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Generate impression based on findings. | 65-year-old male with fifth digit pain Deformity and callus formation consistent with a healing fifth metacarpal fracture. There is mild volar angulation of the distal fragment. | Healing fifth metacarpal fracture. |
Generate impression based on findings. | 50-year-old male with history of third digit injury. No acute fracture or malalignment. The soft tissues are unremarkable. | No acute fracture or dislocation. |
Generate impression based on findings. | History of left lumpectomy in 2012 for DCIS. Patient received radiation and is currently on tamoxifen. Known bilateral breast calcifications. Personal history of basal cell carcinoma of the left arm. History of breast cancer in maternal grandmother diagnosed at the age of 54. Three standard views of both breasts, a lef... | Stable post surgical changes of the left breast and stable bilateral calcifications.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 ... |
Generate impression based on findings. | 71-year-old male status post right TKA Hardware components of a total knee arthroplasty are situated in near anatomic alignment without evidence of complication. Interval removal of drain and surgical staples. There is a moderate joint effusion. Ossification projecting anterior to the distal femur is again noted. Anter... | Status post total knee arthroplasty in near anatomic alignment. |
Generate impression based on findings. | Female; 73 years old. Reason: Assess mass seen on CXR History: mass on CXR LUNGS AND PLEURA: Stable scattered nonspecific pulmonary micronodules. Stable 1.2 x 0.5 cm nodular opacity in the right upper lobe (image 45, series 6), which may reflect scarring and which previously measured 1.1 x 0.6 cm. Grossly stable ovoid ... | No significant interval change. Grossly stable subpleural opacity in the right lower lobe which is most likely rounded atelectasis though continued follow up is recommended to exclude growth. |
Generate impression based on findings. | Ms. Alfred is a 61 year old female with a personal history of left breast lumpectomy in November 2008 for IDC/DCIS followed by radiation and hormonal therapy. Additional history of benign right breast biopsy in 2007. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. ... | Stable postsurgical changes in the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Reason: h/o SGL ca, s/p CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: No significant abnormality noted.CHEST WALL: No significant abnormality noted.ABDOMEN: Absence of enteric contrast material limits sensitivity for abdominal pat... | No evidence of metastatic disease. |
Generate impression based on findings. | Reason: hx H\T\N ca, post CRT, evaluate dx and compare measurements to previous scans History: as above CHEST:LUNGS AND PLEURA: No suspicious nodules or masses. No pleural effusions.Mild scarring/discoid atelectasis in the lingula unchanged.MEDIASTINUM AND HILA: No hilar or mediastinal lymphadenopathy.Cardiac size is n... | No interval change without evidence of metastatic disease. |
Generate impression based on findings. | 60 year-old female with history of renal cell carcinoma, post partial nephrectomy. Evaluate. ABDOMEN:LUNG BASES: Stable trace pericardial effusion. Mild bilateral basilar atelectasis.LIVER, BILIARY TRACT: No focal hepatic lesions. High-density material within the gallbladder likely represents bile. No intra-or extrahep... | 1.Postoperative changes of partial left nephrectomy without specific findings to suggest tumor recurrence.2.Too small to characterize left upper pole hypoattenuating lesion.3.Subcentimeter right upper pole lesion may represent a small angiomyolipoma. |
Generate impression based on findings. | 12 month old male with known hydronephrosis secondary to extrinsic compression from a known adrenal mass. History of retroperitoneal neuroblastoma. BLADDER Wall Thickness: Normal Contents: Distended and normal. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: Not observedKIDN... | Grade 2 left hydronephrosis, not significantly changed from the prior examination.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4: Grad... |
Generate impression based on findings. | Reason: evaluate pulm nodule History: smoking hx, seen on CXR LUNGS AND PLEURA: There is no correlate for the nodule noted on chest radiograph. It may have represented a pulmonary vessel on end.Calcified granuloma on the right. No suspicious pulmonary nodules. There is mild nonspecific bronchial wall thickening.MEDIAST... | 1. There is no correlate for the nodule noted on chest radiograph. It may have represented a pulmonary vessel on end. No suspicious pulmonary nodules. 2. Mild bronchial wall thickening which is nonspecific but most commonly seen with asthma or bronchitis. |
Generate impression based on findings. | 30 year-old male with history of clavicle ORIF. A screw and plate device is appreciated affixing a right midclavicular fracture without evidence of complication. The fracture lines are nearly completely indistinct compatible with continued healing. | Healing clavicle ORIF without evidence of complication. |
Generate impression based on findings. | History of left lumpectomy 3/2013 for DCIS. Patient received adjuvant radiation therapy. History of right mastopexy. History of ovarian cancer in sister. No new breast complaints. Three standard views of both breasts, an additional left ML view and 2 left spot magnification views were performed digitally and reviewed w... | Developing calcifications in the left lumpectomy bed are most likely benign dystropic calcifications in fat necrosis/oil cyst formation. A left unilateral mammogram in 6 months is recommended. Results and recommendations were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup a... |
Generate impression based on findings. | Reason: NSCLC please compare to prior exam. History: NSCLC CHEST:LUNGS AND PLEURA: Right upper lobe nodule (image 31 series 5) demonstrates significant decrease in size now measuring 15 mm x 13 mm previously measuring 21 mm x 19 mm.No additional suspicious nodules can be identified.No pleural effusions.MEDIASTINUM AND ... | 1.Interval decrease in size of the known right upper lobe nodule and clearing of the diffuse pulmonary nodules.2.Interval decrease in right hilar and mediastinal lymphadenopathy. |
Generate impression based on findings. | Reason: mets lung cancer, on Nivolumab now. Pls c/w previous study and evaluate tx response. History: lung ca CHEST:LUNGS AND PLEURA: Postsurgical changes of left lower lobectomy. Mild upper lobe predominant centrilobular emphysema is unchanged. New cluster of punctate subcentimeter nodules in the posterior right upper... | New cluster of punctate subcentimeter nodules in the posterior right upper lobe more typical of infection or aspirate than metastatic disease, though continued CT follow up is recommended. Otherwise stable CT. |
Generate impression based on findings. | Reason: met prostate cancer, evaluation of disease after 12 cycles of investigational treatment. Please complete PCWG2 form History: prostate cancer Degenerative arthritic symmetric radiotracer uptake is again noted. Stable foci of activity in the T1 spinous process and posteriorly in T7-T8 likely represent additional ... | Stable exam. No evidence of progression of bone metastases. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and an 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. Deodorant arti... | Stable benign bilateral masses. 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. | Ms. Dean is a 76 year old female with a personal history of right breast lumpectomy in June 2014 for IDC/DCIS treated with radiation and hormonal therapy. Three standard views of both breasts with two right spot compression view is were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma ... | Expected postsurgical changes in the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diag... |
Generate impression based on findings. | Reason: Evalute for interstitial lung disease History: Wheezing and crackles on exam with reported history of previous pneumonia LUNGS AND PLEURA: Patchy groundglass and mild linear interstitial abnormality diffusely distributed bilaterally. No significant honeycombing or traction bronchiectasis. Minimal airtrapping on... | 1. Persistent patchy groundglass and mild linear interstitial abnormality diffusely distributed bilaterally. No significant honeycombing or traction bronchiectasis. Presuming the patient does not have pulmonary edema, this may represent a more chronic interstitial abnormality such as NSIP.2. Stable mild nonspecific int... |
Generate impression based on findings. | 66-year-old female with history of pubic rami fractures. There are fracture deformities of the superior and inferior pubic rami with adjacent callus formation indicating healing. Moderate osteoarthritis affects the hip joints and visualized lumbar spine. Mild osteoarthritis affects the SI joints. Surgical clips project... | Chronic right pubic rami fracture deformities and degenerative arthritic changes as described above. |
Generate impression based on findings. | 79-year-old female, assess prosthetic Hardware components of a total knee arthroplasty are situated in near-anatomic alignment without evidence of complication. Vascular calcifications project over the soft tissues. | Postoperative total knee arthroplasty without evidence of complication. |
Generate impression based on findings. | 65-year-old female, postoperative assessment Hardware components of a total right hip arthroplasty are situated in near-anatomic alignment without evidence of complication. Lucency about the acetabular component appears unchanged. Surgical clips project over the soft tissues. | Postoperative changes of total right hip arthroplasty in near-anatomic alignment. |
Generate impression based on findings. | Ms. Robinson is a 87 year old female with a personal history of right breast lumpectomy in November 2009 for IDC/DCIS treated with radiation therapy. Family history of breast cancer in sister. Three standard views of both breasts with two right spot compression views were performed digitally and reviewed with the aid o... | Stable postsurgical changes in the right breast. No mammographic evidence of malignancy. Suggest clinical correlation for any further nipple discharge. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the... |
Generate impression based on findings. | 10-year-old male with known humeral fractureVIEWS: Right humerus AP and lateral (two views) 1/12/2015 Again seen is a transverse fracture through the proximal humeral metadiaphysis with increased callus formation and indistinctness of the fracture plane consistent with healing. Persistent and unchanged lateral displace... | Healing transverse fracture of the proximal humeral metadiaphysis as detailed above. |
Generate impression based on findings. | Reason: 77 y/o F with dysphagia to solids and liquids, evaluate etiology; history of breast and lung cancer Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions. Surgical clips are noted in the right axilla. Mild scoliosis is noted.Double contrast evaluation o... | 1.Extrinsic compression on the left cervical esophagus from enlarged left thyroid lobe.2.Hypopharyngeal and duodenal diverticula of doubtful clinical significance. |
Generate impression based on findings. | Multiple myeloma, follow-up Diffuse demineralization limits sensitivitySKULL: No significant abnormality noted other than extensive dental caries.CERVICAL SPINE: Mild degenerative changes most pronounced involving the lower cervical spine including disk base narrowing and osteophytes.THORACIC SPINE: Posterior fixation ... | Scattered numerous lesions largely observed in the extremities concerning for myelomatous involvement. See detail provided above |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts with an 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. No suspicious... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually. Mammography is most sensitive when assessing for interval changes. If outside mammogram is submitted, an comparison can be made.BIRADS: 1 - Negative.RECOMMENDATION: ... |
Generate impression based on findings. | Male 66 years old; Reason: metastatic head and neck cancer, evaluate for treatment. History: as above There is slight focal uptake in the left eighth rib along the lateral aspect. There is heterogeneity along the proximal aspect of the left humerus is of uncertain significance, however this is not suspicious for metast... | No suspicious uptake to suggest metastatic disease.Uptake in the left eighth rib along the lateral aspect is of uncertain significance. In the absence of additional osseous metastatic disease, this is presumably posttraumatic in nature. |
Generate impression based on findings. | 16 year old female with left leg pain for two months with thick bump over inner mid left shin.VIEWS: Left tibia/fibula AP and lateral (two views) 1/12/2015 No acute fracture or malalignment is evident. No soft tissue mass is seen. 2-mm bone excrescence arising off the medial aspect of the proximal tibial diaphysis is o... | 1.No soft tissue mass, fracture or malalignment evident.2.2-mm bone excrescence arising off the medial aspect of the proximal tibial diaphysis of uncertain clinical significance. |
Generate impression based on findings. | 57-year-old presents for 6-month follow-up of left breast calcifications. Three standard views of the left breast, laterally exaggerated CC view and spot magnification views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, ... | Probably benign calcifications in the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATIO... |
Generate impression based on findings. | Female 49 years old; Reason: hematuria and right flank pain. evaluate for nephrolithiasis History: flank pain, hematuria ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: A focal hypodensity in the inferior right liver (3:37) and is grossly stable, and likely represents a small hemangioma.SPLEE... | No evidence of obstructive uropathy.Patient is likely status post interval hysterectomy compared to images from 2011. An incompletely characterized lesion is seen in the right adnexa, measuring up to 4.6 cm. While this could represents a physiologic cyst if the ovaries were not removed, further characterization with US... |
Generate impression based on findings. | Hip pain Pelvis and right hip: Marked interval progression with increased destruction and loss of the superior margin and collapse of the right femoral head. Bone-on-bone narrowing is also increased with extensive sclerosis and subchondral cysts.Less pronounced changes of the left hip with preservation of femoral head ... | Marked interval progression since May 2014 with partial collapse and increased and now moderate to pronounced AVN of the right hip. Less pronounced interval change of the left hip. See detail provided |
Generate impression based on findings. | Pain and swelling, patient fell yesterday with left-sided weakness. Pain specifically involving anterior left knee Mild diffuse demineralization and mottled appearance appears similar to prior exams and prior previously described infarcts. Within this limitation, minimal degenerative changes of the knee are again ident... | Scattered infarcts without evidence of superimposed acute abnormality |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts, additional bilateral CC views and a left MLO view were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. Round marker was pl... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | Supracondylar fracture.VIEWS: Right elbow AP/lateral (two views) 01/12/15 Cast remains in place. Supracondylar fracture is in near-anatomic alignment. There may be some periosteal reaction. | Early healing of supracondylar fracture. |
Generate impression based on findings. | Crushing injury yesterday, tenderness No radiographic abnormality of the minimal soft tissue swelling on the dorsal aspect. Specifically alignment preserved | Mild soft tissue swelling without underlying osseous abnormality |
Generate impression based on findings. | Pain Detail obscured by overlying cast material. Postsurgical fixation of the distal radius with two K wires affixing the scapholunate and scaphocapitate articulations. Osseous structures in gross anatomic alignment. Mild underlying degenerative changes of the radiocarpal joint incompletely visualized | Surgical fixation and gross alignment preserved |
Generate impression based on findings. | Reason: Intracranial stenosis. Recurrent right hemispheric infarction. Left hemiparesis and numbness. Right common carotid artery: There is no stenosis at the carotid bifurcation on the basis of NASCET criteria. There is no evidence for carotid dissection. A right internal artery was relatively small and has delayed fl... | 1.Occlusion of the right internal carotid artery at the ophthalmic segment. The right internal artery is the supply to the right ophthalmic artery.2.Delayed arterial arrival time of the right middle and anterior cerebral artery circulations relative to the left hemisphere as well as the posterior circulation.3.Mild ath... |
Generate impression based on findings. | Ankle fracture.VIEWS: Right ankle AP/lateral/oblique (3 views) 01/12/15 Two screws remain in place in the tibial epiphysis. Alignment is anatomic. Increased callus formation is noted along the posterior lateral aspect of the tibia. Demineralization continues. | Continued healing of distal tibial fracture. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of benign right breast biopsies. Three 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. Two ... | Stable left breast calcifications. 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. | Ms. Boffman is a 82 year old female with a personal history of right breast mastectomy 1999 followed by radiation and chemotherapy. No current breast related 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 composed of scatter... | No mammographic evidence of malignancy. A left unilateral diagnostic mammogram can be performed annually as long as the patient's overall medical condition allows. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 7-week-old former 27 week gestational age patient with chylothorax.VIEW: Chest AP (one view) 01/12/15, 1202 Endotracheal tube tip is below thoracic inlet. Feeding tube tip is distal to GE junction and not included on image. Left upper extremity PICC tip is in left brachiocephalic vein. Left chest tube remains in place.... | Unchanged bilateral pleural effusion. |
Generate impression based on findings. | 59-year-old male with metastatic colon cancer status post hepatic resection in February, 2014. Evaluate for interval recurrence of disease. CHEST:LUNGS AND PLEURA: No significant abnormality noted. No parenchymal lung masses or nodules seen. No pleural disease.MEDIASTINUM AND HILA: No significant abnormality notedCHEST... | 1. Status post right hepatectomy with left lobe of liver remaining normal in appearance without evidence for metastatic disease. 2. No other sites for recurrent or metastatic disease seen. 3. Stable mild left hydronephrosis without other associated abnormality seen. |
Generate impression based on findings. | 41-year-old male with history of end-stage renal disease, exploratory laparotomy for pancreatic necrosectomy. Now leaking copious amounts of bilious fluid from incision site. Rule-out fistula, leakage of bile. ABDOMEN:LUNG BASES: Small left pleural effusion and bibasilar atelectasis. No other abnormalities.LIVER, BILIA... | 1. Open anterior abdominal wound. 2. Apparent fistulous connections from the open wound to the right lower abdomen which appears to connect with: And a second tract through to the right lateral abdominal wall. Lack of orally administered contrast limits ability to definitively evaluate adjacent bowel loops and the pote... |
Generate impression based on findings. | Abdominal pain. Constipation etiology?VIEW: Abdomen AP (one view) 01/12/15, 1227 A small amount of feces is seen in the rectosigmoid. No significantly dilated bowel loops are present. Bowel gas pattern is normal. No abnormal calcification is identified. | Normal examination. |
Generate impression based on findings. | Female 77 years old; Reason: rule out renal recurrence, special attention to left adrenal History: hx of renal cell carcinoma ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Status post cholecystectomy with stable mild intra-and extrahepatic biliary dilatation.SPLEEN: No significant abnormali... | 1.Status post left partial nephrectomy with no evidence of recurrence. Stable left adrenal nodularity. |
Generate impression based on findings. | Female 35 years old; Reason: hx of left radical nephrectomy - US from 5/2014 reveals 2 likely AML's in righ kidney please evaluate History: hx of left radical nephrectomy - US from 5/2014 reveals 2 likely AML's in righ kidney please evaluate ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: 1 c... | 1.Previously seen sonographic echogenic lesions have no direct CT correlate. No suspicious renal mass lesion is noted on today's contrast enhanced CT scan. |
Generate impression based on findings. | Male, 82 years old, history of squamous cell carcinoma of the larynx, follow up exam status post CRT. Subtle asymmetric attenuation and contour persists along the right true vocal cord without significant interval change. No discrete or measurable mass is evident at this location. The left laryngeal ventricle and left ... | Mild asymmetric attenuation and contour of the right vocal cord is unchanged and compatible with sequelae of prior therapy. No findings to suggest local tumor recurrence or pathologic adenopathy are seen. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of right breast cyst removal. History of breast cancer in maternal great aunt. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure smal... | 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. | 46-year-old female with rectal pain. Rule out rectal abscess. History provided to CT examination 2005 states ulcerative colitis status post proctocolectomy with ileoanal anastomosis and 2003. UTERUS, ADNEXA: No significant abnormality noted in the uterus. Post procedure changes seen in the fallopian tubes bilaterally.B... | 1. Status post proctocolectomy with ileoanal pouch with similar appearance to 2005 CT examination. 2. Phlegmonous changes, subcutaneous fat infiltration and emphysematous changes in the right perianal fat consistent with perianal inflammatory disease. No sizable fluid component is seen for drainage at this time. These ... |
Generate impression based on findings. | 67 year-old female with metastatic esophageal cancer status post 12 cycles of chemotherapy. Compare with previous study and evaluate treatment response. CHEST:LUNGS AND PLEURA: Multiple bilateral pulmonary and nodules/masses are again seen, predominantly unchanged or minimally changed. Measurements are provided as foll... | 1. Stable appearance to mild thickening of the mid/distal esophagus. 2. Stable pulmonary mass lesions most consistent with pulmonary metastases. 3. Stable appearance to the lytic left fifth rib lesion. Left sixth posterior rib lesion appears to represent healed rib fracture which appeared acute on the 6/12/14 CT examin... |
Generate impression based on findings. | Pain following fall Moderate effusion with underlying moderate degenerative changes similar and less pronounced in the left knee. Changes are tricompartmental yet largely and more pronounced in the medial compartment. There is however a small somewhat linear calcific density projected lateral to the tibial plateau, pos... | Moderate osteoarthritic changes without a definite superimposed acute abnormality, however small knee effusion is observed with a lateral linear calcific density. See recommendation and description above |
Generate impression based on findings. | Reason: brca - eval disease control on therapy History: breast ca CHEST:LUNGS AND PLEURA: Reference right lower lobe pulmonary nodule measures 5 x 4 mmon image 40/80, unchanged. Additional scattered pulmonary micronodules unchanged. No new suspicious lesions. Minimal basilar scarring/atelectasis. MEDIASTINUM AND HILA: ... | 1.Stable to slightly increased left breast mass, especially along the inferior margin.2.Stable osseous metastases |
Generate impression based on findings. | Left leg pain, lumbago L-spine: Scattered moderate degenerative changes with narrowing, sclerosis and osteophytes with relative sparing of L4 through S1. Alignment and vertebral body heights are both preserved. Neural foramina appear patent. Posterior elements appear intactHip: Moderate hip osteoarthritis with narrowin... | Scattered moderate degenerative changes involving both the upper lumbar spine and hip, as described. |
Generate impression based on findings. | Femur fracture, check rod Continued healing of the distal right femoral diaphyseal fracture with associated IM rod and gross anatomic alignment. The intramedullary rod appears unchanged in position with fractured distal screws, all unchanged | Continued gross stability and to minimal healing of the distal femoral fracture |
Generate impression based on findings. | Female, 41 years old, with history of esophageal cancer and subsequent lymph node in the neck with CRT to the neck. The partially visualized gastric pull-up is not significantly changed from prior. No evidence is seen to suggest locally recurrent disease along that portion of the pull-up which is visualized on this exa... | Redemonstration of postoperative findings without evidence to suggest recurrent primary tumor or pathologic adenopathy. |
Generate impression based on findings. | "Pain" Femur: Proximal small infarct unchanged. Otherwise no discrete femoral abnormality. Soft tissues remain unremarkable.Lower leg: Marked abnormal soft tissue gas involving the lower leg extending from the proximal diaphysis to the overlying accentuated soft tissues and swelling of the ankle. Extensive gas is large... | Concern for necrotizing fasciitis given the appearance or a marked abscess with probable osteomyelitis of the underlying fibula. |
Generate impression based on findings. | Reason: esophageal cancer on chemotherapy, check response History: dysphagia CHEST:LUNGS AND PLEURA: Bilateral pulmonary nodules are unchanged.Left apical nodule (image 15/106) is stable measuring 7 mm./Right lower lobe nodule (image 59/106) stable measuring 5 mm.Interval increase in right pleural effusion. New right u... | 1. Stable esophageal mass and upper abdominal lymph nodes. 2. Stable pulmonary nodules. Increased right pleural effusion.3. Stable right chest wall mass. 4. Other findings as above. |
Generate impression based on findings. | Female 76 years old Reason: AST/ALT >1000 c/w ALF, unknown baseline, please eval with Dopplers for blood flow History: as above, sepsis LIVER: The liver has a smooth contour. Liver measures 10.8 cm in length. The parenchyma is mildly coarse and echogenic. BILIARY TRACT: Gallbladder is not identified; patient is status ... | 1.Findings suggestive of chronic liver disease.2.Patent hepatic vasculature with normal directional flow |
Generate impression based on findings. | Female; 33 years old. Reason: History of breast cancer, evaluate for pulmonary embolus (pt is s/p long car ride and on anti-estrogen therapy), rib fracture History: Right sided pleuritic chest pain PULMONARY ARTERIES: No evidence of pulmonary embolism. Normal caliber of the main pulmonary artery. No evidence of right h... | No evidence of pulmonary embolism. Scattered small opacities in the right lung, some of which are nodular and others more ill-defined, may be post infectious or inflammatory in etiology. However, follow-up to resolution is advised given the patient's history of breast cancer.PULMONARY EMBOLISM: PE: Negative.Chronicity:... |
Generate impression based on findings. | Ms. Logan is a 38 year old female with a personal history of known right breast cancer currently on chemotherapy. She recently had an excisional biopsy of the left breast in July 2014 with results of focal ALH/PASH. She also had a biopsy of the left lateral breast in Nov 2014 with results of focal ALH/sclerosing adenos... | Expected postsurgical changes and stable benign calcifications on the left. Per patient, she is scheduled for a bilateral mastectomy on 1/29/2015. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Reason: PE? Re-expansion pulmonary edema s/p L-sided thora? Pleural disease? History: hypoxemia PULMONARY ARTERIES: No evidence of a pulmonary embolus.LUNGS AND PLEURA: Interval decrease in the moderate left-sided pleural effusion post thoracentesis.Interval increase in the moderate to large right pleural effusion.Unde... | 1.No evidence for pulmonary embolus.2.Bilateral pleural effusions.3.Interval decrease on the left post thoracentesis and interval increase on the right.4.Left basilar consolidation/atelectasis and edema. PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not ap... |
Generate impression based on findings. | Pain Detailed secured by overlying cast material. Gross anatomic alignment and deformity of the distal ulna identified without a discrete fracture plane consistent with interval continued healing.Scapholunate widening is now observed and difficult to determine if new or previously present due to differences in position... | Continued healing of a distal ulnar fracture with preservation of gross anatomic alignment |
Generate impression based on findings. | 12-year-old male status post ureteral reimplantation with history of megaureter/hydronephrosis. BLADDER Wall Thickness: Normal Contents: Distal aspect of the nephroureteral stent is identified within the bladder. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: Not observedKI... | Nephroureteral stent in place, without evidence of hydronephrosis or hydroureter.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4: Grade... |
Generate impression based on findings. | Stenting tongue cancer status post chemoradiation, last 10/2014.RADIOPHARMACEUTICAL: 14.0 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 95 mg/dL. Today's CT portion grossly demonstrates posttherapy changes and borderline enlarged lymph nodes in the left neck. Right chest Port-A-Cath with tip in the SVC.Tod... | Complete interval resolution of previous hypermetabolic left jugular lymph nodes without suspicious FDG avid lesion currently in the neck, chest, abdomen or pelvis. |
Generate impression based on findings. | Line placement.VIEW: Chest AP (one view) 01/12/15, 1337 The left central line has its tip at junction of superior vena cava and right atrium. Right upper extremity PICC tip is at junction of inferior vena cava and right atrium.Cardiothymic silhouette is normal in size. No focal lung opacity is present. No pleural effus... | Right PICC tip at junction of right atrium and inferior vena cava. Left central line tip in superior vena cava. |
Generate impression based on findings. | Frontal sinus: The frontal sinus and frontoethmoidal recesses are clear.Anterior ethmoids: The anterior ethmoid air cells are clear.Maxillary sinuses: Postsurgical changes of endoscopic sinus surgery with interval resection of the bilateral uncinates, increasing the maxillary outflow pathways. Small right maxillary mu... | Postsurgical changes of endoscopic sinus surgery without evidence of acute sinus disease. |
Generate impression based on findings. | Female, 70 years old.Status post lysis of adhesions and ventral hernia repair. Evaluate for radiopaque foreign object. No evidence of unexpected radiopaque foreign objects. Right and left-sided abdominal drains are present. Enteric tube with tip projecting over the proximal gastric body. Multiple surgical clips scatter... | 1.No unexpected radiopaque foreign objects. 2.Postoperative changes as above. 3.Left basilar opacity may represent atelectasis/consolidation.Findings relayed to Dr. Lee, attending surgeon, in the operating room at approximately 1:43 p.m. |
Generate impression based on findings. | 60 year-old male with history of nontraumatic middle finger pain. There is moderate to severe osteoarthritis affecting the third PIP joint, which may be secondary to remote trauma. Additional arthritic changes affect the visualized MCP joints. There is soft tissue swelling about the third PIP joint. There are no acute ... | Soft tissue swelling and degenerative arthritic changes as above. |
Generate impression based on findings. | CHEST:LUNGS AND PLEURA: Visualization of the lung parenchyma is limited by the field of view and length of scan which excludes a substantial amount of the lungs. Diffuse septal thickening and trace pleural effusions. Minimal dependant subsegmental atelectasis. No suspicious pulmonary nodules or masses.MEDIASTINUM AND ... | Mild pulmonary edema and small pleural effusions.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | There has been interval left parietal craniotomy and partial resection of the parietal calvarium. There is an expected amount of pneumocephalus. There is persistent extensive confluent cerebral white matter hypoattenuation with regional sulcal effacement, but no significant midline shift. There is no evidence of intra... | 1. Interval left parietal craniotomy and partial resection of the parietal calvarium for resection of a meningioma. Although there is no definite evidence of residual intracranial tumor, non-contrast CT is relatively insensitive for assessment of this. 2. Persistent left cerebral hemisphere vasogenic edema, but no sign... |
Generate impression based on findings. | Reason: 56 yo M with h/o fungal pna; f/u resolution on posa History: 56 yo M with h/o fungal pna; f/u resolution on posa LUNGS AND PLEURA: Stable scattered calcified and noncalcified micronodules.No focal areas of consolidation or air space opacities.Mild scarring/discoid atelectasis in the right middle lobe.Minimal up... | No acute cardiopulmonary abnormalities identified. No specific evidence of acute infection. |
Generate impression based on findings. | 57 year-old Male with head CT in China with left sided lesions reported, please evaluate. No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No suspicious mass, midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are within normal lim... | No evidence of intracranial hemorrhage or mass effect. Given patient's age, the scattered subcortical white matter hypoattenuation likely represents small vessel ischemic disease which could be confirmed with MRI. |
Generate impression based on findings. | Reason: pt with hx of esoph cancer s/p chemo rads and surg ck response, History: anemia CHEST:LUNGS AND PLEURA: Punctate micronodules are unchanged and presumably benign. No new pulmonary nodules.MEDIASTINUM AND HILA: Postop gastric pull-up. No pathologically enlarged nodes. Stable soft tissue density along superior ri... | No significant interval change or evidence of metastatic disease. |
Generate impression based on findings. | 70 year-old female with history of breast cancer. BRCA. Evaluate disease control on therapy. Abnormal osseous uptake of tracer in the sternum is not significantly changed, compatible with metastatic disease. No new suspicious sites of activity are present. | Stable sternal metastatic disease without evidence of new sites of disease or progression. |
Generate impression based on findings. | 55-year-old female with pain and stiffness, evaluate for rheumatoid arthritis There is mild pes cavus deformity bilaterally. Small talonavicular osteophytes indicate mild osteoarthritis. Mild osteoarthritic changes also affect the first metatarsophalangeal joint bilaterally. No erosions or other specific radiograph fea... | Degenerative arthritic changes without specific radiographic features of rheumatoid arthritis. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Prior mammograms at an unknown outside facility 1-1.5 years ago. Three maternal aunts with breast cancer. A total of 19 digital images had to be performed to completely cover the parenchyma of both breasts in two views, limiting the study. The examination ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | BRAIN:There is a single punctate T2 hyperintensity in the right centrum semiovale (801/18) which is new from the prior exam. The remaining moderate quantity of T2 hyperintense lesions are unchanged. T2 hyperintense lesion in the left cerebellum is unchanged. T2 hyperintense lesions in the pons are stable.The ventricle... | 1. Multiple white matter lesions throughout the brain and cerebellum compatible with patient's known MS. There is a single new punctate lesion in the right centrum semiovale, otherwise lesions are unchanged.2. Scattered cervical spinal cord lesions are unchanged. |
Generate impression based on findings. | Left-sided abdominal pain. Evaluate for renal stone ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Diffuse fatty infiltration of the liver without focal hepatic lesions. SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormalit... | 1.Findings consistent with an obstructing 3 mm stone at the proximal left ureter resulting in mild proximal hydroureteronephrosis.2.Diffuse fatty infiltration of the liver. |
Generate impression based on findings. | Right-sided gingival/mouth cancer status post reconstruction and chemoradiotherapy. History of alcohol abuse and previously had a positive urine drug screen in pain clinic for marijuana. There are postsurgical findings related to partial right hemimandibulectomy with sideplate and screw fixation and graft augmentation.... | 1. Extensive postsurgical findings in the neck without definite evidence of locoregional tumor recurrence or significant lymphadenopathy.2. Unchanged right mandibular plate fracture with anteromedial dislocation of the left mandibular condyle.3. Persistent effacement of the left fossa of Rosenmuller likely secondary to... |
Generate impression based on findings. | 72-year-old male with history of recurrent hyperparathyroidism after two prior parathyroid operations. Also s/p thyroidectomy (per EMR: subtotal right and subtotal left thyroidectomies in the late 60s and early 70s). Please evaluate for any adenomas. There is physiologic distribution of the radiopharmaceutical. On earl... | Focus of abnormal delayed radiotracer uptake posteroinferior to the left thyroidectomy bed, compatible with left parathyroid adenoma. |
Generate impression based on findings. | Reason: metastatic disease? History: renal mass LUNGS AND PLEURA: Basilar scarring and atelectasis. No evidence of pulmonary metastases. Calcified granuloma on the right.MEDIASTINUM AND HILA: No significant abnormality noted.CHEST WALL: Small axillary lymph nodes bilaterally.UPPER ABDOMEN: Absence of enteric contrast m... | No evidence of pulmonary metastases. |
Generate impression based on findings. | Recurrent breast cancer left chest wall. Restaging exam for other recurrent sites.RADIOPHARMACEUTICAL: 13.6 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 78 mg/dL. Today's CT portion grossly demonstrates surgical clips in the left axilla. Sclerotic lesions are seen in the right medial iliac wing and medial... | 1.Hypermetabolic subcutaneous soft tissue focus in the left inferomedial breast, compatible with the patient's history of recurrent tumor. A punctate hypermetabolic focus slightly more superior and medial in the left subcutaneous breast may represent a second recurrent tumor focus versus inflammation.2.Punctate hyperme... |
Generate impression based on findings. | Female 22 years old Reason: Assess small bowel abnormality History: abd pain ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS... | No abnormal findings to explain abdominal pain except possibly for greater than average stool burden which might explain constipation. Specifically no evidence of median arcuate ligament syndrome or small bowel abnormality. |
Generate impression based on findings. | Female; 64 years old. Reason: nsclc, previous therapy. History: nsclc CHEST:LUNGS AND PLEURA: Reference right upper lobe pulmonary nodule 14 x 9 mm (image 27, series 5), not significantly changed compared to prior study when it measured 13 x 9. Multiple additional nodules are also not significantly changed. Bilateral l... | No significant interval change in pulmonary nodules and bilateral basilar masslike consolidations, all most compatible with multicentric mucinous adenocarcinoma. |
Generate impression based on findings. | Recent DVT's with lovenox treatment, worsening lethargy, subarachnoid hemorrhage from ruptured ACOM aneurysm that was coiled on 7/20/14. There are post-treatment findings related to ACOM aneurysm coiling. Streak artifact from the metal hardware partially obscures surrounding structures. Within this limitation, there is... | 1. Post-treatment findings related to ACOM aneurysm coiling without evidence of large acute intracranial hemorrhage. 2. Unchanged appearance of the shunted ventricular system. 3. Chronic-appearing right inferior frontal lobe infarcts and multiple lacunar infarcts, as well as small vessel ischemic disease. |
Generate impression based on findings. | Reason: PANCREATIC NEUROENDOCRINE TUMOR EVALUATE FOR DISEASE PROGRESSION History: PANCREATIC CANCER CHEST:LUNGS AND PLEURA: Interval development of patchy ground glass opacities with a basilar predominant distribution, left greater than right. There are no discrete solid masses or pleural effusions.MEDIASTINUM AND HILA... | 1.Stable appearance of arterially enhancing hepatic lesions as described above. Stable appearance also to postnecrotic treatment scars and hypovascular prior treated lesions.2.Interval development of patchy bilateral pulmonary groundglass opacities which are nonspecific and could represent drug reaction or atypical inf... |
Generate impression based on findings. | 71 year-old female with left adrenal mass noted on the outside hospital CT. Evaluate. ABDOMEN:LUNG BASES: Left basilar bronchial mucous plugging is again noted. Cystic lesion in the left base with a thin wall, unchanged.LIVER, BILIARY TRACT: Multiple hepatic hypoattenuating lesions with peripheral nodular discontiguous... | 1.Left adrenal mass compatible with a lipid rich adenoma.2.Multiple hepatic hemangiomas. |
Generate impression based on findings. | Reason: 86 yo with CXR showing L perihilar opacity. Pls evaluated. Mild cough History: cough, abnl cxr LUNGS AND PLEURA: Small left pleural effusion. Subpleural reticulation with areas of consolidation traction bronchiectasis in the lingula (image 47/101) likely accounts for the abnormality noted on chest radiograph. T... | Abnormality on CXR represents a small left pleural effusion and subpleural reticulation with areas of consolidation and traction bronchiectasis in the lingula. This is presumably secondary to radiation pneumonitis. An underlying mass or pneumonia could be obscured by this opacity and therefore a follow-up CT in 3 to 6 ... |
Generate impression based on findings. | Ms. Rudall is a 72 year old female with a personal history of right breast lumpectomy in 2010 for IDC followed by radiation and hormonal therapy. Family history of breast cancer in maternal aunt, maternal niece, and paternal cousin. Three standard views of both breasts were performed digitally and reviewed with the aid... | Stable postsurgical changes in the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagno... |
Generate impression based on findings. | 57 years old, Male, Reason: follow up liver with suspected iron deposition. LIVER: The liver is normal in size and measures 15.2 cm in length. Significantly increased echogenicity in the parenchyma consistent with iron deposition. No focal hepatic lesions or masses are identified. The portal vein is patent demonstratin... | 1. Spleen at the upper limits of normal in size.2. Increased echogenicity of the hepatic parenchyma. |
Generate impression based on findings. | Reason: perforated duodenal ulcer s/p gram patch on 1/10/2015 History: same Injection of diluted Omnipaque 350 showed good opacification of the duodenum without evidence of contrast extravasation. The visualized stomach and proximal jejunum were unremarkable.TOTAL FLUOROSCOPY TIME: 3:14 minutes | No evidence of contrast extravasation. |
Generate impression based on findings. | Female; 60 years old. Reason: s/p left pneumonectomy, smal cell lung cancer History: follow-up CT CHEST:LUNGS AND PLEURA: Postsurgical changes from left pneumonectomy with stable expected postoperative changes and fluid in the left hemithorax. The right lung again demonstrates mild emphysema and minimal bronchial wall ... | Stable postsurgical changes in the chest. No evidence of recurrent or metastatic disease in the chest and abdomen. |
Generate impression based on findings. | Male 80 years old; Reason: metastatic prostate cancer, evaluation of disease during treatment with investigational therapy. please complete PCWG2 form History: metastatic prostate cancer, Again seen is widespread osseous metastatic lesions involving the axialskeleton including the spine, ribs, sternum, and pelvis uncha... | Unchanged multifocal osseous metastases without new lesions. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of left cyst aspiration in 2004. History of breast cancer in mother at age 55 and sister. 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... | Benign progression of bilateral calcifications. 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: NSC - Screening Mammogram. |
Generate impression based on findings. | Ms. Slazas is a 44 year old female with a personal history of right breast mastectomy in 2008 for poorly differentiated IDC followed by chemotherapy. History of left breast implant. No current breast related complaints. Three standard views of the left breast along with three implant displaced views were performed digi... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Granulation tissue left anterolateral trachea. Posterior compression on trachea distal to tracheostomy tube. Significant compression of left mainstem bronchus by a bulge of posterior tracheal wall.EXAMINATION: CT angiogram chest without and with IV contrast material 01/12/15 The heart is in the right chest. The right v... | Hypoplastic right lung. No right bronchus or right bonchi containing mucus. Compression of trachea and left bronchus at multiple levels, with stenosis/narrowing at the left mainstem bronchus. |
Generate impression based on findings. | 65 years, Female. Reason: post op ileus History: hypoactive bowel sounds, nausea/vomiting Right chest tube and epicardial leads are again seen. Patient is status post sternotomy. Pelvic phleboliths noted.Nonobstructive bowel gas pattern. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 18 year-old female with history of right thumb pain. No acute fracture or malalignment. The soft tissues are unremarkable. | No radiographic findings to account for the patient's pain. |
Generate impression based on findings. | The colon is adequately cleansed of stool and adequately distended. There is a small to moderate amount of retained liquid and liquid feces which is well tagged with oral contrast.The descending colon is a markedly redundant sigmoid and right colon. The colon in the distribution of the expected "transverse colon" is a... | Proximal and distal midgut malrotation. Nephrolithiasis. Severe diffuse fatty liver; correlate with LFTs.No significant sized colonic polyps or masses.*OPTIONAL C-RADS CLASSIFICATION:C-1E-3*(see full definitions in: Zalis et al. CT Colonography reporting and data system: a consensus proposal. Radiology 2005;236:3-9)C1:... |
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