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Generate impression based on findings. | 76er old female with history of pulmonary nodule and ILD. LUNGS AND PLEURA: Mild centrolobular predominant emphysema. There is redemonstration of upper lobe predominant subpleural reticulation and bronchiectasis with areas of honeycombing especially within the left upper lobe. Scattered pulmonary micronodules, nonspeci... | 1. Right lower lobe mixed density nodule is no longer visualized, likely indicating a resolved infectious etiology.2. Mild upper lobe predominant somewhat focal subpleural reticulation and traction bronchiectasis compatible with a nonspecific fibrosis which may be related to prior inflammatory process.3. Stable mediast... |
Generate impression based on findings. | 3-year-old female coughing with feedsEXAMINATION: Oropharyngeal motility study 3/31/15 1019 Beth Harrison, speech and language therapist, supervised the examination.42 seconds of fluoroscopy was used.During the oral phase there was decreased suction, decreased bolus expression, and decreased bolus containment with prem... | No penetration or aspiration with oral and pharyngeal deficits.Please see the speech and language therapist's report for feeding recommendations. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and additional right MLO view were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. Multiple benign s... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 75-year-old male. Bladder cancer. Evaluate for mets. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Numerous tiny hypoattenuating foci in the hepatic dome (3 mm and smaller; series 7, image 21), new from prior, early metastatic disease cannot be excluded; infection is another consideration. S... | Numerous tiny hypoattenuating foci in the hepatic dome, early metastatic disease cannot be excluded; infection is another consideration. Special attenuation on follow-up scans. No other sites of disease are evident. |
Generate impression based on findings. | 58-year-old male with history of head and neck cancer No mass or significant cervical lymphadenopathy. The thyroid gland is unremarkable. The major salivary glands are unchanged in appearance. The major cervical vessels are patent. There is unchanged multilevel degenerative spondylosis. The airways are patent. The imag... | Stable interval exam with no evidence of lymphadenopathy or recurrent mass. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Three standard digital views with tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, micr... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Generalized abdominal painVIEW: Abdomen AP (one view) 3/31/15 Normal abdominal gas pattern. No evidence of obstruction, free air, pneumatosis intestinalis or portal venous gas. | Normal examination. |
Generate impression based on findings. | Reason: Low grade melanoma of right leg, please perform node mapping prior to sentinel node bx RADIOPHARMACEUTICAL: The right lower extremity surrounding the lesion was prepared in a sterile manner. A total of 0.49 mCi Tc-99m filtered sulfur colloid was injected in four peri-lesional sites. Three foci of increased acti... | Sentinel nodes identified in the right inguinal and femoral regions. |
Generate impression based on findings. | 43-year-old male patient with history of pancreatic pseudocyst. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Left portal vein is not well opacified, suggesting with portal vein thrombosis. Hepatic segments 7 hyperattenuating lesion probably measures 2.9 x 2.4 cm (series 3 image 25) unchange... | Significant interval decrease in size of intra and peripancreatic fluid collections with interval removal of percutaneous drain. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are digital mammographic images (2/2/15, 7/30/14, 7/3/14), ultrasound images of left breast (2/2/15, 7/30/14) performed at McNeal Hospital. DIGITAL MAMMOGRAPHIC IMAGES (7/30/14, 7/3/14):The breast parenchyma is heterogeneously dense. Two triangular mark... | Left breast masses, likely fibroadenomata. As there is no significant interval change, clinical and mammographic follow up is recommended in 6 months.BIRADS: 3 - Probably benign finding.RECOMMENDATION: T - Take Appropriate Action - No Letter. |
Generate impression based on findings. | Reason: evaluate for insulin secreting neuroendocrin tumor History: post bariatric surgery hyperinsulinemic hypoglycemia Normal physiologic radiotracer distribution is seen in the spleen, kidneys, liver, bowel and bladder. There is no abnormal focus of activity to indicate an octreotide avid lesion. | No suspicious octreotide avid lesion identified to indicate a neuroendocrine tumor. |
Generate impression based on findings. | Male, 7 years old. Fell on stairs, pain in big toeVIEWS: Left foot AP. Left first toe AP, lateral (3 views) 3/31/15, 1041 The osseous structures and joint spaces are normal.No significant soft tissue swelling. | Normal examination. |
Generate impression based on findings. | 72 years, Female. Reason: Eval NGT placement History: AS above. The pelvis is excluded from the field of view. There is a nasogastric tube with its tip projecting over the fundus of the stomach. There are multiple dilated loops of small bowel measuring up to 3 cm in diameter favor a small bowel obstruction given evolut... | 1.Nasogastric tube tip projects over the fundus of the stomach.2.Multiple dilated loops of small bowel favor a more distal small bowel obstruction over ileus as described above. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Mother and sister with breast cancer. Personal history of skin cancer on lower leg, in remission. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may o... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microcalcifications or ar... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 22 years, Male. Reason: nausea vomiting. s/p gsw to neck, trach, now w/ N/V History: nausea vomiting The pelvis is excluded from the field of view. There is a Dobbhoff tube coiled in the stomach with its tip projecting over the prepyloric stomach. Multiple air containing loops of large and small bowel compatible with i... | Multiple air containing loops of large and small bowel compatible with ileus. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of benign right breast biopsy. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. Few benign calcifications are s... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | 53-year-old female with lung nodule for follow up LUNGS AND PLEURA: Central airways are patent. No pneumothorax or pleural effusion. Minimal dependent bibasilar atelectasis.The previous described cluster of pulmonary nodules in the periphery of the right lower lobe are unchanged in size, the largest measuring 5 mm (ser... | No significant change in pulmonary nodules. One additional follow up in 12 months could be obtained. |
Generate impression based on findings. | Abdominal pain right lower quadrant. History renal tumor. ABDOMEN:LUNG BASES: Small bilateral pleural effusions again noted. Left lower rib metastasis unchanged.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No sign... | Interval placement of right lower quadrant percutaneous drainage catheter with interval near complete resolution of previously noted loculated right pelvic fluid collection. Other findings including metastatic disease unchanged. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. Few scattered calcifications, including arteria... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Male, 13 years old. Pes planus status post lateral column lengthening and calcaneal osteotomy.VIEWS: Left foot AP, lateral (two views) 3/31/15, 1058 Splint material and K wires have been removed. Diffuse osseous demineralization.Postoperative changes of trapezoid bone graft and osteotomy appear similar to prior. No acu... | Postoperative findings without acute abnormality. |
Generate impression based on findings. | Reason: left ankle pain History: left ankle pain Three views of the right ankle demonstrate normal anatomic alignment, without evidence of acute fracture or significant soft tissue swelling. Tiny midfoot osteophytes suggest minimal osteoarthritis. A sclerotic focus in the talus likely represents a benign bone island. | Minimal mid foot osteoarthritis. No acute fracture or malalignment. |
Generate impression based on findings. | Reason: ap lateral views 1 year follow up ACDF History: 1 year follow up ACDF Two views of the cervical spine again demonstrate an anterior plate and screws entering the C5 and C6 vertebral bodies. Bone graft material is seen between the C5 and C6 vertebral bodies, with new bridging bone along the posterior aspect of t... | Postoperative changes of ACDF and stable degenerative changes as above. |
Generate impression based on findings. | Reason: rule out myositis ossificans History: pain Two views of the right femur demonstrate tiny ossicles along the posterior superior rim of the acetabulum, of questionable clinical significance. We see no large focus of soft tissue mineralization to suggest myositis ossificans. There is perhaps a slight CAM deformity... | No radiographic evidence of myositis ossificans. Other findings as above. A clinically palpable mass may be further evaluated with MRI, if clinically warranted. |
Generate impression based on findings. | 50 year old with history of right mastectomy for inflammatory breast cancer in 2013. Patient received radiation and chemotherapy. No current breast complaints. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is mostly fatty replaced, uncha... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, left unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Reason: History of DJD and myeloma History: Knee pain Two views of the right knee demonstrate severe tricompartmental osteoarthritis, including joint space narrowing, osteophytosis, and subchondral sclerosis. The bones appear slightly demineralized, which may reflect the underlying diagnosis of multiple myeloma. Arteri... | Severe osteoarthritis without evidence of acute fracture. |
Generate impression based on findings. | Reason: s/p hemiarthroplasty History: above Four views of the left shoulder demonstrate components of a left shoulder hemiarthroplasty in near anatomic alignment, without radiographic evidence of complication. Evaluation is slightly limited by overlying artifact on the patient's skin. Gas in the adjacent soft tissues r... | Components of a left shoulder hemiarthroplasty, as above. |
Generate impression based on findings. | Please note that there are only 11 rib bearing vertebral bodies. However, to maintain consistency with prior imaging studies and the operative report, the vertebral body numbering scheme from prior exams will be propagated which assumes 12 thoracic and 5 lumbar vertebral levels.Redemonstrated is posterior spinal fusio... | 1. Please note for the purposes of numbering there are 11 thoracic ribs and numbering is performed as per prior report. Interval evolution of postoperative related to posterior spinal fusion extending from T10 through S1 and decompressive laminectomies from L2 through L5. 2. Interval removal of L5-S1 spacer device comp... |
Generate impression based on findings. | 46 year old male with nausea, vomiting, tremor. Increased BUN/Creatinine RENAL TRANSPLANT:LOCATION: Right iliac fossa. PERITRANSPLANT TISSUES: No significant abnormality notedKIDNEY: Measures 10.5 cm in length and is increased in echogenicity. COLLECTING SYSTEM/URETER: Moderate hydronephrosis is noted which does not ch... | 1. Increased echogenicity of the transplanted kidney suggestive of parenchymal dysfunction. Moderate hydronephrosis is noted. 2. There appear be two anastomotic sites with no evidence of stenosis at the anastomosis or intrarenal vasculature. 3. Postvoid residual noted. |
Generate impression based on findings. | Reason: Evaluate for fracture/healing History: Hx of fracture now with decreased mobility Three views of the right hand demonstrate mild deformity of the fifth metacarpal, compatible with a healed fracture. There is also mild deformity of the base of the mid phalanx of the ring finger, that we suspect to represent a he... | Findings compatible with prior trauma, as above. No acute fracture is evident. |
Generate impression based on findings. | 59-year-old female patient history of degenerative disk disease with acute onset right flank pain. Evaluate for possible kidney stone. 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:... | No significant intra-abdominal abnormalities to account for patient's pain. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are digital mammographic images (3/2/15, 3/9/15), ultrasound images of left breast (3/9/15), images from ultrasound guided biopsy of left breast and post procedural left mammographic images (3/16/15) performed at CDH Breast Health Center. For comparison... | Biopsy proven carcinoma in the left breast.BIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Male; 49 years old. Reason: mets lung cancer, s/p multiple chemo, ALK+, s/p 2 cycles of Alectinib. Pls c/w previous study and evaluate tx response. History: mets lung cancer ABDOMEN:LUNG BASES: Please refer to separate chest CT report for description of intrathoracic abnormalities.LIVER, BILIARY TRACT: Multiple bilobar... | 1. Interval decreased size of numerous bilobar hepatic metastatic lesions and peri-celiac metastatic adenopathy/encasement.2. New mild diffuse gallbladder wall thickening/edema, suggestive of acute inflammation. Clinical correlation is recommended.3. Please refer to separate chest CT report for description of intrathor... |
Generate impression based on findings. | Female, 10 years old. Unicameral bone cyst with fracture s/p fixation.VIEWS: Right hip AP, lateral (2 views) 3/31/2015, 1112 Surgical plate and screws affix the femoral neck and diaphysis. No evidence of hardware complication or fracture.Alignment is anatomic. The femoral head is round and smooth and well directed into... | No evidence of hardware complication. |
Generate impression based on findings. | Stage IV melanoma. History of metastatic melanoma from right cheek to right parotid status post parotidectomy. Re-evaluate disease status following drug intolerance; compare to previous and provide bi-dimensional measurements. Redemonstrated is evidence of partial right parotidectomy with superficial scarring and skin ... | Stable examination without significant interval change in the right premaxillary soft tissue nodule, compared to 2/6/2012 allowing for differences in technique. No evidence of new nodules or cervical lymphadenopathy. |
Generate impression based on findings. | Pain on right arm. Question of fracture. Two views of the right humerus show no acute fracture or malalignment. | No acute fracture is evident. |
Generate impression based on findings. | 71-year-old female with history of right mastectomy for ILC in 2011. Patient received chemotherapy. History of benign left breast biopsy. No new breast complaints. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is heterogeneously dense, u... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, left unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Sciatica. Three views of the lumbar spine show no acute fracture. Alignment is anatomic. Small anterior osteophytes are noted throughout the spine. Vertebral body heights and disk spaces are maintained. | Mild degenerative changes of the lumbar spine. |
Generate impression based on findings. | Bilateral knee pain. Four views of the left knee show marked medial and lateral compartment joint space narrowing. There is tricompartmental osteophyte formation. No acute fracture is evident.Four views of the right knee show severe medial greater than lateral compartment joint space narrowing with tricompartmental ost... | Severe osteoarthritis. |
Generate impression based on findings. | Per EPIC, 16-month-old female with past medical history of anterior synostotic plagiocephaly and right partial unicoronal synostosis and partial metopic synostosis, status post bifrontal craniotomy, bifrontal orbital advancement and reshaping and multiple unilateral radial osteotomies(supraorbital bandeau) for treatmen... | 1. Post-operative findings related to supraorbital bandeau osteotomy, barrel stave osteotomy as well as bilateral anterior parietal osteotomies. Scattered anterior parietal region bony defects.2. Mild flattening of the right occipital bone.3. Diffuse opacification of the paranasal sinuses. |
Generate impression based on findings. | Male, 7 years old. Mouth breathing. Evaluate for adenoid hypertrophy.VIEWS: Soft tissue neck lateral (1 view) 3/31/2015, 1112 Mild adenoid hypertrophy, without obstruction of the posterior nasopharynx.Moderate hypertrophy of the palatine tonsils. The paranasal sinuses are well pneumatized.No prevertebral soft tissue sw... | Mild nonobstructive adenoid hypertrophy. Moderate palatine tonsillar hypertrophy. |
Generate impression based on findings. | Reason: h/o HNC/CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Stable left apical calcified granuloma and paraseptal emphysema. Nodular fissural density in the left major fissure (4/55) is stable in size, favoring intrapulmonary lymph node. Left upper lobe cyst unchanged.No interval su... | No evidence of metastatic disease. |
Generate impression based on findings. | Right-sided pain in patient with metastatic melanoma. Metallic BBs denote the site of the patient's pain. Three views of the ribs show a mild deformity of the right lateral ninth rib with sclerosis in the region of interest; this appears to correlate with an old rib fracture on prior CTs. Additional rib deformities are... | Mild deformity of the right lateral ninth rib with sclerosis in the region of interest; this appears to correlate with an old rib fracture on prior CTs. |
Generate impression based on findings. | Reason: low back pain History: low back pain Two views of the lumbar spine demonstrate moderate degenerative disk disease at L3-4, and perhaps mild disk disease affecting the remainder of the lumbar levels. There is also multilevel facet joint osteoarthritis, particularly affecting the lower lumbar spine. There is grad... | Degenerative arthritic changes, as above. |
Generate impression based on findings. | Female, 8 days old. Frequent desaturationVIEW: Chest and abdomen AP (two views) 3/31/2015, 1123 ET tube tip below the level of the thoracic inlet. Feeding tube with distal sideport above the level of the GE junction. Right arm PICC crosses midline with tip at the left IJ/subclavian vein confluence. Removal of umbilical... | Right upper lobe atelectasis with a questionable small right apical pneumothorax. Mildly dilated bowel loops. |
Generate impression based on findings. | 9 year old male with history of cervical fusion VIEWS: Cervical spine ap, lateral, flexion, extension (4 views) 3/31/15 Posterior pedicle screws entering C1 and C2 are again noted without evidence of hardware complication. The atlantodens interval is preserved on flexion and extension views. No subluxation or fracture.... | No radiographic evidence of hardware complication. |
Generate impression based on findings. | Left knee pain. Four views of the left knee show medial joint space narrowing and osteophyte formation. No acute fracture or joint effusion is identified. | Moderate osteoarthritis. |
Generate impression based on findings. | Status post fracture. Three views of the left wrist again show a transverse fracture of the distal radius with fracture fragments in near anatomic alignment. The fracture line is less distinct suggestive of healing. The ulnar styloid fracture appears similar to the prior study. Extensive vascular calcifications are not... | Healing fracture of the distal radius. |
Generate impression based on findings. | New onset right rib pain, evaluate for potential fracture. Three views of the ribs show no acute rib fracture. The bones appear demineralized. | No acute rib fracture is identified. |
Generate impression based on findings. | The proximal colon is well distended. The sigmoid colon remained poorly distended despite repositioning and continued air insufflation. Residual fluid throughout the colon is well tagged with oral contrast. Mild residual particulate fecal matter is identified within the colon. The sigmoid colon is markedly tortuous. F... | 1. Persistent narrowing of the sigmoid colon which is inseparable from an adjacent enlarged uterus. Given the presence of peritoneal nodularity the appearance is highly suspicious for gynecological malignancy. Post contrast CT the abdomen and pelvis is recommended for further evaluation.2.The colonic evaluation for pol... |
Generate impression based on findings. | Female, 9 years old. S/p VDRO.VIEWS: Pelvis AP (1 view) 3/31/2015, 1133 Plate and screws affix bilateral femoral osteotomies.Increasing periosteal reaction at the osteotomy sites.Alignment is anatomic. No evidence of hardware complication.The femoral heads are round and smooth, and well directed into dysplastic acetabu... | Healing osteotomies, without evidence of hardware complication. |
Generate impression based on findings. | 62 year-old female with cryptogenic cirrhosis. Evaluate for HCC. LIVER: Coarse echogenicity of the liver with nodular contour measuring 10.9 cm. No focal hepatic lesions are noted. Main portal vein is patent with appropriate directional flow; peak velocity measures 0.14 m/sec. There are sequela of portal hypertension n... | 1. Cirrhotic liver morphology with sequelae of portal hypertension. No focal hepatic lesions.2. Splenomegaly. 3. Unchanged cystic appearance at the center of the right kidney which may represent mild hydronephrosis or parapelvic cysts. 4. Possible left mild hydronephrosis. |
Generate impression based on findings. | Reason: mets lung cancer. s/p mulitple chemo, ALK+, s/p 2 cycles of Alectinib. Pls c/w previous study and evaluate tx response. History: lung ca LUNGS AND PLEURA: Interval decreased size and number of the previously noted multiple pulmonary nodules. The right pleural effusion is nearly completely resolved, with minimal... | Interval reduced size and number of the pulmonary metastases. Referenced right upper lobe nodule markedly reduced in size, 5 mm as compared to 8 mm. Improved aeration of the right middle and lower lobes with the right middle and lower lobe bronchi compressed but now patent. Near complete resolution of previous right pl... |
Generate impression based on findings. | Scoliosis surgery, preoperative evaluation. History of Pelizaeus-Merzbacher syndrome There are 7 cervical, 12 thoracic, and 5 lumbar type vertebral bodies. Craniocervical junction is unremarkable. Examination of cervical spine demonstrates normal development of the vertebral column. There is reversal of cervical lordos... | Examination for operative planning. Again seen is severe levoscoliosis with apex at the thoracolumbar junction, reversal of cervical kyphosis, and exaggerated lordosis at the lumbosacral junction. No focal congenital osseous anomalies are identified in the spine. |
Generate impression based on findings. | 60 year old with history of left lumpectomy on 4/14/14 and re-excision on 5/21/14 at outside hospital for DCIS/IDC presents for annual mammogram. No current breast complaints. Three standard views of both breasts and two spot magnification views of the left breast were performed digitally and reviewed with the aid of R... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Female 64 years old; Reason: 64 y/o female with Pancreatic Ca History: Known kidney stones and nephrolithiasis and hematuria. CHEST:LUNGS AND PLEURA: Minimal left-sided patchy air space disease, image 44 series 6, may be related to atelectasis but nonspecific and attention on follow-up recommended. No pleural effusion.... | 1. Moderate left-sided hydronephrosis with obstructing 6-mm distal left ureteral calculus.2. Status post Whipple procedure with small fluid and soft tissue attenuation seen at postoperative sites described, attention on follow up recommended. Mild to moderate gastric preanastomotic wall thickening. Multiple small mesen... |
Generate impression based on findings. | Clinical question: Evaluate for hemorrhage. Signs and symptoms: Ex-31 weeks, now with frequent apnea. Nonenhanced head CT:There are bilateral ( L > R ) high density subdurals hematomas along the inferior surface of tentorium. Measuring at 2.3-mm on the left and 1.7-mm on the right on coronal reformatted images. There i... | 1.Small acute subdurals along the inferior surface of tentorium measuring at 2.3-mm on the left and 1.7 mm thick on the right as detailed/measured above.2.Bilateral scalp edema in posterior parietal and occipital region as result of recent delivery.3.Unremarkable nonenhanced head CT otherwise. |
Generate impression based on findings. | 18 year old with palpable lump in the left breast presents for ultrasound study. The patient feels the lump has decreased in size. With physical exam, a mobile mass is palpated at 3 o'clock position in the left breast. Focused ultrasound was performed. Detected is a lobulated hypoechoic mass with parallel orientation a... | Palpable left breast mass, likely a fibroadenoma. Follow up with ultrasound in 6 months is recommended. If clinically indicated, palpation guided biopsy can be performed. Patient has an appointment with Dr. Chhablani on April 2. BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at Short Interval (1-11 ... |
Generate impression based on findings. | Reason: Breast caner, rule out mets History: N/A CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules. The pleural spaces are clear.MEDIASTINUM AND HILA: No significant abnormality noted.CORONARY ARTERY CALCIFICATION: None.CHEST WALL: There is bilateral dense glandular tissue of the breasts. In the lateral left brea... | No evidence of pulmonary metastases. |
Generate impression based on findings. | 65-year-old female patient with leukocytosis and perforated gallbladder. Date for abscess formation. Note that examination is limited due to the lack of intravenous contrast in the vasculature due to extravasation. Exam is not sensitive for detecting lesions in the bowel and solid organs due to the lack of intravenous ... | 1.Expected postoperative changes from cholecystectomy without measurable discrete fluid collection.2.New small right pleural effusion with bilateral atelectasis versus consolidation.3.Stable favored benign lipomatous lesion that may be arising from the uterus or the adnexa.4.Contrast extravasation. |
Generate impression based on findings. | The internal auditory canals are symmetrical and normal in size and signal intensity. There is mild dysplasia of the bilateral cochleae, with suggestion of modiolar structures; however, they do not appear to be dense on CT. The other inner ear structures are normal, with normal T2 signal and no pathological enhancemen... | Mild dysplasia of the bilateral cochleae with modiolar abnormality better delineated on CT, which may be on the spectrum of incomplete partition, type I. |
Generate impression based on findings. | Clinical question: Suprasellar mass causing the diplopia. Signs and symptoms: Question of metastatic melanoma versus pituitary adenoma. Medtronic diffusion sinus CT:Provided clinical information questions metastatic melanoma versus pituitary adenoma. Review of past history indicates patient having multiple myeloma and ... | 1.Mass within the sphenoid sinus and with bony erosion and extention superiorly into the sella and basal cistern. This finding compared to prior MRI exam demonstrate interval decreased size which may be secondary to interim respond to radiation therapy which would favor a myeloma over a pituitary adenoma.2.Sphenoid sin... |
Generate impression based on findings. | 73 year old with history of left mastectomy in 2005 for breast cancer and right benign lumpectomy in 2014. No current 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 elements, unc... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, right unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Reason: patient with a history of urothelial cancer, status post chemotherapy. please assess for disease progression History: urothelial cancer LUNGS AND PLEURA: No suspicious pulmonary nodules or pleural effusion.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. No mediastinal or hilar lymphadenopat... | No evidence of metastatic disease. Bilateral moderate to severe hydronephrosis with the kidneys partially included in the field-of-view. |
Generate impression based on findings. | Male, 67 years old, history of TxN2cM0 squamous cell carcinoma status post chemo/RT and right neck dissection. Head:No mass effect, focal edema or suspicious enhancement is seen to suggest brain parenchymal metastatic disease. The bones of the calvarium and skull base are intact. Neck:Again seen is marked edema involvi... | 1. Redemonstration of treatment related findings in the neck with no evidence to suggest recurrent disease.2. No intracranial metastatic disease. |
Generate impression based on findings. | Reason: Evaluate lung nodule History: Cough, CXR with nodule PULMONARY ARTERIES: The quality of this examination is diagnostic for the evaluation of pulmonary embolism. No pulmonary embolus is present.LUNGS AND PLEURA: There is a moderate left pleural effusion with mild enhancement of the pleura which is partially calc... | Obliteration of the left lower lobe bronchus with associated left lower lobe atelectasis from an ill-defined soft tissue density. Nodular soft tissue invading the posterior wall of the left upper lobe bronchus. Mediastinal, supraclavicular and mesenteric lymphadenopathy. Moderate left and small right pleural effusions.... |
Generate impression based on findings. | Male 42 years old; Reason: assess for colonic mets History: Hx of colon CA CHEST:LUNGS AND PLEURA: Multiple bilateral pulmonary metastases, demonstrating interval decrease in size. Index right lower lobe nodule decreased in size, measuring 0.7 x 0.5 cm, image 77 series 5, previously measured 1 x 0.6 cm. Index left lowe... | 1. Improvement in metastatic disease.2. Decrease in size of pulmonary and hepatic metastases. 3. Essentially stable right sided hydronephrosis, however degree of delayed nephrogram on right appears improved, mild interval decrease in size of ill-defined soft tissue focus at level of right ureteral obstruction.4. Retrop... |
Generate impression based on findings. | Male, 35 years old, with persistence, progressively worsening sinusitis with congestion and ear pain. Also with parotid swelling and intermittent tenderness. Neck:The aerodigestive mucosa is unremarkable. Likewise, the deep soft tissues are within normal limits. No mass, adenopathy, or fluid collections are detected. T... | 1. Unremarkable evaluation of the soft tissues of the neck.2. Mild inflammatory findings in the left maxillary sinus. Otherwise the paranasal sinuses, mastoid air cells and middle ear cavities are unremarkable. |
Generate impression based on findings. | The ventricles and sulci are within normal limits. The basal cisterns remain patent. There is no midline shift or mass effect. There are no areas of abnormal signal. There is no diffusion abnormality. No extra-axial fluid collection is identified.Normal flow-voids are demonstrated in the major intracranial vascular st... | Unremarkable noncontrast MRI brain. |
Generate impression based on findings. | Age: 70 yearsGender: FemaleReason for Study: Reason: Cough ro pneumonia History: cough The cardiomediastinal silhouette is unremarkable. Nodular left midlung opacity compatible with neoplastic history.Left hilar mass and mediastinal lymphadenopathy noted on recent CT not as well appreciated on this radiograph.No focal ... | Left mid lung nodule compatible with known neoplasm. No specific evidence of acute infection. |
Generate impression based on findings. | Female 39 years old; Reason: Evaluate for stone History: Flank pain, blood in urine ABDOMEN:LUNGS BASES: Small left basilar linear atelectasis or scarring.LIVER, BILIARY TRACT: Diffuse hepatic steatosis. SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant a... | 1. No hydronephrosis.2. Diffuse hepatic steatosis. |
Generate impression based on findings. | Male; 56 years old. Reason: follow up evaluation for patient with h/o carcinoid tumor s/p resection of small bowel primary, with possible local recurrence History: none CHEST:LUNGS AND PLEURA: Stable scattered pulmonary micronodules. No new suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HI... | 1. Stable enlarged para-aortic lymph node, which demonstrated increased activity on Octreotide scan dated 12/15/14 and is suspicious for carcinoid metastasis.2. No focal liver lesions are evident. The patient will contacted to return for arterial phase images of the liver at no additional charge. |
Generate impression based on findings. | 67-year-old female with metastatic left breast cancer CHEST:LUNGS AND PLEURA: No suspicious nodule or mass. Central airways are patent. No pneumothorax or pleural effusion.MEDIASTINUM AND HILA: Heterogeneous, nodular thyroid with punctate calcifications is similar to that seen on the prior exam. No significant mediasti... | 1.Interval decrease in size of left breast mass and ipsilateral axillary lymphadenopathy. 2.Diffuse lytic metastatic disease will be better evaluated on accompanying nuclear medicine bone scan. No significant change in CT appearance.3.Stable appearance of indeterminate right lobe of liver lesion.4.Heterogenous, calcifi... |
Generate impression based on findings. | Pain to right hip for greater than two weeks limiting ambulation. AP view the pelvis and two views of the bilateral hips show bilateral osteoarthritis of the hips with osteophyte formation and medial joint space narrowing. No acute fracture is evident. Vascular calcifications are noted. | Bilateral hip osteoarthritis. |
Generate impression based on findings. | Right knee pain. Four views of the right knee show slight joint space narrowing. Tiny osteophytes are noted along the undersurface of the patella. A small joint effusion is seen. No acute fracture is evident. | Mild osteoarthritis. |
Generate impression based on findings. | RIGHT TEMPORAL BONE: The external auditory canal is clear. The tympanic membrane is faintly visualized. The scutum remains sharp.The tympanic cavity and mastoid air cells are clear. The ossicular chain and tegmen tympani are intact.The cochlea is mildly dysplastic along its apical and middle turns, with an ill-defined... | Mild dysplasia of the bilateral cochleae with deficient modiolus on the right and near absence of the modiolus on the left, which may be on the spectrum of incomplete partition, type I. Vestibular aqueducts are normal. |
Generate impression based on findings. | There is a stable area of encephalomalacia in the right middle frontal gyrus. There is no acute intracranial hemorrhage. There is no mass effect or midline shift. The ventricles and sulci are normal in size and configuration. The imaged paranasal sinuses and mastoid air cells are clear. | Stable encephalomalacia in the right frontal lobe, otherwise unremarkable CT of the brain. |
Generate impression based on findings. | 75 year old female with new left breast mass. Left ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a hypoechoic 2.0 cm lobulated mass in the 11 o'clock position with increased vascularity, 6 cm from the nipple. The lesion was readily visible.PROCEDURE: The procedure and its risks, in... | Successful ultrasound-guided core biopsy of the left breast lesion and clip placement. This is most likely a malignancy. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Pain, limp. Evaluate for evidence of an acute fracture. Three views of the right ankle show no acute fracture or malalignment. | No acute fracture is evident. |
Generate impression based on findings. | Neck pain with rotation to the right. Some tingling at the right neck. Question of DJD. Six views of the cervical spine show no acute fracture. Alignment is anatomic. Vertebral body heights are preserved. There is anterior osteophyte formation from C3 to C7, most predominantly affecting C5/C6. There is marked disk spac... | Degenerative changes of cervical spine as described above. |
Generate impression based on findings. | Right knee pain. Four views of the right knee show no acute fracture or malalignment. No joint effusion is identified. | No specific radiographic findings to account for the patient's symptoms. |
Generate impression based on findings. | Follow-up. Three views of the right ankle show a side plate and screw device affixing the distal fibula. A sideplate and screw device also affixes the distal tibia with the screw abutting the fibula along with two orthopedic screws within the posterior distal tibia. The fracture fragments are in near anatomic alignment... | Orthopedic fixation of tibia and fibula fractures. |
Generate impression based on findings. | Reason: ? location of activity, ? uptake History: clinical thyrotoxicosis with large right lobe and firm 2 x 2.5 nodule on left There are multiple bilateral areas of increased and decreased activity consistent with hot and cold nodules. The largest dominant hot nodule is in the left mid-lower pole. The largest cold nod... | 1. Autonomously functioning thyroid gland as described above; toxic multinodular goiter is favored over Graves disease. 2. Multiple cold nodules, the largest of which is in the right mid-upper pole. Superimposed malignancy cannot be excluded on this examination, and correlation with the patient's physical examination a... |
Generate impression based on findings. | Bilateral knee pain. Four views of the left knee show severe medial compartment joint space narrowing and tricompartmental osteophyte formation. No acute fracture is evident. No joint effusion is identified.Four views of the right knee shows severe medial compartment joint space narrowing and tricompartmental osteophyt... | Severe osteoarthritis. |
Generate impression based on findings. | 79 year old female with history of benign breast biopsies presents after recurrence of mass adjacent to biopsy clip from previous cyst aspiration. Left ultrasound re-identified the target lesion for biopsy. On today's ultrasound, the lesion to be targeted is noted to be a hypoechoic, septated cyst measuring 13 mm at th... | Successful ultrasound-guided aspiration of a left breast cyst.Annual screening mammogram is recommended. Findings and recommendations were discussed with the patient and conveyed to Donna Christian at the time of dictation. BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Bulging cervical disk, preop planning for a laminectomy or fusion. Evaluate instability. Left arm triceps atrophy and arm pain. Five views of the cervical spine show no acute fracture. Anterior osteophyte formation is noted from C5 through C7. Marked disk space narrowing is noted at C5/C6 and C6/C7. Alignment is anatom... | Degenerative changes of the cervical spine without evidence of instability. |
Generate impression based on findings. | Postoperative changes are again seen along the right neck, with scattered surgical clips along the anterior aspect of the right carotid space and right floor of the mouth. Additional postoperative changes related to free fibula reconstruction for mandibular hypoplasia are again noted. Delineation of the margins of the... | Limited direct comparisons given differences in technique and imaging modality. No significant interval change in extent of large trans-spatial mass in the anterior neck, with better delineation of intrinsic components by MRI. This is again consistent with venolymphatic malformation, with slight interval increased size... |
Generate impression based on findings. | 72-year-old female with pleural mesothelioma CHEST:LUNGS AND PLEURA: Postoperative changes of a right pleurectomy and decortication with mesh in the right lung base. Nodular thickening along the right major and minor fissures is similar to the prior exam.No pleural effusion or pneumothorax. Central airways are patent.I... | 1.Stable postoperative changes of a right pleurectomy and decortication.2.Slight improvement of pleural disease with reference measurements as provided above.3.Right major fissure soft tissue density continues to decrease in size, possibly loculated fluid. |
Generate impression based on findings. | History of waterskiing accident. Told he had broken ribs at outside hospital. Evaluate resolution. Chest soreness. Three views of the ribs show a slight disruption of the cortex of multiple left lower ribs just prior to the costochondral junction compatible with nondisplaced rib fractures. | Non-displaced left lower rib fractures. |
Generate impression based on findings. | Reason: evaluate for memory difficulty History: trouble with memory, attention, language, empathy There is significantly decreased perfusion to the left anterior temporal lobe. More focally decreased perfusion is seen in the left posterior frontal region. | Decreased cerebral perfusion most notably involving the left anterior temporal lobe. While not entirely specific, given the history this may indicate asymmetric temporal predominant frontotemporal dementia. |
Generate impression based on findings. | Status post left total hip arthroplasty. AP view of the pelvis and single view of the left hip show a left total hip arthroplasty device situated in anatomic alignment. No acute fracture is evident. A surgical drain is noted in the soft tissues of the left hip. Foci of air within the soft tissues is post-surgical. | Left total hip arthroplasty in anatomic alignment. |
Generate impression based on findings. | Left knee pain. Four views of the left knee show no acute fracture or malalignment. No joint effusion is identified. | No specific radiographic findings to account for the patient's symptoms. |
Generate impression based on findings. | 61-year-old female with history of right breast invasive ductal carcinoma grade 3, status post right lumpectomy 6/2014. Status post neoadjuvant chemotherapy. Family history of breast cancer and paternal grandmother. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. T... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Pain to second, third and fourth phalanges and same metacarpals post trauma. Fracture? There is mild soft tissue swelling along the dorsum of the hand, but I see no underlying fracture or malalignment. | Mild soft tissue swelling without fracture evident. |
Generate impression based on findings. | 72-year-old female. Status post conversion of Indiana pouch to ileal conduit, POD 8 now with abdominal pain and leukocytosis. Assess for abscess. ABDOMEN:LUNG BASES: Trace left pleural effusion. Calcified right lung base granulomas. Mild emphysema.LIVER, BILIARY TRACT: Calcified hepatic granulomas. Subcentimeter hypoat... | 1. Findings consistent with a small bowel obstruction. Transition point is suspected to be in the central pelvis at site of small bowel loops that are tethered to, and possibly invaded by the left pelvic mass.2. No loculated fluid collection is evident. Small amount of pelvis ascites.3. Mild increased size of soft tiss... |
Generate impression based on findings. | Reason: rule out pulmonary embolus History: tricuspid regurgitation The ventilation images show a uniform distribution of activity on single-breath and wash-in images. There is no abnormal Xe-133 retention during the wash-out phase. The perfusion images show a very small defect in the right lower lobe. Otherwise, there... | Very low probability of pulmonary embolism. |
Generate impression based on findings. | Right ankle ORIF. There is a plate along the distal fibula with two transsyndesmotic screws affixing the distal fibula and tibia in near-anatomic alignment. Lucency along the inferior screw is noted, but appears similar to that seen on fluoroscopy spot images from March 18 and therefore is probably of no clinical signi... | Orthopedic fixation of distal tibiofibular syndesmosis as above. |
Generate impression based on findings. | Subdural collections overlying the bilateral parietal lobes are again noted, but have further decreased in size and density compared to the prior examination. The right subdural collection measures up to 7 mm in thickness, previously 8 mm, and the left subdural collection measures 4 mm, previously 8 mm. Linear areas o... | 1.Continued evolution of bilateral subdural collections with decrease in size and slight re-expansion of the lateral ventricles.2.No new intracranial hemorrhage.3.Mild white matter small vessel ischemic disease, similar to prior examinations.4.Mild to moderate scattered mucosal thickening in the paranasal sinuses, plea... |
Generate impression based on findings. | 64 years, Male. Reason: kidney stone History: kidney stone Previously seen calcific density in the right renal fossa not seen on today's examination. There is a nonobstructive bowel gas pattern. | Previously seen calcific density in the right renal fossa not seen on today's examination. |
Generate impression based on findings. | Female 10 years old Reason: fracture History: fracture aVIEWS: Left wrist AP and lateral 3/31/15 (two views) Pronator fat pad displacement and possible Salter-Harris one fracture of the distal radius. Alignment is anatomic. | Joint effusion possible Salter-Harris one fracture of the distal radius. |
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