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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, version 9.3. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. A cluster of pleomorphic calcifications has developed when co... | Developing cluster of pleomorphic calcifications at upper outer quadrant in the left breast. Spot magnification views with possible ultrasound study are recommended. BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EC - Additional Mammo/Ultrasound Workup Required. |
Generate impression based on findings. | 49-year-old female callback from screening mammogram for new focal asymmetry within the left upper inner quadrant. One standard ML view and two spot compression views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure sm... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Reason: low back pain, evaluate for instability History: see above Four views of the lumbar spine demonstrate grade 1 anterolisthesis of L4, which does not change on flexion/extension views. Anterior vertebral body osteophytes are most prominent at L4, but are also present at L3 and L5. There is mild multilevel disk sp... | Degenerative arthritic changes as above. No evidence of instability. |
Generate impression based on findings. | Female; 79 years old. Reason: eval for perf/abscess or other acute process History: severe abdominal pain and TTP, recent colonoscopy, vomiting ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Status post cholecystectomy. SPLEEN: No significant abnormality notedPANCREAS: No significant abnormal... | No significant interval change or acute abdominopelvic abnormality. |
Generate impression based on findings. | Pain and swelling. Evaluate for inflammatory arthritis. Three views of the left hand show narrowing of the DIP joints of the middle, ring, and fifth fingers indicating osteoarthritis, most severely affecting the fifth DIP joint. We see no specific evidence of inflammatory arthritis. A small lucency with sclerotic margi... | Osteoarthritis without radiographic features of inflammatory arthritis. |
Generate impression based on findings. | Female, 7 months old. Cough, hypoxia, increased work of breathing. Evaluate for pneumonia.VIEW: Chest AP (one view) 4/1/15, 1420 The cardiac silhouette is mildly enlarged.Mild peribronchial thickening. Right upper lobe and bilateral lower lobe opacities, compatible with atelectasis, increased from prior.No significant ... | Cardiomegaly with increasing bilateral pulmonary opacities on a background of bronchiolitis. |
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, version 9.3. The breast parenchyma is extremely dense, limiting the sensitivity of mammography and increasing the importance of physical examination, unchanged i... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral 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, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. Stable benign masses and calcificatio... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - 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, version 9.3. The breast parenchyma is mostly fatty replaced, unchanged in pattern and distribution. Stable right duct ectasia and bilateral calcifications are pr... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard and pushback views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. Retropectoral silicone implants ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - 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, version 9.3. The breast parenchyma is composed of scattered fibroglandular elements. No suspicious masses, microcalcifications or areas of architectural distorti... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - 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, version 9.3. Tomosynthesis images are also obtained. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distributio... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of benign bilateral breast biopsies. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD, version 9.3. Tomosynthesis images are also obtained. The breast parenchyma is heterogeneously dense, unchanged in pa... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 45-year-old female. Evaluate for breast masses in patient with prior calcifications. Three standard views of both breasts, additional right laterally and medially exaggerated CC views and right MLO and ML spot magnification views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | The ventricles and sulci are within normal limits. FLAIR hyperintensity associated with the left greater than right atrial choroid likely are related to incidental xanthogranulomas. The basal cisterns remain patent. There is no midline shift or mass effect. There are no areas of abnormal signal. There is no diffusion ... | Unremarkable noncontrast MRI of brain. |
Generate impression based on findings. | Female 97 years old Reason: esophagus dil History: esoph dilation. Limited study due to poor patient positioning and compliance.Single contrast evaluation of the esophagus showed a dilated and patulous esophagus. There was aperistalsis of contrast which flowed with gravity. No contrast was observed to pass through the ... | 1. Aperistalsis with patulous and dilated esophagus. 2. No passage of contrast through the GE junction. Follow up abdominal plain films are recommended for continued observation of passage of contrast through esophagus. When patient is mobile and can tolerate standing up, examination may be reattempted. |
Generate impression based on findings. | 59-year-old female status post left lumpectomy in 1995 with radiation and hormonal therapy. Family history of breast cancer diagnosed in maternal aunts at age 75 and 56. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered ... | 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. | Reason: hip pain mild OA in the past. R/o progression History: hip pain; s/p bilateral knee replacements Four views of the lumbar spine demonstrate severe disk space narrowing of L4-5 and L5-S1. There is grade 1 anterolisthesis of L4. Anterior vertebral body osteophytes affect the lower lumbar spine. Vacuum joint pheno... | 1.Degenerative arthritic changes of the lumbar spine as above.2.Bilateral total knee arthroplasties as above. |
Generate impression based on findings. | 70 year-old female with groundglass opacity pneumonitis. LUNGS AND PLEURA: Stable to mild interval improvement of basilar predominant groundglass opacities with mild interstitial thickening and bronchiectasis. Minimal bronchial plugging. No focal consolidation. No honeycombing. Subcentimeter scattered nonspecific micro... | Stable to mild improvement in basilar predominant groundglass opacities which may represent early NSIP. |
Generate impression based on findings. | The ventricles and sulci are prominent, consistent with mild to moderate global volume loss greater than expected for the patient's stated age. The basal cisterns remain patent. There is no midline shift or mass effect. There is question subtle asymmetrically a right anterior and medial temporal white matter 1101/23 a... | 1. Equivocal finding of asymmetric there hyperintensity in the anteromedial right temporal pole subcortical white matter which is nonspecific. Correlation with clinical history and EEG findings is recommended.2. Mild to moderate global volume loss greater than expected for the patient's stated age. |
Generate impression based on findings. | Female 45 years old Reason: infertility History: infertility Scout AP film of the pelvis was normal. Opacification of the uterine cavity revealed a normally oriented uterine cavity without mucosal irregularity or filling defects in the uterine cavity. The left tube freely opacified with free spillage on the left side i... | Normal uterine cavity. Patent left fallopian tube. No opacification of the right fallopian tube. |
Generate impression based on findings. | Reason: pain to leg, evaluate for fracture History: pain and swelling Two views of the tibia/fibula demonstrate thick periosteal reaction along the posteromedial aspect of the distal tibial diaphysis and underlying endosteal callus formation. There is also a poorly defined longitudinal lucency in the adjacent cortex. | Distal tibial stress fracture as above.Findings discussed with Maricela Sandoval by phone at the time of dictation. |
Generate impression based on findings. | Reason: fx f/u History: pain Three views of the right shoulder demonstrate a side plate and screws affixing a proximal humeral fracture, in near anatomic alignment. The bones appear slightly demineralized. There is no radiographic evidence of hardware complication. The fracture plane is slightly indistinct, which may r... | Orthopedic fixation of proximal humeral fracture, as above. |
Generate impression based on findings. | 51 year-old female with left ankle injury 3 weeks ago, with continued pain and swelling. Three views of the left ankle and 3 views of the left foot demonstrate mild soft tissue swelling along the lateral aspect of the ankle. A tiny linear density dorsal to the head of the talus could conceivably represent a tiny minima... | Small linear density dorsal to the talus could conceivably represent a minimally displaced avulsion fracture, if this corresponds to the area of the patient's pain. We otherwise see no acute fracture. |
Generate impression based on findings. | 51-year-old male with history of orthotopic heart transplant with subpleural nodular opacities. LUNGS AND PLEURA: Right upper and middle lobe ground glass opacities have resolved. Residual left lower lobe scarring/atelectasis. No suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: Severe ... | Resolved right upper and middle lobe ground glass opacities. Persistent left basilar atelectasis/consolidation. Resolving pericardial effusion. |
Generate impression based on findings. | Reason: history of knee injury with swelling and increased protrusion. Rule out fluid vs fibrosis vs calcification vs bone on bone vs other. History: knee injury Four views of the left knee demonstrate moderate osteoarthritis with osteophytosis and mild medial compartment joint space narrowing. A well corticated ossifi... | Joint effusion and degenerative arthritic changes, without evidence of acute fracture. |
Generate impression based on findings. | The internal auditory canals are symmetrical and normal in size and signal intensity. The inner ears are normal, with normal T2 signal and no pathological enhancement. No abnormal mass or abnormal enhancement is seen within the cerebellopontine angle, cisterns bilaterally or within the internal auditory canals.The ven... | 1. Unremarkable contrast-enhanced MR appearance of the IACs.2. Moderate-severe chronic small vessel ischemic changes without acute infarct. Scattered foci of susceptibility likely relating to chronic hemosiderin deposition, or less likely mineralization3. Mild narrowing and irregularity of the posterior cerebral arteri... |
Generate impression based on findings. | Metastatic ovarian carcinoma CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Stable left thyroid nodule.CORONARY ARTERY CALCIFICATION: None.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY TRACT: Stable hepatic dome subcentimeter cystic focus.SPLEEN: No significant abno... | Interval decrease in size of left pelvic adenopathy. |
Generate impression based on findings. | Reason: lumbar pain History: lumbar pain Two views of the lumbar spine demonstrate minimal multilevel degenerative disk disease, particularly affecting L2-3. The vertebral body heights are preserved. Alignment is within normal limits. Surgical clips project over the L2 vertebral body as well as the right upper quadrant... | Minimal degenerative disk disease, otherwise, normal appearing spine. |
Generate impression based on findings. | 44 years, Male. Reason: OG placement History: OG The pelvis is excluded from the field of view. There is a nasogastric tube with its tip out of the field of view and likely in the duodenum, but its side port projects over the antrum of the stomach. Please refer to concomitant chest radiograph for thoracic findings. | NG tube side port projects over the antrum of the stomach, the tip is out of the field of view and likely in the duodenum. |
Generate impression based on findings. | 17-year-old female evaluate for sarcoidVIEWS: Chest PA/lateral (two views) 4/1/15 at 1449 The cardiothymic silhouette is normal. Overall low lung volumes. Left lower lobe opacity likely represents atelectasis. No pleural effusion or pneumothorax. No lymphadenopathy. | No lymphadenopathy. Scattered subsegmental atelectasis. |
Generate impression based on findings. | Reason: eval for gouty changes History: PIP 2 swelling and pain x 6 weeks, worse past 2 weeks; she is s/p injection today Three views of the right hand demonstrate significant swelling of the soft tissues of the index finger. There is severe osteoarthritis of the distal interphalangeal joint and to a lesser degree the ... | Soft tissue swelling of the index finger and arthritic changes of the hand, which appear predominantly degenerative in etiology. We see no specific radiographic features of gout. |
Generate impression based on findings. | Dislocated/open fracture. Question of fracture. Three views of the right hand show complete dorsal dislocation of the middle finger PIP joint. No definite acute fracture is identified. Soft tissue swelling is noted about the middle finger. | Complete dislocation of the middle finger PIP joint. No definite fracture is identified, however, post-reduction radiographs are recommended. |
Generate impression based on findings. | 16 year-old male with neutropenic fever CHEST:LUNGS AND PLEURA: Bilateral pleural effusions, left greater than right. Compressive atelectasis secondary to pleural effusions. Again the left atelectasis is worse secondary to a larger left pleural effusion. Scattered ground glass opacities are present along the right majo... | 1. Bilateral pleural effusions and compressive atelectasis, left greater than right. Ground glass opacities within the right upper lobe may be infectious or inflammatory in etiology.2. Extensive postsurgical changes of the mediastinum with sacrifice of the left brachiocephalic vein. The left internal jugular and left s... |
Generate impression based on findings. | Male 68 years old; Reason: hx of penile cancer, please evaluate pelvic and inguinal lymph nodes History: see above ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: There is normal morphology. No suspicious hepatic lesions. The hepatic and portal veins are patent. Gallstones layer within the ga... | 1.Postsurgical changes of penectomy. There is residual enhancing soft tissue at the surgical margin suspicious for residual disease.2.Stable to decrease in the size of the inguinal nodes. |
Generate impression based on findings. | There is conventional takeoff of the great vessels from the aortic arch without evidence for stenosis of the origin of the great vessels or of the bilateral vertebral arteries. Retropharyngeal left internal carotid artery noted. Attenuation of the left carotid caliber on post-contrast images which is likely due to art... | Unremarkable MRA neck. |
Generate impression based on findings. | 22-year-old male with history of leukocytosis and tachycardia. Evaluate for infection. LUNGS AND PLEURA: Motion limits sensitivity, especially at the bases. Tracheostomy tube is in place. There is minimal dependent atelectasis. No suspicious nodules or masses. No evidence of infection.MEDIASTINUM AND HILA: Metallic fra... | No specific evidence of infection in the chest. Resolving superior mediastinal hematoma is better evaluated on same day neck CT. |
Generate impression based on findings. | Female; 71 years old. Reason: Severe pain in L hip/groin - no improvement after injections, possibly referred from knee; now with recurrent breast CA, history of RA. Decreased soft tissue activity overlying the left breast is compatible with prior mastectomy. Mild osteoarthritis of the right hip and moderate osteoarthr... | 1.No evidence of bone metastases or fracture.2.Moderate left hip osteoarthritis which may be contributing to the patient's symptoms. |
Generate impression based on findings. | Restaging tonsillar cancer status post chemoradiation completed January 2014. Lung mass.RADIOPHARMACEUTICAL: 10.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 96 mg/dL. Today's CT portion grossly demonstrates bilateral maxillary sinus mucus retention cysts or polyps. Left anterior chest wall Port-A-Cath w... | No convincing FDG avid tumor currently. Several mild to moderately hypermetabolic foci involving lymph nodes in the left neck and mediastinum as well as a left lower lobe pulmonary parenchymal opacity are all considered more likely inflammatory than tumor. Attention to these regions can be made follow-up exams. |
Generate impression based on findings. | Altered mental status with question of seizure like activity. There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. The mastoid air cells are clear. There is... | No evidence of acute intracranial hemorrhage or mass. However, CT is insensitive for the detection of seizure foci and an MRI may be useful for further evaluation if there are no contraindications. |
Generate impression based on findings. | Left clavicular pain, evaluate for fracture.VIEWS: Left clavicle AP and axial 4/1/15 (two views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Loss of balance/hand dexterity. Lumbar spinal stenosis. Evaluate for spondylolisthesis/DDD. The junction of C7/T1 is not visualized due to overlying anatomy. Two views of the cervical spine show severe degenerative changes of the cervical spine with grade 2 anterolisthesis of C3 on C4. There is severe degenerative spac... | Severe degenerative arthritic changes as above. |
Generate impression based on findings. | Pain and swelling. Left foot injury. Evaluate for fracture. Three views of the left foot show no acute fracture or malalignment. No soft tissue swelling is seen. | No acute fracture is evident. |
Generate impression based on findings. | 54-year-old female with bilateral knee pain Four views of the right knee demonstrate perhaps slight varus deformity of the knee. No evidence of acute fracture or joint effusion. Four views of the left knee demonstrate perhaps slight varus deformity of the knee. No evidence of acute fracture or joint effusion. | Slight varus deformity bilaterally, otherwise, normal exam. |
Generate impression based on findings. | Penile cancer status post resection. Staging exam. Attention pelvic/inguinal lymph nodes.RADIOPHARMACEUTICAL: 14.0 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 90 mg/dL. Today's CT portion of the neck and chest demonstrates an approximately 1.3 cm densely calcified right upper lobe pulmonary nodule. Multi... | 1.Markedly hypermetabolic activity involving the distal resected penile margin is suspicious for recurrent tumor although could also represent significant inflammation.2.Multiple small somewhat hypermetabolic bilateral inguinal lymph nodes, inflammatory versus metastatic.3.Two small somewhat hypermetabolic right lower ... |
Generate impression based on findings. | 59-year-old male patient. Living kidney donor transplant CT scan. CT ANGIOGRAM: The aorta and its branches are normal in caliber without significant atherosclerotic changes. The celiac axis, SMA, and bilateral single renal arteries are patent without significant abnormality. Replaced left hepatic artery to the left gas... | 1.Renal vasculature anatomy as described above.2.No significant intra-abdominal abnormalities. |
Generate impression based on findings. | Three weeks of right groin pain and intermittent right lower extremity paresthesias without trauma. Evaluate for hip pathology. AP view of the pelvis and bilateral views of the hips show no acute fracture or malalignment. The bilateral hips, pubic symphysis, and sacroiliac joints appear normal for age. | No specific radiographic findings to account for the patient's symptoms. |
Generate impression based on findings. | 64 year old male with history of MM; post-auto SCT evaluation. RADIOPHARMACEUTICAL: 9.4 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 92 mg/dL. Today's CT portion grossly demonstrates postsurgical changes in the midline occipital region. Sclerosis of the left lateral fourth rib is compatible with a healing... | No suspicious FDG avid lesions to indicate current tumor activity. If the prior outside PET exam is submitted, an official comparison can be made. |
Generate impression based on findings. | Reason: cervical neck pain with h/o trauma, eval for instability History: see above Two views of the cervical spine demonstrate perhaps slight loss of height of the C5 vertebral body anteriorly, but the clinical significance of this is uncertain. On the extension view, there is minimal (1mm or less) of retrolisthesis o... | 1.Slight loss of height of C5 of uncertain clinical significance. CT may be considered for further evaluation, if clinically warranted.2.We see no frank instability. |
Generate impression based on findings. | Female; 48 years old. Reason: Ct per living donor kidney protocol History: kidney donor CT ANGIOGRAM: Normal caliber of the abdominal aorta and its branch vessels. The celiac artery, SMA, single bilateral renal arteries, and IMA are patent.ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Cholel... | Conventional renal anatomy as detailed above. |
Generate impression based on findings. | Female 21 months old Reason: r/o pneumonia History: difficulty breathingVIEWS: Chest AP/lateral (two views) 4/1/15 at 1552 hrs.COMPARISON 9/20/14 at 1155 hours. Gastrostomy tube and pectus carinatum again noted. No focal lung opacities, effusions or pneumothorax | Normal examination. |
Generate impression based on findings. | Male; 68 years old. Reason: SBO History: Abdominal pain and distention, h/o SBO ABDOMEN:LUNGS BASES: Minimal basilar atelectasis.Coronary artery stents.LIVER, BILIARY TRACT: No focal hepatic lesions. Cholelithiasis within the gallbladder remnant, similar to prior study. Stable dilation of the common bile duct with dist... | Distal small bowel obstruction without evidence of ischemia. |
Generate impression based on findings. | Fever of unknown origin workup in a neutropenic patient: history of synovial myxoid sarcoma. There is moderate mucosal thickening within portions of the left maxillary sinus. There are also subcentimeter hyperattenuating structures projecting into the alveolar recess of the maxillary sinuses, which may represent ectopi... | 1. No evidence of acute sinusitis.2. Fluid levels within the left mastoid air cells may indicate mastoiditis. |
Generate impression based on findings. | 24 year-old female with history of bilateral air space opacities on chest radiograph. Evaluate for consolidation, edema, or PE. PULMONARY ARTERIES: No evidence of acute pulmonary embolus.LUNGS AND PLEURA: There are diffuse bilateral groundglass opacities, worse at the bases with bibasilar atelectasis/consolidation. The... | 1. No evidence of acute pulmonary embolus.2. Diffuse bilateral ground glass opacities, small bilateral pleural effusions, and bibasilar atelectasis/consolidation which is favored to represent acute edema, although infection is possible but considered less likely given appearance.PULMONARY EMBOLISM: PE: Negative.Chronic... |
Generate impression based on findings. | Female 7 years old Reason: r/o fracture History: pain s/p fallVIEWS: Left elbow and wrist AP, lateral and oblique the left forearm AP and lateral 4/1/15 (8 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Male, 10 years old. Reason: signs of hemosiderosis, ground glass opacities History: cough, hypoxia, concern for Heiner's Syndrome LUNGS AND PLEURA: Atelectasis of the apical posterior segment of the left upper lobe and superior segment of the lingula. Scattered streaky subsegmental atelectasis of the bilateral lower lo... | Nonspecific mild scattered ground glass opacity in lower lobes and scattered streaky subsegmental atelectasis. |
Generate impression based on findings. | Male; 75 years old. Reason: 75 y/o mesothelioma receiving chemotherapy, restage History: see above ABDOMEN:LUNG BASES: See report from dedicated CT chest performed concomitantly. LIVER, BILIARY TRACT: Stable right hepatic hemangioma measuring up to 1.6-cm (series 7/38). Cholelithiasis.Right pleural mesothelioma seen ex... | No evidence of intra-abdominal invasion of mesothelioma. No evidence of metastatic disease in the abdomen or pelvis. |
Generate impression based on findings. | Leukocytosis in context of retropharyngeal hematoma from GSW to neck, now s/p trach, evaluate for increase air tracking in the neck planes History: leukocytosis, tachycardia There is a left carotid artery stent without evidence of a residual pseudoaneurysm. There are postoperative findings related to neck exploration w... | 1.The left carotid artery stent appears to be patent and without evidence of residual pseudoaneurysm.2.Continued evolution of postoperative findings related neck exploration with a residual bullet lodged in the right paraspinous muscles lateral to the cervical spine at the C5 level and a BB pellet in the right paratrac... |
Generate impression based on findings. | 75-year-old male with mesothelioma receiving chemotherapy, for restaging. LUNGS AND PLEURA: Interval resolution of large right pleural effusion and improvement in adjacent atelectasis. Prominent nodularity along the major and minor fissures may have been obscured by the large right pleural effusion.At the level of the ... | 1. Interval resolution of large right pleural effusion and improvement of atelectasis2. Better appreciation of diffuse nodular pleural disease with extension into the fissures with reference measurements as above. |
Generate impression based on findings. | Male, 14 years old. sc pain and swelling of 1-2 week after a pop in basketball. Eval for left sc separationVIEWS: Sternoclavicular joints AP, right oblique (two views) 4/1/15, 1551Multiple unsuccessful attempts were made at a left oblique view. Only AP and right oblique images are provided.The right sternoclavicular jo... | Limited radiographic imaging without evidence of sternoclavicular joint separation. If there is continued strong clinical concern, CT imaging may be useful for further evaluation. |
Generate impression based on findings. | 67 year-old female with left lower pelvic pain ABDOMEN:LUNG BASES: Minimal bibasilar atelectasis.LIVER, BILIARY TRACT: Liver is enlarged measuring 19.8 cm in craniocaudal dimension with nodular contour suggestive of cirrhosis. Hypodense focus in the right hepatic lobe is too small to characterize but appears stable sin... | 1. Cirrhotic liver morphology. Hypodense focus in the right hepatic lobe is too small to characterize but stable since CT study in 2006 likely a benign cyst. 2. Bilateral non obstructing nephrolithiasis. 3. Cholelithiasis with no evidence of cholecystitis. |
Generate impression based on findings. | Hip dislocation.VIEWS: Pelvis AP and frog leg on 7/16/14 (2 view/s) Bilateral hardware or VDRO is noted and unchanged. Left femur coxa valga deformity with 25% uncovering of the femoral head. Right femoral head is well directed into the acetabulum. Mild fecal accumulation. | Unchanged appearance of the hips. No hardware complication. |
Generate impression based on findings. | 6 year old male with grade 3 left hydronephrosis, evaluate flow and function; assess for UPJ obstruction. The exam demonstrates an apparent horseshoe kidney congenital variant with prompt, symmetric perfusion to the bilateral renal moieties on angiographic images. There is also prompt uptake and excretion of the radiop... | 1.Apparent horseshoe kidney congenital variant with symmetric function of both moieties. 2.Moderately dilated left pelvicaliceal system which demonstrates prompt washout of radiotracer without evidence of current obstruction. |
Generate impression based on findings. | Intractable epilepsy.RADIOPHARMACEUTICAL: 63 mCi F-18 fluorodeoxyglucose (FDG)BLOOD GLUCOSE (FASTING): 90 mg/dL Today's CT portion demonstrates no gross intracranial pathology.Today's PET examination is trace very slight decreased activity corresponding to the left anterior and mid temporal lobe. Given history, this is... | Very slight hypometabolism involving the left anterior and mid temporal lobe is of some suspicion but equivocal for an interictal seizure focus. |
Generate impression based on findings. | Male; 72 years old. Reason: NSCLC restaging after 6 cycles of chemotherapy. RADIOPHARMACEUTICAL: 10.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 95 mg/dL. Today's CT portion grossly demonstrates extensive mainly right paramediastinal upper lung opacities consistent with post radiation inflammation. Foca... | Marked improvement with near complete to complete resolution of hypermetabolic tumor burden. Focal nodular uptake at the right lung apex may reflect inflammation or small residual tumor metabolism. |
Generate impression based on findings. | Clinical question: Fall and syncope. Signs and symptoms: Syncope. Nonenhanced head CT:There is no detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.There is mild prominence of cortical sulci and ventricular system as well as the cerebellar and ... | 1.No acute intracranial process.2.Mild prominence of cortical sulci, ventricular system and cerebellar vermian folia for age. |
Generate impression based on findings. | Clinical question: Evaluate for hemorrhage. Signs and symptoms: AMS. Nonenhanced head CT:There is no detectable acute intracranial hemorrhage, mass, mass effect or midline shift or hydrocephalus.Diffuse periventricular and subcortical low attenuation right matter highly suggestive of age indeterminate small vessel isch... | 1.No acute intracranial process.2.Extensive age indeterminate small vessel ischemic strokes. |
Generate impression based on findings. | Clinical question: Rule out ischemia. Signs and symptoms: Right-sided weakness. Nonenhanced head CT:No detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system and CSF spaces in the supr... | 1.No acute intracranial process.2.Parenchymal volume loss of cerebellum and vermis for patient's stated age of 46. |
Generate impression based on findings. | Clinical question: 74-year-old male with history of previous CVA, now altered mental status. Signs and symptoms: AMS. Nonenhanced head CT:There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect or midline shift.Large focus of encephalomalacia involving the cortex and subcortical white matter of ... | 1.No acute intracranial process.2.Large chronic left MCA territory ischemic stroke and a small chronic right superior cerebellar stroke as detailed. |
Generate impression based on findings. | Clinical question: Evaluate ICH. Signs and symptoms: ICH. Nonenhanced head CT:The examination demonstrates stable severely dilated right lateral ventricle. Extensive acute hemorrhage in the left lateral ventricle and a smaller amount in the dependent right occipital horn demonstrate no change. Deviation of midline to t... | 1.No convincing evidence of an acute or new findings since prior exam.2.Stable severely dilated right lateral ventricle.3.Stable rightward deviation of midline since prior exam.4.Stable extensive left ventricular hemorrhage and left parietal acute hemorrhage. |
Generate impression based on findings. | Clinical question: Evaluate ICH. Signs and symptoms: ICH. Unenhanced head CT:No convincing evidence of internal change in size or extent of a large right cerebellar and vermis acute hematoma since prior exam. Surrounding vasogenic edema and associated mass effect evident by decreased for ventricular size, crowding at t... | 1.No convincing evidence of an acute or new finding since prior exam.2.Large dissecting hematoma in the right cerebellum and vermis remains a stable.3.Increased intracranial pressure in the posterior fossa nearly identical to prior exam.4.Dilated supratentorial ventricular system and right frontal approach ventricular ... |
Generate impression based on findings. | Clinical question: Evaluate ICH. Signs and symptoms: Evaluate ICH. Unenhanced head CT:Examination demonstrate a stable large focus of vasogenic edema surrounding a previously evacuated hematoma cavity is again identified and without evidence of change.Patchy foci of acute hemorrhage within this region as well as serosa... | 1.There is no evidence of any acute or new finding since prior exam.2.Stable large focus of vasogenic edema, patchy foci of acute parenchymal hemorrhage, serosanguineous density of the evacuated hematoma cavity and overall mass effect from the constellation of findings remains identical to prior study.3.Shunted non-dil... |
Generate impression based on findings. | Male 46 years old; Reason: Evaluate for progression of metastatic disease; compare to previous scan if able. CHEST:LUNGS AND PLEURA: Multiple solid pulmonary parenchymal lesions bilaterally that have increased in size since prior examinations. A reference lesion in the right lower lobe measures 3.2 x 2.6 cm (series 5, ... | 1.Multiple solid pulmonary metastases have increased in size compared to prior study.2.New small hilar lymph nodes are new compared to prior study.3.Presacral soft tissue is equivocally fuller on today's study. Attention can be paid to this area on follow-up surveillance imaging.4.Splenomegaly of uncertain significance... |
Generate impression based on findings. | known right hemispheric SDH Maximum diameter of the known right hemispheric SDH is measured about 9.6mm, this is slightly increased in size since prior exam. In addition, mass effects toward underlying right hemisphere also appears to be slightly aggravated comparing to prior exam. However, the degree of midline shift ... | Slightly increased maximum diameter of the right hemispheric SDH and its mass effects toward underlying right hemisphere since prior exam as described above.Discussed with Neurosurgery team at the time of this dictation. |
Generate impression based on findings. | Female, 6 years old. Evaluate Dobbhoff tube placement.VIEW: Abdomen AP (one view) 4/1/15, 1703 Enteric tube coiled upon itself, with tip terminating in the body of the stomach. The guidewire is in place. There may be a kink in the catheter just distal to the guidewire tip.Nonobstructive bowel gas pattern. Small-to-mode... | Enteric tube with tip in the gastric body. |
Generate impression based on findings. | 12-week-old male with pneumothorax.VIEW: Chest AP (one view) 4/2/15 at 0708 Endotracheal tube is at the level of carina. Nasogastric tube tip proximal side-port are within the gastric body.Cardiothymic silhouette is normal. Small persistent left apical pneumothorax. No mediastinal shift. Left lower lobe retrocardiac op... | Small persistent left apical pneumothorax, decreased from prior. |
Generate impression based on findings. | 12-week-old male post intubationVIEW: Chest AP (one view) 4/1/15 at 2055 Endotracheal tube is just above the level of the carina. Nasogastric tube with tip and side-port in the gastric body.The cardiac thymic silhouette is normal. New left apical pneumothorax. Retrocardiac opacity suggests atelectasis/consolidation. Mi... | New left apical pneumothorax. |
Generate impression based on findings. | Male, 5 years old. Reason: 5 yo M with multiple food allergies s/p ng tube placement. eval tube locationVIEW: Abdomen AP (one view) 4/1/15, 1759 Enteric tube with distal side port below the GE junction.Nonspecific mild dilation of bowel loops, without evidence of obstruction. Small to moderate stool burden.No free air.... | No evidence of obstruction. Enteric tube tip within the stomach. |
Generate impression based on findings. | 12-week-old male with pneumothorax.VIEW: Chest AP (one view) 4/2/15 at 0454 Endotracheal tube is at the level of the carina. Nasogastric tube tip and partial side-port are within the gastric body.Multiple overlying lines and tubes obscure fine detail of the left hemithorax. Persistent left apical pneumothorax. Left low... | Persistent left apical pneumothorax. |
Generate impression based on findings. | Colon cancer, malaise and fatigue No evidence of acute ischemic or hemorrhagic lesion on this scan.Multifocal patchy non specific small vessel ischemic disease.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shi... | No evidence of acute ischemic or hemorrhagic lesion on this scan. |
Generate impression based on findings. | 8-year-old female with pain and swellingVIEWS: Right wrist PA, lateral; right forearm AP, lateral; right elbow AP, oblique, lateral (7 views) 4/1/15 at 2255 Right wrist: No fractures are identified in the wrist. No malalignment or significant soft tissue swelling.Right forearm and elbow: Elbow joint effusion is present... | Salter-Harris II fracture of the radial head. Elevated periosteum along the proximal ulnar metaphysis may represent a healing fracture or subperiosteal hematoma. |
Generate impression based on findings. | Known bi-hemispheric subdural hemorrhage follow-up Bihemispheric subdural hematoma with midline shift toward right side, no change since prior exam.Previously shown SAH on the left hemisphere is not demonstrated on this scan.There is no evidence of new ischemic or hemorrhagic lesion on this scan.Right anterior temporal... | 1. No interval change of bihemispheric subdural fluid collections, midline shift toward right side and postop changes since prior exam.2. No evidence of new ischemic or hemorrhagic lesion on this scan. |
Generate impression based on findings. | 61 year-old female with dyspnea on exertion PULMONARY ARTERIES: Technically adequate examination without evidence of pulmonary embolism. Main pulmonary artery caliber is within normal limits. LUNGS AND PLEURA: Central airways are patent. No pneumothorax or pleural effusion. Linear atelectasis in the lingula. Mild centr... | 1.No evidence of pulmonary embolism.2.Soft tissue density in the anterior mediastinum is nonspecific and may represent a lymph node or residual thymic tissue. 3.Mild centrilobular and paraseptal emphysema. PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applic... |
Generate impression based on findings. | Reason: osteomyelitis History: diabetic with foot wound No osteophytes are seen to suggest osteomyelitis. No acute fracture or malalignment is evident. | No definitive evidence of osteomyelitis. MRI is more sensitive in the detection of osteomyelitis. |
Generate impression based on findings. | 65-year-old female patient with history of cecal cancer, untreated, here with diffuse abdominal pain. ABDOMEN:LUNG BASES: No suspicious pulmonary nodules.LIVER, BILIARY TRACT: Subcentimeter bilobar hypoattenuating lesions are too small to characterize.SPLEEN: No significant abnormality noted.PANCREAS: No significant ab... | 1.Small bowel obstruction with transition point at cecal mass.2.Cecal mass with regional lymph node involvement and concern for tumor spread along the lateral colonic fascia.3.Subcentimeter hypoattenuating lesions in the liver are too small to characterize, however, they are concerning for metastatic disease.4.Soft tis... |
Generate impression based on findings. | 63 year-old female. Severe flank pain, strong family history of kidney stones (5 out of 11 siblings). Lack of intravenous and oral contrast limits evaluation for solid organ pathology.ABDOMEN:LUNG BASES: Bibasilar linear scarring and/or subsegmental atelectasis.LIVER, BILIARY TRACT: No significant abnormality notedSPLE... | 1. No renal or ureteral stones. 2. 1.8 cm cystic focus in the left adnexa, for which further evaluation with pelvis US is recommended. |
Generate impression based on findings. | Reason: Status post middle finger PIP reduction History: Status post middle finger PIP reduction Overlying splint material limits fine bone detail. There has been interval reduction of the previously seen dislocation of the third PIP joint. There is subtle cortical irregularity along the posterior aspect of the third m... | Status-post reduction of third PIP dislocation. No definite fracture plane is identified. Subtle cortical defect in the third metacarpal, without overlying soft tissue swelling is unlikely to represent a fracture. However, follow-up may be considered, as clinically indicated. |
Generate impression based on findings. | 12-year-old male with fever and coughVIEWS: Chest PA/lateral (two views) 4/1/15 at 2304 Cardiothymic is normal. Bronchial wall thickening and mild increase in lung volumes is consistent with bronchiolitis/reactive airway disease pattern. Streaky left basilar retrocardiac opacity likely represents atelectasis. | Bronchiolitis/reactive airway disease pattern. |
Generate impression based on findings. | 26 years, Male. Reason: eval for obstruction History: n/v Nonobstructive bowel gas pattern. Visualized lung bases are unremarkable. Linear metallic density overlying left lung compatible with patient's nipple piercing. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Male; 64 years old. Reason: concern for aneurysm , dissection History: chest pain, hx of abdominal pulsatile mass CT ANGIOGRAM:No acute aortic dissection or rupture.Normal caliber of the thoracic aorta. Minimal atherosclerotic calcifications of the thoracic aorta. Moderate atherosclerotic calcifications of the coronary... | 1. No acute aortic dissection or rupture or other acute abnormality is evident.2. Stable ectasia of the distal abdominal aorta and right common iliac artery.3. Stable small, calcified distal right renal artery aneurysms. |
Generate impression based on findings. | 2-day-old female with congenital diaphragmatic herniaVIEW: Abdomen AP (one view) 4/1/15 at 2331 The endotracheal tube tip is below the thoracic inlet and above the carina. Enteric tube with tip in the gastric body and most proximal sidehole in the esophagus. UVC in the right atrium. UAC at T9 - T10.The cardiothymic sil... | Large left congenital diaphragmatic hernia. Moderate to large right pneumothorax. |
Generate impression based on findings. | 52 years, Male. Reason: assess for colonic dilation History: see above Several gas-filled loops of small bowel are present in the mid abdomen with gas seen in the colon which may reflect an ileus. No specific evidence of colonic distention. Contrast is noted in the right hemiabdomen. | Gas-filled loops of small bowel are present in the mid abdomen with gas seen in the colon which may reflect an ileus. No specific evidence of colonic distention. |
Generate impression based on findings. | Male 16 hours old Reason: evaluate umbilical line placement, lung fields History: 31.4 week twin with RDS on CPAP with newly placed umbilical linesVIEW: Chest and abdomen AP (two views) 4/1/15 at 1658 hrs. NG tube terminates at GE junction. UAC tip is at T9. UVC terminates at the left portal vein.The aortic arch, cardi... | Misplaced NG tube and umbilical lines.Diffuse lung haziness consistent with TTN versus RDS.Normal abdominal gas pattern. |
Generate impression based on findings. | Male, 4 years old. Reason: r/o bladder perforation s/p foley placement History: bright red urine in Foley, tender abdomenVIEW: Abdomen AP (one view) 4/1/15, 1806 High density lymphangiographic contrast material within inguinal pelvic and abdominal lymph nodes. Previously administered IV contrast opacifies the bladder. ... | No specific radiographic evidence of bladder leak. |
Generate impression based on findings. | 62-year-old male with history of metastatic head and neck cancer. RML nodule biopsy proven metastatic disease. CHEST:LUNGS AND PLEURA: There is a well marginated nodule in the anterior aspect of the right middle lobe measuring 9 mm, previously 11 mm (image 60 of series 5). A second nodule is present in the left upper l... | 1. Bilateral metastatic pulmonary nodules are stable to slightly decreased in size. No new sites of disease identified.2. Soft tissue density in the anterior mediastinum may represent thymic hyperplasia. |
Generate impression based on findings. | Male 10 years old Reason: follow up History: sepsisVIEW: Chest AP (one view) 4/2/15 at 506 hours. NG tube is transpyloric, tip is not visualized. Central line terminates at the right atrium. Pericardial drain unchanged. ET tube terminates below thoracic inlet.Cardiac silhouette size is enlarged, but stable. Persistent ... | Multifocal opacities in the right side pleural effusion unchanged. |
Generate impression based on findings. | MVC, rule out bleed Head: No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hydrocephalus.Small right maxillary muc... | 1. No evidence of intracranial hemorrhage or skull fracture.2. No evidence of fracture or subluxation within the cervical spine.3. Emphysematous changes in the lung apices |
Generate impression based on findings. | 65 years, Female. Reason: s/p ng placement, confirm if in stomach History: small bowel obstruction. There is a nasogastric tube with its tip projecting over the body of the stomach. Focally dilated loop of small bowel in the midline pelvis is compatible with distal small bowel obstruction seen on recent CT examination.... | Nasogastric tube tip projects over the body of the stomach. |
Generate impression based on findings. | Female 70 years old; Reason: hx of microscopic hematuria, evaluate for disease with delayed imaging, CT urogram History: see above ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality not... | 1.No evidence of renal stone or renal or ureteric mass. There is mild focal circumferential bladder wall thickening however the bladder is suboptimally distended and it is not possible to evaluate for focal lesion.2.Severe bilateral osteoarthritis of both femoroacetabular joints with bilateral iliopsoas bursitis and jo... |
Generate impression based on findings. | Postoperative changes are seen from interval C1 laminectomy and suboccipital decompression. On sagittal T1-weighted images, the previously seen small plaque-like dorsal mid C2 level meningioma is no longer appreciated, also consistent with interval resection. There is therefore resolved mass effect upon the dorsal asp... | 1. Interval expected postoperative changes with decreased crowding of structures around the level of the intramedullary cervicomedullary junction presumed ependymoma, with resolved mass effect on the dorsal cord at the mid C2 level due to interval resection of a small meningioma.2. Grossly stable appearance of other sc... |
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