits for age without evidence o... | 1. No evidence of intracranial hemorrhage or skull fracture. There is a left occipital subgaleal hematoma.2. No acute fracture or subluxation is seen in the cervical spine. |
Generate impression based on findings. | Projectile injury.VIEW: Right femur AP (one view) 03/28/15, 1720 The distal two thirds of the femur are normal in appearance in this single plane. No projectile fragment is present. | No projectile fragments or large fracture. |
Generate impression based on findings. | Altered mental status. Right sided weakness. Evaluate status post hematoma evacuation. Redemonstrated is a left frontal approach ventricular catheter with the tip terminating near the right frontal horn, which is unchanged in position. No significant change in ventricular size. There are postoperative changes related t... | 1. Evolution of postoperative changes related to a left parietal craniectomy for hematoma evacuation with slightly fuller appearance of blood products in evacuation cavity and left to right midline shift measuring 10 mm, previously 9 mm. Increased width of overlying hemorrhage measuring 3 mm and stable subarachnoid blo... |
Generate impression based on findings. | 5-day-old former 28 week gestational age patient with line placement.VIEW: Chest AP (one view) 03/28/15, 1606 Right upper extremity PICC tip is in right subclavian vein. Endotracheal tube tip is below thoracic inlet. Feeding tube tip is in gastric body. Umbilical arterial line is no longer seen. Umbilical venous line t... | Right upper extremity PICC tip in right subclavian vein. |
Generate impression based on findings. | Reason: evaluate for injury History: pain, difficulty w/ambulation Minimal osteoarthritis affects the right hip. Sclerosis along the iliac margin of the right sacroiliac joint is suggestive of osteitis condensans ilii. There is no evidence of acute fracture or malalignment. | No evidence of acute fracture or malalignment. |
Generate impression based on findings. | Fire arm injury.VIEW: Left femur AP (one view) 03/28/15, 1722 The distal two thirds of the femur are included. Entrance and exit markers are seen along the medial thigh at the level of the metaphysis and overlying the intercondylar notch. Subcutaneous emphysema is noted. The lateral cortex of the metaphysis and the epi... | Subcutaneous emphysema and no retained projectile fragment. Fracture of medial aspect of distal femur. |
Generate impression based on findings. | Reason: 22F with right midline distal pain and swelling, previous heavy runner (6-10 miles/day), ?acute vs. stress fracture? Cortical irregularity and periosteal reaction of the distal diaphysis of the third metatarsal is compatible with a stress fracture. Bifid sesamoid bones are again noted. | Distal third metatarsal stress fracture as above. |
Generate impression based on findings. | Projectile injury.VIEWS: Abdomen AP/cross table lateral (two views) 03/28/15, 1706 and 1709 An entrance or exit wound marker is noted on the right. On the cross table lateral view this marker appears to be posteriorly positioned however no subcutaneous emphysema is identified at this level. The projectile fragment is n... | Entrance wound is located anteriorly and projectile fragment is lodged in the subcutaneous tissues of the left anterior abdomen. No definite pneumoperitoneum. |
Generate impression based on findings. | [ Reason: better assess fracture characteristics r/o radial head fracture History: coronoid fx ] Comminuted fracture involving greater than 50% of the coronoid process, compatible with a type III fracture. Additional transverse fracture through the tip of the olecranon process, as well as the lateral condyle. A small c... | 1.Type III fracture of the coronoid process.2.Transverse fracture through the tip of the olecranon process. 3.Tiny avulsion fracture through the lateral epicondyle.4.Multiple ossific densities are present within the joint. |
Generate impression based on findings. | Reason: arthritis, crystalopathy History: extreme pain, swelling Moderate soft tissue swelling about the medial and lateral aspects of the right ankle. There is no evidence of acute fracture or malalignment. An orthopedic screw affixes the distal first metatarsal, in near-anatomic alignment. There is no radiographic ev... | Moderate soft tissue swelling, degenerative arthritic changes, and orthopedic hardware as above. No evidence of hardware complication, acute fracture or malalignment. No evidence of crystalline arthropathy, as clinically queried. |
Generate impression based on findings. | 4-month-old former 27 to 28 week gestational age patient with recurrent pleural effusion.VIEW: Chest AP (one view) 03/28/15, 1615 Feeding tube tip is in gastric body. Lower extremity central line tip is in right atrium. Left rib healing fractures are as described on CT from 03/20/15.Cardiothymic silhouette is mildly en... | Changes from chronic lung disease. Probable small left pleural effusion. |
Generate impression based on findings. | Fall, hematoma to scalp Head:No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. There is moderate global parenchymal volume loss, commensurate with patient's age. Infratentorial volume loss also noted... | 1. No evidence of intracranial hemorrhage or skull fracture.2. Global parenchymal volume loss and small vessel ischemic changes as seen previously.3. No acute fracture or subluxation within the cervical spine. |
Generate impression based on findings. | Reason: Distal 1/3 radius/ulna Fx on 02/8 at OSH, evaluate Fx History: Both bone forearm Fx on 02/08/2015, pain Overlying cast material limits fine bone detail. There is an oblique, intra-articular fracture of the distal radial epiphysis, with mild dorsal displacement of the distal fracture fragment. A fracture through... | Distal radial/ulnar fractures as above. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.