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Generate impression based on findings. | Female, 54 years old, with subdural hemorrhage now more somnolent. An aneurysm coil is redemonstrated in the right paraclinoid region. Streak artifact from the coiling obscures visualization of the right middle cranial fossa.Parenchymal hemorrhage is partially visualized in the right anterior temporal lobe. Thin subdur... | 1.Stable ischemic lesions in the right frontal operculum, right parietal and occipital lobes, and right caudate nucleus.2.Stable thin subdural hemorrhage along the right cerebral hemisphere.3.Stable parenchymal hemorrhage in the right anterior temporal lobe which is partially visualized. No new intracranial hemorrhage ... |
Generate impression based on findings. | 55 years, Female, Reason: 55 you F with history of breast cancer now with suspected progresssion of disease with rising tumor marker. History: lower back pain. Lesion at the left lesser trochanter is unchanged. Increased uptake in the medial left distal femur is unchanged. Increased uptake within the thoracolumbar spin... | Stable exam. No new lesions evident. |
Generate impression based on findings. | Check for cartilage disorder Mild scapholunate widening raising concern for ligamentous injury without additional distinct radiographic abnormality. Soft tissues unremarkable | Questionable scapholunate ligamentous injury |
Generate impression based on findings. | Check wrist fracture healing Continued interval healing and increased visualization of the fracture planes involving the distal radius and ulnar styloid fractures. This is compatible subacute timing. Decreased soft tissue swelling | Interval continued healing of the distal radial and ulnar styloid fractures. No new complications or interval change in alignment |
Generate impression based on findings. | Reason: Evaluate for PE and lung nodules History: OSH CT scan with report of PE but not anticoagulated, also report of pulmonary nodules and lymphadenopathy. PULMONARY ARTERIES: Technically adequate. Previously bilateral lower lobe segmental pulmonary emboli are no longer visualized. No acute pulmonary embolus. LUNGS A... | 1.Interval resolution of bilateral lower segmental pulmonary emboli. No acute pulmonary embolus.2.Interval resolution of right apical ground glass opacity in bilateral lower lobe consolidation. This may have represented infarct or hemorrhage. Residual scarring in the bases.3.No evidence of lymphadenopathy in the chest.... |
Generate impression based on findings. | 86-year-old male with history of HCC and TACE procedure. CHEST:LUNGS AND PLEURA: Biapical scarring. Moderate centrilobular emphysema. Two 5-mm left lower lobe pulmonary nodules have not significantly changed when compared to the chest CT from 1/2015, although continued follow-up is recommended. No pleural effusions or ... | 1. Progressive multifocal hepatocellular carcinoma as above with new arterial enhancing lesions in segment 4/5, highly suspicious for additional sites of disease.2. Unchanged EVAR with type 2 endoleak. |
Generate impression based on findings. | Check fracture healing Mild calcification without change in underlying alignment indicates continued healing of the oblique distal fibular fracture. Mortise remains intact. Soft tissues unremarkable with partially decreased soft tissue swelling | Healing distal fibular fracture |
Generate impression based on findings. | 51-year-old female patient status post right lumpectomy for DCIS presents for bilateral diagnostic mammogram. History of breast carcinoma in maternal aunt diagnosed at the age of 40. Three standard views of both breasts, two spot magnification views of the right breast, and repeat CC view of the right breast were perfo... | Expected post lumpectomy changes in the right breast and ectatic ducts 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 -... |
Generate impression based on findings. | Pain Interval removal of overlying cast material. Distal radial fracture continues to demonstrate healing with callus formation and less well visualized fracture planes | Healing distal radial fracture without a change in alignment |
Generate impression based on findings. | History of dysphagiaEXAMINATION: Oropharyngeal motility study 10:30:00 Dana Sussman, speech and language therapist, supervised the examination.2:25 minutes of fluoroscopy was used.Positive for aversive behaviors, bolus holding, increased oral transit time, decreased bolus control, and decreased posterior bolus propulsi... | Patient tolerated small taste of thin liquids. Aspiration with nectar thick liquid with slightly delayed cough that cleared aspiration. Patient to follow up with ENT. Please see the speech and language therapist's report for feeding recommendations. |
Generate impression based on findings. | 49 year old female with history of right lower quadrant and flank pain. ABDOMEN:LUNG BASES: Minimal dependent atelectasis bilaterally.LIVER, BILIARY TRACT: Multiple hypoattenuating foci with the liver parenchyma, nonspecific but may represent benign cysts. Indeterminate focus of hypoattenuation (3/34) can be evaluated ... | 1.Right UVJ 3-mm stone and associated right renal perinephric stranding.2.Indeterminate hypoattenuating focus in the left lobe of the liver, may be evaluated with ultrasound or dedicated hepatic imaging. |
Generate impression based on findings. | Radicular pain Moderate degenerative changes with mild reversed or doses of the mid cervical spine largely affecting C3 through C6. Posterior foramina appear grossly patent however with unremarkable overlying soft tissues. | Moderate osteoarthritic largely involving the mid cervical spine |
Generate impression based on findings. | 84 year old male. Gout? CPPD? RA? erosions? Left knee: Severe osteoarthritis, lateral greater than medial tibiofemoral compartment with bone-on-bone apposition. Tricompartmental osteophytes. Vascular calcifications. Bony excrescence arising from the posterior lateral femoral diaphysis. Right knee: Severe osteoarthritis... | Osteoarthritis, as described above, with erosive osteoarthritis affecting the hands. |
Generate impression based on findings. | 8 years, Female, Reason: To determine if delayed gastric emptying. Patient has family history of delayed gastric emptying History: nausea, intermittent vomiting, abdomnal pain. Visually there was significant and progressive gastric emptying. Using anterior and posterior geometric means, residual gastric activity at the... | Gastric emptying within normal limits. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are images from stereotactic guided right breast biopsy (3/13/2015) performed at Rush University Medical Center. For comparison, bilateral screening mammogram (6/27/2014), right diagnostic mammogram (8/21/2014), images from right stereotactic guided bre... | Post-biopsy images of the right breast demonstrating a dumbbell-shaped clip at the site of biopsy, with no significant residual calcifications identified. Per reports, this biopsy revealed grade 3 DCIS. MRI can be considered to evaluate extent. Additionally, needle-wire localization can be performed for surgical guidan... |
Generate impression based on findings. | The procedure, indications, benefits, risks/complications and alternatives were described to the patient and informed consent was obtained. The patient was placed in the prone position and the inferior back was prepped with Betadine, draped and anesthetized with 1% lidocaine subcutaneously into the deeper soft tissues... | Successfully performed lumbar puncture without complications. |
Generate impression based on findings. | Rhabdomyosarcoma, assess for pulmonary metastases LUNGS AND PLEURA: No focal lung opacity or suspicious nodule. No pleural effusions. MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Cardiac size is normal. No pericardial effusion.CHEST WALL: Small bilateral axillary lymph nodes, of no clinical significan... | No evidence of pulmonary metastatic disease. |
Generate impression based on findings. | 54-year-old male status post urethroplasty on 3/18. Check for extravasation of urine. Suprapubic catheter in place. The bladder was maximally distended with approximately 550 cc's of Cystografin. No filling defects or mucosal abnormalities are identified within the bladder. Note is made of a smooth long segment strictu... | 1. Long segment stricture of the posterior/prostatic urethra, with reference measurements provided above.2. The patient experienced difficulty voiding with resultant significant bladder post void residual. |
Generate impression based on findings. | 82-year-old male with bladder cancer -- please evaluate upper tracts. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: Normal right adrenal gland. Small Left adrenal... | 1. Persistent diffuse bladder wall thickening. 2. New marked dilatation of bilateral ureters entire length to the bladder without obstructing mass or lesion seen of uncertain etiology, but bilaterality raises question of reflux. 3. Right ureter focal circumferential wall thickening with enhancement -- while this may re... |
Generate impression based on findings. | Reason: evaluation right upper lobe History: evaluation right upper lobe. Patient with history of NSCLC status post CRT and right upper lobe wedge resection on 12/12/2014. LUNGS AND PLEURA: Redemonstration of postsurgical changes of the right upper lobe wedge resection. Septal thickening, traction bronchiectasis, and a... | 1.Postsurgical changes of right upper lobe wedge resection. Loculated hydropneumothorax at site of resection is slightly decreased compared to prior. A definitive bronchopleural fistula is not seen.2.Unchanged 5 mm right lower lobe pulmonary nodule. No new nodules.3.Scattered left upper lobe bronchial/bronchiolar wall ... |
Generate impression based on findings. | 55-year-old male status post robotic prostatectomy. Evaluate for extravasation of contrast. Foley catheter in place. Approximately 300 cc's of Cystografin was instilled via the patient's existing Foley catheter. The bladder is normal in appearance and contour without evidence of filling defect or mucosal irregularity. ... | Anastomotic leak at the level of the prostatic urethra, as detailed above. These findings were relayed to the clinical service (pager 9301) via phone at 12:30 p.m. on 4/6/2015. |
Generate impression based on findings. | Reason: head and neck cancer/ post induction scans History: see above CHEST:LUNGS AND PLEURA: New ground glass and interstitial opacity in the left lower lobe posteriorly is most likely due to aspirate though continued follow-up is recommended. A similar but milder abnormalities noted at the right posterior lung base. ... | 1. Stable reference left paratracheal lymph node. An additional posterior mediastinal node on the left is stable to marginally increased. Continued follow-up is recommended to exclude growth/metastases.2. New ground glass and interstitial opacity in the left lower lobe posteriorly is nonspecific but most likely due to ... |
Generate impression based on findings. | History of HNC and anaplastic lymphoma for staging. Per EPIC, Merkel Cell CA was diagnosed in November 2014 and patient had surgery in 3/2015. History of NHL diagnosed in 2010 that was treated via living donor stem cell transplant in 2011. HEAD: There is no evidence of acute intracranial hemorrhage or mass effect. The ... | 1. Postoperative findings related to a right parotidectomy with nonspecific soft tissue within the parotidectomy bed. This can serve as a baseline study for future studies. Followup as clinically warranted.2. Progression of right level 2A, 3, 4 and supraclavicular fossa lymphadenopathy. 3. Subcentimeter right thyroid l... |
Generate impression based on findings. | 3-year-old male with history of right single kidney and left sided megaureter. BLADDER Wall Thickness: The urinary bladder is thickened. Contents: The bladder is partially distended with anechoic urine. Distal Ureter -- SFU Grade** Right: 2 Ureteral Jets Right: Not observed KIDNEYS Cortical Echogenicity: Normal ... | Persistent right hydroureteronephrosis appearing similar to the prior study. 1.2-cm lower collecting system echogenic focus may represent a non-shadowing renal calculus.*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 a... |
Generate impression based on findings. | Mandibular hypoplasia and trismus from trama. There is deformity of the bilateral mandibular condyles, which demonstrate irregular and sclerotic subchondral bone with flattening of the articular surfaces as well as subchondral cyst formation. There is associated hypertrophic bone along the lateral aspect of the mandibu... | 1. Post-traumatic mandibular deficiency associated with bilateral temporomandibular joint degenerative changes and pseudoarthroses between the mandibular necks and zygomatic arches bilaterally and associated 10 mm of maxillary overjet and 6 mm of overbite, but no evidence of bony ankylosis. An MRI of the temporomandibu... |
Generate impression based on findings. | 51-year-old female with complex solid and cystic right breast mass presents for ultrasound guided right breast biopsy. Right ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a mixed echogenicity mass which is difficult to measure in a single image due to large size. The area to be bio... | Successful ultrasound-guided aspiration and core biopsy of the right breast lesion and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | History of alveolar rhabdomyosarcoma. Assess for progression of disease. UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: Reference right inguinal lymph node measures 11 x 6 mm (series 9, image 38), stable from prior study.BOWEL, MESENTERY: Small amount of pelvic f... | 1.No distinct mass visualized in the right ischioanal fossa.2.Stable faintly-enhancing non-specific right acetabular lesion.3.Unchanged reference right inguinal lymph node.4.Stable post-therapy related changes in the right internal obturator muscle. |
Generate impression based on findings. | 45-year-old male with a history of rectal cancer. Status post LAR 3/11/15. Please evaluate healing of the anastomosis. Note is made of postsurgical changes consistent with the patient's history of LAR. The anastomosis appears widely patent without evidence of significant stenosis, occlusion, or anastomotic leak. The an... | Postsurgical changes without evidence of anastomotic leak or other complication, as clinically questioned. |
Generate impression based on findings. | Metastatic prostate carcinoma CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: Interval increase in size of AP window lymph node seen on image 39 of series 3 measuring 1.7 x 1.9 cm; this is in comparison to 1.5 x 1.6 cm on 2/2/2015.CORONARY ARTERY CALCIFICATION: Severe.CHEST WALL: No signif... | Slight interval increase in size of presumably metastatic AP window mediastinal lymph node; otherwise stable examination. |
Generate impression based on findings. | Redemonstrated are changes from right frontal craniotomy. There is decreasing minimal blood products in the surgical cavity. There is residual underlying postoperative/tumoral vasogenic edema, and persistent mass effect is again noted on the anterior horn of the right lateral ventricle. Overlying scalp changes have re... | 1.Expected postoperative changes involving bifrontal lobes.2.If there is continued clinical concern for acute ischemia, MRI would be recommended. |
Generate impression based on findings. | 75 years, Male. Reason: abdominal distension History: abdominal distension Multiple dilated loops of small bowel with relative paucity of gas within the colon is suggestive of a small bowel obstruction. Multiple surgical clips and suture material project over the pelvis. No acute cardiopulmonary abnormality is identifi... | Findings suggestive of small bowel obstruction.Findings discussed with the ordering provider, Dr. Choi, on 4/6/15 at 15:33. |
Generate impression based on findings. | Reason: follow up lung cancer History: fatigue CHEST:LUNGS AND PLEURA: Right upper lobe subpleural mass abutting the right major fissure measures 28 x 30 mm (series 5 image 20). Adjacent postobstructive atelectasis/consolidation due to narrowing of the right upper bronchus by right hilar lymphoid tissue. Probable surro... | 1.Right upper lobe mass compatible with patient's history of known primary lung cancer. 2.Right hilar lymphoid tissue with narrowing of the right upper bronchus and postobstructive atelectasis/consolidation. Possible invasion into the right pulmonary artery. 3.Subcarinal lymphadenopathy. 4.Left adrenal nodule may repre... |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: Large right apical bullae and fibrosis is unchanged from the prior study. Right middle lobe and right basilar lung scarring is unchanged. No new pulmonary nodules.MEDIASTINUM AND HILA: Status post tracheostomy. Right chest p... | No evidence of pulmonary metastases |
Generate impression based on findings. | Reason: check position of NG tube History: ? positioning of tube The pelvis is excluded from the field-of-view. An NG tube tip projects over the distal gastric body. Multiple surgical clips are again seen in the pelvis. A right-sided vascular stent, compatible with recent TIPS procedure is unchanged. Residual contrast ... | NG tube in the distribution of the distal gastric body. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of breast cancer in mother diagnosed at 65 years of age. Two standard digital views of both breasts and additional right MLO were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular densi... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Male 64 years old. Reason: R scapula chondrosarcoma, evaluate for recurrence. History: above. Two views of the left scapula again demonstrate postoperative changes of a partial scapular resection as previously described. There are small ossicles along the humeral head which may represent loose bodies, but these appear ... | Postoperative changes of a partial scapular resection without evidence of tumor recurrence. |
Generate impression based on findings. | Fall from monkey bars, evaluate for fractureVIEWS: Left elbow PA oblique lateral (3 views) 13:15:27, left forearm AP lateral (2 views) 13:02:56, left wrist PA oblique lateral (3 views) 12:58:59 Elbow: No evidence of acute fracture or malalignment. No joint effusion.Forearm: Displaced fracture of the distal radial diaph... | Fracture of the distal radial diaphysis with posterior angulation. |
Generate impression based on findings. | Age: 69 years. Sex : Male. Reason for study: Reason: head and neck ca post crt scans History: as above. Fluoroscopic guidance was provided for an oropharyngeal motility study performed by the Speech Pathology section of the ENT service. The examination was recorded on videotape. No static or hard copy films were obtain... | The exam was negative for penetration and negative for aspiration. |
Generate impression based on findings. | Female 51 years old. Reason: pain. History: pain. One view of the pelvis shows a circular focus of sclerosis in the left femoral head suggesting avascular necrosis. The sclerotic focus measures approximately 2.5 cm in diameter. We see no subchondral fracture or articular surface collapse.Two views of the right hip show... | 1. Mild osteoarthritis of the right hip with cam deformity.2. Findings suggestive of avascular necrosis of the left femoral head. |
Generate impression based on findings. | 48-year-old male with history of cirrhosis. HCC screening. LIVER: The liver measures 17 cm in length. Liver parenchyma coarsely echogenic with a nodular contour, consistent with history of cirrhosis. No evidence of biliary ductal dilatation. The portal vein demonstrates hepatopetal blood flow. Common duct is normal in ... | Hepatic cirrhosis without mass or other new significant abnormality. |
Generate impression based on findings. | 32-year-old female. Evaluate ORIF. Two screws affix a proximal radial head fracture in anatomic alignment. The fracture line is less distinct with mild sclerosis at its margins indicating interval healing. | Healing radial head fracture in anatomic alignment. |
Generate impression based on findings. | Reason: lung CA, s/p chemoRT. followup scan History: cough CHEST:LUNGS AND PLEURA: Significant interval reduction in size of the spiculated right upper lobe mass (image 42 series 4) now measuring 2.1 cm x 2.7 cm previously measuring 2.9 cm x 3.6 cm.Previously noted satellite nodule cannot be identified on this exam.Sev... | 1.Significant interval reduction in left upper lobe spiculated mass with resolution of the previously noted satellite nodule.2.Interval decrease in mediastinal and right hilar lymphadenopathy.3.No new sites of disease identified. |
Generate impression based on findings. | 27-year-old female. Hand pain status post fall. Right hand: No fracture or dislocation.Right wrist: No fracture or dislocation. | No significant abnormality. |
Generate impression based on findings. | Redemonstrated is hypodensity within the white matter, confluent in locations, without associated mass effect The ventricles and sulci are normal in size. There are no masses, mass effect or midline shift. There is no evidence for intracranial hemorrhage or acute cerebral or cerebellar cortical infarction. There are n... | Small vessel ischemic disease of indeterminate ages. If there is continued clinical concern for acute ischemia, MRI would be recommended. |
Generate impression based on findings. | Female 63 years old Reason: is there arthritis? History: knee pain and crepitus. Swollen DIP joints. Four views of the right knee demonstrate near bone-on-bone apposition of the medial tibial-femoral compartment and tricompartmental osteophytes indicating moderate to severe osteoarthritis. We see no large joint effusio... | Osteoarthritis of the hands and right knee. |
Generate impression based on findings. | Lymphoma CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: No significant abnormality noted.CORONARY ARTERY CALCIFICATION: MinimalCHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY TRACT: Stable low attenuation fociSPLEEN: Previously noted splenic focus not appreciated on c... | Stable examinationCurrent exam date/time: 4/6/2015 11:30:00INDEX LESION MEASUREMENTSSEGMENT 7 RIGHT LOBE LIVER MASS: 1.1 x 0.8 cm (Image 80, Series 4); 0.9 x 1.1 cm on prior (1/6/2015) (Image 75, Series 3).SEGMENT 6 RIGHT LIVER LOBE LESION: 2.1 x 1.2 cm (Image 107, Series 4); 1.6 x 2.2 cm on prior (1/6/2015) (Image 101... |
Generate impression based on findings. | 35-year-old female. Right knee pain. Evaluate for arthritic changes. History of gout. Tricompartmental osteophytes and mild joint space narrowing, medial greater than lateral tibiofemoral compartment, consistent with mild osteoarthritis. Minimal osteoarthritis affects the left knee as seen on the frontal view. No acute... | Mild osteoarthritis. |
Generate impression based on findings. | 46-year-old male with history of bladder cancer status post cystectomy and neobladder creation. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: The heart size is normal without pericardial effusion. No mediastinal or hilar lymphadenopathy.CORONARY ARTERY CAL... | 1. Increase in left sided hydronephrosis raising the question of stent malfunction.2. Stable soft tissue mass involving the left mid to distal ureter and left pelvic wall soft tissue mass with adjacent osseous erosion. |
Generate impression based on findings. | 26-year-old female. Right femur chondrosarcoma. Status post curettage. Evaluate for recurrence. Elongated postsurgical defect along the lateral aspect of the distal femoral metadiaphysis with bone graft material in the medullary space, similar to prior. Again seen are small densities in the soft tissues lateral to the ... | Postoperative changes of chondrosarcoma curettage and bone grafting, not significantly changed. |
Generate impression based on findings. | 64 year old female status post right lumpectomy in 2004 for DCIS, presents today for routine follow up. Patient received radiation therapy. No current breast complaints. No family history of breast cancer. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast ... | Stable postsurgical changes of 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. | 56-year-old male. History of fracture. Evaluate for interval healing. Oblique fracture of the distal fibula in anatomic alignment. Indistinctness of the fracture line and adjacent callus formation indicating healing. Vascular calcifications. Calcific Achilles tendinopathy. | Healing distal fibula fracture. |
Generate impression based on findings. | 72 year old female with history of right-sided abdominal spasms. LIVER: The liver measures 13 cm in length. Liver parenchyma is of normal homogeneous echogenicity. No evidence of biliary ductal dilatation. The portal vein demonstrates hepatopetal blood flow. Common duct is normal in caliber measuring 5 mm in diameter. ... | No significant abnormality to explain the patient's history of spasms. |
Generate impression based on findings. | 64-year-old male with cough, wheezing. History of ARDS, COPD. LUNGS AND PLEURA: Marked interval improved aeration of the lungs with minimal residual ground glass opacities predominately in the anterior upper lobes bilaterally. Emphysema. Bronchial wall thickening with multiple areas of mucus plugging.No pleural effusio... | Bronchial wall thickening with multiple areas of mucus plugging. Improved interstitial and ground glass opacities, likely improved edema. |
Generate impression based on findings. | Reason: metastatic breast CA with pleural effusion. Followup History: shortness of breath LUNGS AND PLEURA: Small left pleural effusion, slightly decreased compared to prior. Upper lobe predominant centrilobular and paraseptal emphysema. No suspicious pulmonary nodule or mass.MEDIASTINUM AND HILA: Right chest port with... | 1.Small left effusion, slightly decreased in size.2.No new findings in the chest.3.Fullness in the region of the left adrenal gland and pancreatic tail appears more prominent than prior 10/7/2014 exam, and similar to prior 12/10/2014 exam. Recommend continued observation with special attention paid to this region. |
Generate impression based on findings. | Reason: r/o dysphagia History: dysphagia Scout fluroscopic image of the chest showed mediastinal and hilar calcifications with no abnormal pulmonary opacities, or pleural effusions.Double contrast evaluation of the esophagus and gastric cardia/fundus revealed an approximately 1.2 x 8mm midesophageal anterior outpouchin... | 1. Diverticulum of the mid esophagus as described above - this could be a traction diverticulum given adjacent calcifications, with a pulsion diverticulum also to be considered.2. Esophageal dysmotility, as described above. Hold up of barium tablet at the gastroesophageal junction could be related to this dysmotility, ... |
Generate impression based on findings. | Female 19 years old. Reason: eval for fx. History: soreness and weakness after arm caught in car door. Per the technologist, the patient denied pain. The patient experienced only numbness and stiffness. Three views of the left wrist demonstrate no fracture or malalignment.Two views of the left humerus show no fracture. | No fracture evident. |
Generate impression based on findings. | Reason: assess lungs - pneumonia, pneumothorax, trapped lung History: persistent pneumothorax LUNGS AND PLEURA: Moderate small right hydropneumothorax. Interval placement of right chest tube with tip at the right base posteriorly. Small to moderate left pleural effusion, increased compared to prior. Right middle lobe n... | 1.Moderate right hydropneumothorax with right chest tube, new compared to prior CT, with associated compressive atelectasis. Tip of chest tube is located posteriorly within the fluid. Discussed with Dr. Dante at time of dictation.2.Small to moderate left pleural effusion, slightly increased compared to prior.3.Left upp... |
Generate impression based on findings. | 65 your old female. Prosthetic assess. Hardware components of a total right knee arthroplasty in near anatomic alignment without radiographic evidence of hardware complication. Moderate osteoarthritis affects the left knee as seen on the frontal view. | Total right knee arthroplasty device without radiographic evidence of hardware complication. |
Generate impression based on findings. | Esophageal cancer s/p stent and jejunal pull up. A limited single contrast evaluation of the esophagus and gastric cardia/fundus was performed. The patient was unable to be placed upright and could not rotate/turn.Given these limitations, there was no obvious leak of contrast. There was hold up of contrast as it traver... | Limited study as above. No obvious leak. Hold up of contrast through the stent and moreso at the anastamosis could be related to postsurgical edema, but correlate with procedural timeframe. |
Generate impression based on findings. | 54-year-old male with history of multiple myeloma. Screening for clinical trial. Baseline plasmocytoma evaluation. CHEST:LUNGS AND PLEURA: Minimal bibasilar atelectasis and small pleural effusions. Scattered small foci of groundglass opacities, some of which are more nodular in appearance (5/36), nonspecific. Minimal e... | Interval increase in size of plasmacytomas with corresponding osseous lytic lesions as above. |
Generate impression based on findings. | 62 years old Male. Reason: s/p initial consult, needs staging for treatment History: h/o HNC and anaplastic lymphoma. RADIOPHARMACEUTICAL: 12.03 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 102 mg/dL. Today's CT portion grossly demonstrates several small lymph nodes in the right neck. Hepatomegaly and spl... | 1.New FDG avid hypermetabolic lymph nodes in the right neck and diffuse and intense FDG uptake in the enlarged liver, consistent with lymphoma.2.Inflammatory change in the right lung. |
Generate impression based on findings. | 49 year-old female with right empyema status post chest tube. LUNGS AND PLEURA: Left sided pulmonary nodules appear increased in size and number from prior study. For example in the left upper lobe a solid nodule measures 19 mm x 14 mm (series 5, image 32) previously 11 mm x 11 mm. Left apical nodule measures 7 mm (ser... | 1. Extraluminal contrast right posterior to the distal esophagus near the hiatus presumably due to leak. Persistent right hydropneumothorax though the air component has marginally decreased. 2. Increasing size and number of left sided pulmonary nodules which are nonspecific. The relatively rapid change is more typical ... |
Generate impression based on findings. | 83year old female with a history of left lumpectomy and sentinel node biopsy for IDC on 09/12. Patient underwent radiation therapy only. Patient has history of keloids over the chest. No current breast complaints. Three standard views of both breasts 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 diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.Findings reviewed with Dr. S. Kulkarni at the time of dictation. BIRADS: 2 - Benign finding.RECOMMENDAT... |
Generate impression based on findings. | 32 year old male. Pain. Evaluate for fracture. Again seen is an oblique fracture through the proximal fifth metatarsal diaphysis in near anatomic alignment. The fracture line is indistinct medially with increased sclerosis consistent with interval healing. | Healing fifth metatarsal fracture. |
Generate impression based on findings. | 65 years old, Male, History: presyncope with standing Head CT: There is no evidence of intracranial hemorrhage or mass. Evidence of old infarct in the left cerebellar hemisphere. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or... | 1. No evidence of intracranial hemorrhage, mass, or cerebral edema.2. No evidence of intra- or extracranial arterial stenosis, occlusion, or aneurysm.3. Evidence of old infarct in left cerebellar hemisphere. |
Generate impression based on findings. | 61 years, Male, Reason: evaluation of RML preoperatively History: evaluation of RML preoperatively. The ventilation images show a uniform distribution of activity on single-breath and wash-in images. There is no abnormal Xe-133 retention during the wash-out phase. The perfusion images show a physiologic distribution of... | Normal symmetric ventilation and perfusion images as quantified above. |
Generate impression based on findings. | 51-year-old female. Right hand pain and weakness. No fracture or dislocation. Bones appear within normal limits for patient age. | No abnormality to explain the patient's symptoms. |
Generate impression based on findings. | 31-year-old female. Right distal fibula fracture. Evaluate for healing. Nondisplaced oblique fracture of the distal fibula. The fracture line is indistinct and mild callus formation is seen at its lateral aspect consistent with healing. Orthopedic screws are again seen in the first metatarsal. Mild soft tissue swelling... | Healing distal fibula fracture. |
Generate impression based on findings. | 75 year old female. Fall. No acute fracture or dislocation. Chondrocalcinosis in the pubic symphysis and right hip joint. Vascular calcifications and injection granulomas. Mild osteoarthritis of the hips. Mild degenerative changes of the lower lumbar spine. | Osteoarthritis and chondrocalcinosis. No acute fracture is identified. |
Generate impression based on findings. | Age: 61 years. Sex : Male. Reason for study: Reason: HNSCC. 1Y FUP post CRT. 10-069 protocol. History: as above. Fluoroscopic guidance was provided for an oropharyngeal motility study performed by the Speech Pathology section of the ENT service. The examination was recorded on videotape. No static or hard copy films we... | The exam was positive for penetration and positive for aspiration. |
Generate impression based on findings. | 22-year-old male. Metacarpal fracture. Evaluate for healing. Transverse fracture of the fourth metacarpal in the mid-diaphysis with significantly increased dorsal and radial angulation of the distal fracture fragment. Mild callus formation is seen adjacent to the fracture. | Significantly increased dorsal and radial angulation of the 4th metacarpal fracture. |
Generate impression based on findings. | Abdominal pain concerning for Crohn's diseaseEXAMINATION: MR enterography without and with IV contrast ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No ... | Abnormal wall thickening and enhancement of the descending colon, sigmoid colon and rectum representing inflammatory bowel disease. The small bowel including the terminal ileum is normal.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 76 years, Male, Reason: metastatic prostate cancer, evaluation of disease after 6 cycles of investigational therapy. please complete PCWG2 form History: metastatic prostate cancer. Left sacral lesion is unchanged.. Right inferior pubic ramus lesion is unchanged. Left mid humerus lesion is unchanged. No new suspicious l... | No significant change. No new lesions. |
Generate impression based on findings. | 31 year-old female with a history of UC, status post IPAA in 1/2014. Please evaluate the pouch for leaks and for interval healing. Note is made of postsurgical changes consistent with the stated history of ileoanal anastomosis. The anastomosis appears widely patent without evidence of significant stenosis, obstruction ... | Postsurgical changes consistent with the stated history of ileoanal anastomosis without fluoroscopic evidence of anastomotic leak or complication, as clinically questioned. |
Generate impression based on findings. | Reason: Hx lung CA (non small cell), pls compare to previous and measure History: none CHEST:LUNGS AND PLEURA: Right upper lobe previously cavitary lesion measures 2.1 x 1.9 cm (series 6 image 18), previously 1.8 x 1.9 cm, with increased internal solid component.Large left upper lobe centrally necrotic mass with adjace... | 1.Slight interval increase in size and increasing solid component of the right upper lobe previously cavitary mass.2.Slight interval increase in large left upper lobe necrotic mass.3.Mediastinal nodes are stable or slightly decreased.4.No new sites of disease.5.Additional findings as above. |
Generate impression based on findings. | 24 year old female. Pain with flexion. Left knee: No fracture or dislocation.Right knee: No fracture or dislocation. | No significant abnormality. |
Generate impression based on findings. | 66 years old Male. Reason: rib pain History: h/o NSCLC to left lung with rib destruction and worsening lytic lesions, re-evaluate disease. RADIOPHARMACEUTICAL: 10.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 114 mg/dL. Today's CT portion grossly demonstrates a large left lung and chest wall mass with bo... | 1.Hypermetabolic masses in the left upper lobe and left chest wall, consistent with the lung cancer.2.Hypermetabolic mediastinal lymph nodes in the subcarinal region, prevascular space and superior mediastinal regions, which are highly suspicious for nodal metastasis.3.Contralateral right hilum hypermetabolic lymph nod... |
Generate impression based on findings. | 70 female patient with right breast discomfort x 5 to 6 weeks. No personal or family history of breast cancer. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is fatty, unchanged in pattern and distribution. Benign bilateral calcifications are... | No specific findings to account for patient's breast discomfort. 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: ND... |
Generate impression based on findings. | The exam is limited by streak artifact from patient's posterior cervical spine orthopedic hardware. There are postoperative findings related to total laryngectomy with tracheostomy, neck dissection, as well as effects of radiation therapyn. There are also interval postoperative findings related to resection of a mass ... | 1. Interval resection of the right anterior lower neck subcutaneous tissue tumor without evidence of residual tumor, although the evaluation is partly limited by streak artifact. Therefore, subsequent follow up via PET may be useful. 2. Stable appearance of the larynx with extensive post-treatment effect, but no convin... |
Generate impression based on findings. | The history UTI, AP, hydronephrosis. RIGHT KIDNEY: No significant abnormalities noted. Right kidney measures 10 cm, and there is no hydronephrosis.LEFT KIDNEY: No significant abnormalities noted. Left kidney measures 10.6 cm, and there is no hydronephrosis.URINARY BLADDER: Urinary bladder is decompressed with Foley cat... | Ascites in the abdomen/pelvis, without other significant abnormality. |
Generate impression based on findings. | Female 26 years old Reason: evaluate L mandible fracture History: s/p plating of left mandible fracture. Again seen is a plate and screw device affixing the right mandibular body in near-anatomic alignment. The underlying fracture is less distinct than on the prior study suggesting some interval healing. Also seen is a... | Mandibular fractures as above. |
Generate impression based on findings. | 75-year-old female. Status post fall. PFA. Postsurgical changes of total knee arthroplasty device in anatomic alignment. No radiographic evidence of hardware complication. No fracture is identified. | Total knee arthroplasty device, as above. |
Generate impression based on findings. | 73 years old Male with a history of head and neck cancer, status post chemoradiation therapy. This study was performed for restaging.RADIOPHARMACEUTICAL: 10.4 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 93 mg/dL. Today's CT portion grossly demonstrates patchy and interstitial opacities in the upper lungs... | 1.Splenomegaly with mildly increased activity, which has decreased as compare with prior study.2.Diffuse increased bone marrow uptake is most likely due to bone marrow proliferation.3.Diffuse and mild FDG uptake in the patchy and interstitial opacities in the upper lungs, which are consistent with the inflammatory chan... |
Generate impression based on findings. | There are recent postoperative findings related to left occipital cranioplasty with minimal extra-axial hyperattenuating blood products and pneumocephalus subjacent to the surgical site, as well as in the overlying scalp soft thickening. The ventricles and basal cisterns are normal in size and configuration with mild ... | Expected postoperative findings related to left occipital cranioplasty for fracture fixation. |
Generate impression based on findings. | History of rectal cancer status post resection. CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: Right anterior chest wall Port-A-Cath with tip of the catheter in the distal superior vena cava. No significant adenopathy seen. No significant coronary artery calcifications.CHEST WALL: Stable ... | 1. Descending/sigmoid colostomy without abnormality or evidence of obstruction. 2. Stable appearance to rectal surgical bed with probable postsurgical/radiation changes. 3. Increasing size and new presumed liver hepatic metastases. |
Generate impression based on findings. | 65-year-old male. Lumbar radiculopathy. RLE pain. Posterior rods and screws affix the L4 to S1 vertebrae. No radiographic evidence of hardware complication. Spacer device at L5-S1 and mature bone graft seen along the lateral aspects of the lower lumbar spine, similar to prior. No significant change in positioning of th... | Postoperative changes of lumbosacral fusion, similar to prior. |
Generate impression based on findings. | Female; 30 years old. Reason: evaluate for evidence of IBD History: RLQ pain ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Few subcentimeter hypoattenuating lesions in the right hepatic lobe are too small to characterize but likely due to benign cysts.SPLEEN: No significant abnormality note... | No significant abnormalities seen in the abdomen or pelvis. No findings seen to suggest inflammatory bowel disease or presenting symptomatology. |
Generate impression based on findings. | Female, 59 years old, with memory loss. The cerebral and cerebellar hemispheres and brainstem are normal in attenuation and morphology. No intracranial hemorrhage or abnormal extra-axial fluid is seen. There is no evidence of mass effect or parenchymal edema. The ventricular system is normal in size and morphology. The... | No acute intercranial abnormality and no specific findings to account for the patient's memory loss. |
Generate impression based on findings. | 43 year old female. Status post curettage of bone cyst. Evaluate wrist cyst healing. 6 mm lucency in the central lunate consistent with a cyst, similar to prior. No acute fracture or dislocation. | Small lunate cyst. |
Generate impression based on findings. | Reason: recurrent pneumothorax History: ptx LUNGS AND PLEURA: Large left pneumothorax with some rightward mediastinal shift. A left chest tube lies in the lateral left chest, a portion appears to reside within a cyst or bleb and may not fully terminate in the pleural space. There is a loculated hydropneumothorax compon... | Large left pneumothorax with some rightward mediastinal shift. A left chest tube lies in the lateral left chest, a portion appears to reside within a cyst or bleb and not fully in the pleural space. There is a loculated hydropneumothorax component along the fissure, laterally.Findings communicated to the hospitalist se... |
Generate impression based on findings. | 62 year-old female with history of known kidney stones, now asymptomatic. ABDOMEN:LUNG BASES: Scattered pulmonary micronodules, nonspecific. Mild bibasilar atelectasis.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: ... | Nonobstructing punctate calculus in the left upper pole. |
Generate impression based on findings. | FractureVIEWS: Right little finger AP, oblique and lateral Again noted healing volar plate fracture involving the middle phalanx of the little finger not significantly change from prior study. | Nondisplaced volar plate fracture of the middle phalanx of the little finger not significantly changed. |
Generate impression based on findings. | 64-year-old female with history of anal cancer, Nigro protocol, hysterectomy and rectopexy now with presacral fluid collection. Evaluate collection. UTERUS, ADNEXA: Status post hysterectomy and bilateral salpingo-oophorectomy.BLADDER: No significant abnormality notedLYMPH NODES: Scattered mildly enlarged inguinal and p... | Decrease in size of presacral enhancing complex fluid collection with adjacent soft tissue component. Differential includes necrotic tumor, abscess, or possibly a resolving hematoma. Continued followup to document resolution is recommended. |
Generate impression based on findings. | 73 years old Female with right upper lobe lung nodule. Reason: evaluate for mediastinal or extrathoracic malignancy. RADIOPHARMACEUTICAL: 9.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 167 mg/dL. Today's CT portion grossly demonstrates two pleural based nodules in the right upper lobe apex with associat... | 1.Two right apical pleural based nodules with increased metabolic activity, highly suspicious for lung cancer.2.Hypermetabolic lymph nodes in the right hilar/right paratracheal region, highly suspicious for nodal metastasis.3.Right chest wall mass with the bony destruction of the right 5th rib, highly suspicious for ma... |
Generate impression based on findings. | 22 year old female. MVC with point tenderness to palpation. Evaluate for fracture. No fracture is identified. Small osseous spur arising from the inferior acromion. | No fracture. |
Generate impression based on findings. | 3 year old with concern for duodenal hematoma. History of chronic granulomatous disease and bone marrow transplant. Recent EGD. ABDOMEN:LUNG BASES: Right pleural effusion with associated atelectasis. Partially imaged intravenous catheter tip in the right atrium.LIVER, BILIARY TRACT: Periportal edema. Common bile duct i... | 1.Large hematoma involving the distal second and third portion of the duodenum.2.No evidence of pneumoperitoneum.3.Large amount of ascites. |
Generate impression based on findings. | 62-year-old male. Increase in pain 3&4th MTH's left foot. Evaluate for AVN vs DJD 3rd & 4th MTH's left foot. No acute fracture or dislocation. No significant osteoarthritis. No radiographic evidence of osteonecrosis. | No significant abnormality to explain the patient's pain. |
Generate impression based on findings. | 50 year-old female with suspicious left breast lesion presents for ultrasound-guided biopsy. Left ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a mixed echogenicity area measuring 1.5 x 0.5 x 0.6 cm at the 6 o’clock position with increased vascularity, 3 cm from the nipple. The les... | Successful ultrasound-guided core biopsy of the left breast lesion and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Vaginal carcinoma status post chemo radiation and loop colostomy with complaint of colostomy prolapse ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: AbsentPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS,... | Moderately large peristomal hernia with multiple colonic bowel loops within the hernia sac without evidence for bowel wall edema or obstruction. Prolapse of loop colostomy. |
Generate impression based on findings. | Female 21 years old. Reason: evaluate for fracture of scaphoid. History: fall on outstretched hand, pain in snuff box. Four views of the right wrist show soft tissue swelling along the radial aspect. We see no fracture. There is slight increase in the scapholunate interval measuring approximately 3 mm, which is borderl... | No fracture evident. Other findings as above. |
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