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Generate impression based on findings. | Port placement to drain right pleural effusionVIEW: Chest AP Right upper extremity PICC and left central line unchanged. Interval placement of a right-sided chest port with tip projected over the medial right lower lobe. Cardiothymic silhouette normal. No pleural effusion or pneumothorax. Retained lymphatic contrast ma... | Placement of a right-sided chest port with tip projected over the medial right lower lobe. |
Generate impression based on findings. | 69 year old female who was recalled from screening mammogram for right breast asymmetry. No family history of breast cancer. An ML view and 3 spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density... | 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. | 75 years, Female. Reason: r/o bowel obstruction History: no bm Motion artifact limits examination. NG tube tip projects at the level of the antrum of the stomach. Gaseous distention of the stomach. Otherwise relative paucity of abdominal bowel gas. Marked degenerative changes affect the hips and lower lumbar spine. Vas... | Relative paucity of abdominal bowel gas without evidence of obstruction. |
Generate impression based on findings. | 84 year-old female with subdural hematoma Redemonstration of subdural hematoma measuring up to 2.3 cm in greatest dimension at its greatest dimension, unchanged. Leftward midline shift measures 7 mm and is stable. The lateral ventricular sizes are unchanged with persistent mild effacement of the right. Redemonstration ... | Unchanged subdural hemorrhages. |
Generate impression based on findings. | 57 years, Male. Reason: c/f bowel obstruction vs ileus. intubated and sedated but still withdraws significantly to abdominal exam History: abdominal pain Note is made of dilated loops of small bowel, measuring up to 3.8 cm in diameter. There is a large amount of stool noted throughout the colon. NG tube tip projects at... | Findings suspicious for adynamic ileus, although an early low grade, partial small bowel obstruction is a consideration. Above average stool burden. |
Generate impression based on findings. | 22 years, Male. Reason: obsructive pattern? History: constipation Gaseous distention of multiple loops of bowel, suggestive of an adynamic ileus. No evidence of pneumatosis intestinalis or portal venous gas. Small right pleural effusion with underlying atelectasis/consolidation. Bibasilar opacities consistent with the ... | 1. Findings suggestive of an adynamic ileus.2. Findings suggestive of pulmonary edema, better characterized on recent chest CT examination. |
Generate impression based on findings. | 51 year old female with history of metastatic breast cancer on therapy. Evaluate treatment response in extent of disease. CHEST:LUNGS AND PLEURA: Left lower lobe partially calcified nodule (4/221) measures 1.2 x 1 .2 cm, unchanged in size. Left upper lung fibrosis is unchanged, presumably due to radiation therapy. Righ... | 1.Findings suspicious for new hepatic metastases as above. 2.New right hilar lymph node as above.3.Additional reference nodules and other findings appear stable. Refer to bone scan from today for more detailed evaluation of the skeleton. |
Generate impression based on findings. | Female 64 years old; Reason: ro renal recurrence History: hx of renal cell ca, sp left partial nephrectomy ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No si... | 1.Status post left partial nephrectomy. No CT evidence of recurrence. |
Generate impression based on findings. | There are multiple focal nodular areas of abnormal signal which are isointense to gray matter on all sequences along the predominantly the lateral margins of the lateral ventricles bilaterally. There is an abnormal appearance of the cerebellum, with likely hypoplasia and dysplasia of the malformed right cerebellar hem... | 1. Bilateral sub-ependymal nodular gray matter heterotopia.2. Hypoplasia and dysplasia of the right cerebellum, including the vermis.3. Diffuse prominence of the ventricular caliber, although this may in part be related to slightly diminished white matter volume.4. Symmetric globular appearance of the hippocampi withou... |
Generate impression based on findings. | 25 year old male with family history of aortic aneurysm. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. No focal airspace opacities, pleural effusions or pneumothorax.MEDIASTINUM AND HILA: There is no aneurysm or dissection involving the ascending aorta, transverse arch, or descending thoracic aorta... | No evidence of aortic aneurysm or acute aortic pathology as clinically questioned. |
Generate impression based on findings. | 62 year old female who has a complaint of physician palpated a right breast mass. Personal history of endometrial carcinoma at age 55. History benign left breast biopsy. No family history of breast cancer. MAMMOGRAM: Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. ... | No mammographic or sonographic 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. | No definite mass lesion is identified along the vocal cords, and laryngeal ventricles appear symmetric. There is no significant cervical lymphadenopathy. The laryngeal cartilages appear to be intact. The parotid and submandibular glands are normal in size and symmetric bilaterally without masses. There are no thyroid ... | No definite mass lesion or soft tissue prominence is identified. No significant cervical lymphadenopathy. |
Generate impression based on findings. | 74-year-old female with history of metastatic cancer. CHEST:LUNGS AND PLEURA: Reference right upper lobe nodule measures 9 x 7 mm, previously 9 x 8 mm (image 15 of series 5). Scattered pulmonary micronodules. Nodule located in the left major fissure measures 12 x 8 mm, previously 12 x 7 mm (image 55 of series 5).MEDIAS... | Worsening liver metastases as above. Otherwise, stable metastatic disease. |
Generate impression based on findings. | Trisomy 21. History of limp and abnormal posture. History of developmental hip dysplasia.EXAMINATION: Pelvis AP/frog leg (two views) 04/13/15 A large amount of feces is present in the rectosigmoid.The right hip is normal in appearance.The left acetabular roof is slightly flattened. The left femoral head is laterally un... | Minimal residual left developmental hip dysplasia. |
Generate impression based on findings. | Male 73 years old; Reason: history of gross hematuria History: gross hematuria, CT urogram, evaluate upper tracts ABDOMEN:LUNG BASES: Dense coronary calcifications.LIVER, BILIARY TRACT: Stable subcentimeter nonspecific hypodensity.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADREN... | 1.Mild interval decrease in size of index portacaval node. Otherwise, essentially unchanged. No CT identifiable cause of hematuria. |
Generate impression based on findings. | Female 81 years old; Reason: gastric cancer carcinomatosis restaging after chemo with CKD CHEST:LUNGS AND PLEURA: New small left pleural effusion and enlarging large right pleural effusion with underlying compressive atelectasis. Mild airspace disease seen in dependent portions of right upper and lower lobes, superimpo... | 1. Circumferential gastric wall thickening seen, most pronounced in regions of gastric body and antrum and without significant change. New small adjacent ascites, nonspecific. Decreased size of reference perigastric lymph node, additional multiple subcentimeter gastrohepatic lymph node seen similar to earlier study. Mi... |
Generate impression based on findings. | Stage IVa Burkitt lymphoma status post 3 cycles of chemotherapy. Evaluate treatment response.RADIOPHARMACEUTICAL: 6.6 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 98 mg/dL. Today's CT portion of the neck demonstrates no significant pathology. Please see diagnostic CT reports for details of the chest, abdo... | 1.Complete interval resolution of previous extensive hypermetabolic tumor activity without convincing FDG avid tumor currently. Small linear right groin activity considered most likely inflammatory.Diagnostic CTs of the chest, abdomen, and pelvis also performed at today's visit will be reported separately. |
Generate impression based on findings. | Male 80 years old Reason: malignancy, ?metastatic disease History: 80M w h/o sinonasal melanoma, bladder cancer both reportedly in remission now w bleeding ileal mass, diffuse colonic disease \T\ RP disease concerning for metastatic disease, unclear primaryRADIOPHARMACEUTICAL: 9.5 mCi F-18 fluorodeoxyglucose (FDG).BLOO... | 1.Widespread hypermetabolic metastatic disease including the right axilla, bowel, peritoneum, and retroperitoneum. The distribution favors melanoma over bladder cancer.2.Left upper lobe hypermetabolic lung nodule may represent an additional metastatic lesion or synchronous lung primary cancer. |
Generate impression based on findings. | Female, 41 years old. Reason: evaluate for cholestasis and ascites. History: elevated bilirubin, abdominal pain, ascites LIVER: The liver measures 18.8 cm, with diffusely increased echogenicity, and no focal lesion.The main portal vein is patent, with normal hepatopetal flow.GALLBLADDER, BILIARY TRACT: No intrahepatic ... | Increasing ascites. Hepatosplenomegaly and echogenic liver are again seen. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microca... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Female, 29 years old. Reason: Had transplant on 4/7. Now Cr up from 1.1 to 1.7 KIDNEY: The transplanted kidney in the right iliac fossa measures 11.6 cm in length, with normal echotexture. Mild to moderate fullness of the collecting system.RENAL ARTERY: No evidence of narrowing at the anastomosis with the right iliac a... | Renal transplant without evidence of anastomotic stricture. Mild to moderate fullness of the collecting system. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history breast cancer in her mother. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. No suspicious microcalcifications or areas... | Multiple left breast masses, two of which have been biopsied. Given that biopsy clips are seen, presumably the patient has multiple prior mammograms at another institution. Submission of outside images is necessary in order to determine stability of the findings.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluatio... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microca... | 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. | All of the paranasal sinuses are clear as are the bilateral mastoid air cells and middle ear cavities and there are no air-fluid levels. The bilateral maxillary sinus ostia are patent as are the bilateral frontoethmoidal and sphenoethmoidal recesses. The lamina papyracea are intact bilaterally. Note is made of small b... | Negative CT scan of the sinuses. |
Generate impression based on findings. | 31 year old female who has a complaint of excessive left breast tissue. No family history of breast cancer. Three standard views of both breasts, and a single spot compression view of the left breast, were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibrog... | Accessory fatty tissue within the left axillary tail. No mammographic evidence of malignancy. Consultation with the patient's primary care physician, or breast surgeon, is recommended for clinical management. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annu... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. No suspicious masses... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Male 44 years old Reason: r/o osteo History: wounds, cellulitis Two views of the left tibia/fibula show soft tissue swelling affecting the lower leg with ulceration over the lateral aspect of the ankle. Diffuse bony changes that we presume relate to patient's sickle cell disease but we see no evidence of osteomyelitis.... | Diffuse bony changes that we presume relate to patient's sickle cell disease but we see no evidence of osteomyelitis. |
Generate impression based on findings. | Reason: h/o BOT ca and CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Debris in the trachea. Bilateral lower lobe tree in bud opacities increased compared to prior in the bilateral lower lobes compatible with aspiration bronchiolitis. New right lower lobe consolidation foci of gas and ... | 1.No evidence of metastases.2.New right lower lobe consolidation with foci of gas suspicious for a necrotizing pneumonia and possibly empyema.3.Worsening aspiration 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 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microcalcifications or ar... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Evaluate pneumothoraxVIEWS: Chest AP and lateral There are surgical staples present at the left apex. The small left apical pneumothorax is not significantly changed. Cardiothymic silhouette normal. Patchy atelectasis left lower lobe. | Post surgical changes at the left apex with a small apical pneumothorax not significantly changed. |
Generate impression based on findings. | Female, 27 years old. Reason: 27yo G1P0 at 34w0d with Crohn's, h/o portal v. thrombosis. Elevated LFTs, epigastric pain LIVER: The liver measures 18.5 cm, with homogeneous echotexture, and no focal lesion.The main portal vein is patent, with normal hepatopetal flow.GALLBLADDER, BILIARY TRACT: No intrahepatic or extrahe... | 1. Bilateral moderate hydronephrosis may be physiologic and related to gravid uterus.2. No evidence of portal venous thrombosis, cholelithiasis, or acute cholecystitis. |
Generate impression based on findings. | 59-year-old male with ventilator dependence. Unable to wean. Evaluate diaphragm. Note is made of streaky bibasilar opacities most consistent with subsegmental atelectasis. Low lung volumes. Left jugular catheter tip projects at the level of the right atrium. Sternotomy wires and plates in place. Tracheostomy tube in pl... | Expected bilateral diaphragmatic descent with maximum inspiratory effort. No evidence to suggest diaphragmatic paralysis, as clinically questioned. |
Generate impression based on findings. | Female, 58 years old.Surgical Case Information | Procedure(s): Procedure(s): | EXPLORATORY LAPAROTOMY | ABDOMINAL HYSTERECTOMY /C BSO | Operating Room: CDOR 20 CENTRAL | Surgeon(s) and Role: | * Ernst R. Lengyel, M.D. - Primary No unexpected radiopaque foreign object. A nonobstructive bowel gas pattern is identified. N... | No suspicious radiopaque foreign object is identified.These findings were discussed by telephone with Dr. Lengel, the attending surgeon, on 4/13/15 at 15:02. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microcalcifications or ar... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Retracted UVCVIEW: Chest AP NG tube tip in the stomach. The umbilical venous catheter tip at the IVC/right atrial junction. Cardiothymic silhouette normal. Patchy atelectasis left lower lobe. No pleural effusion or pneumothorax. | The umbilical venous catheter tip at the IVC/right atrial junction. |
Generate impression based on findings. | Reason: 68 yo female with history of pSBO. Please eval for adhesive disease History: multiple episodes of pSBO Scout radiograph showed multiple dilated loops of small and large bowel, a large hernia sac in the right lower quadrant, vascular calcifications, degenerative changes of the lumbar spine and bilateral hips.The... | 1. Partial high-grade obstruction of the large bowel at the level of the hernia sac.2. Adhesive disease, most marked in the left lower quadrant.3. Persistent dilatation of the colon and small bowel to the level of the sigmoid, suggestive of large bowel obstruction.4. Mild scalloping of the cecum is concerning for some ... |
Generate impression based on findings. | Female 25 years old Reason: relapsed classical Hodgkin lymphoma History: relapsed classical Hodgkin lymphoma s/p 2 cycles of ICE Chemotherapy in need of restaging. Please compare to OSH.RADIOPHARMACEUTICAL: 6.3 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 100 mg/dL. Today's CT portion of the neck demonstr... | Complete resolution of previously present hypermetabolic tumor with no convincing tumor activity currently.Diagnostic CTs of the chest, abdomen, and pelvis also performed at today's visit will be reported separately. |
Generate impression based on findings. | Pain at the base of the first metatarsalVIEWS: Right hand AP, oblique and lateral No acute fracture or dislocation. | Normal examination. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in her mother. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. ... | No 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. | The lumbar spine is in normal alignment, with a normal lumbar lordosis. The vertebral body heights are well-maintained. There is stable moderate severe disk narrowing L5-S1, with diffuse disk desiccation. There is a prominent Schmorl's node along the superior endplate of L4 which appears similar. No worrisome focal ma... | 1. No significant interval change in appearance of multilevel moderate spondylosis, most prominent at L4-5 where there is persistent impingement upon the exiting right L4 nerve root due to a right foraminal/far lateral prominence of a disk bulge.2. Up to moderate-severe right foraminal narrowing at L5-S1 |
Generate impression based on findings. | Male 33 years old; Reason: 33 yrs male with h/o HIV/AIDS, hepatitis B (exposure) and stage IVA Burkitt lymphoma s/p 3 cycles of DA EPOCH R in need of restaging CHEST:LUNGS AND PLEURA: Small medial left lower lobe consolidation/scarring present. Evaluation of pulmonary parenchyma suboptimal secondary to respiratory moti... | 1. Ill-defined right groin soft tissue attenuation measuring 2.3 x 1.8 cm on image 197 series 701. While this may be inflammatory in etiology/reflect scarring, continued follow-up recommended to exclude neoplasm. 2. Hepatomegaly.3. Please refer to concomitant PET exam from same day for additional findings. |
Generate impression based on findings. | 50 year-old male with history of base of tongue cancer with chemoradiation therapy, compare to prior with measurements. Redemonstrated are post-treatment findings in the neck with minimal residual asymmetric patchy enhancement in the region of the right tongue base, which previously measured up to 5 x 15 mm, and is cur... | 1.Minimal residual asymmetric patchy enhancement in the region of the right tongue base, which previously measured up to 5 x 15 mm, is currently smaller, ill-defined, and not discretely measurable. 2.There is no evidence of significant cervical lymphadenopathy based on size criteria.3.The bilateral parotid and submandi... |
Generate impression based on findings. | The risks (including, but not limited to, those of bleeding, infection, allergic reaction, inability to access the joint, and failure of medication to relieve pain) and benefits of the procedure were explained to the patient, and informed written consent was obtained. A pre-procedural “time-out” form was completed.The... | Successful fluoroscopic-guided steroid and lidocaine injection of the left sacroiliac joint. |
Generate impression based on findings. | 62 year old with a lump palpated by her nurse practitioner. The skin over the lump is marked by the nurse practitioner, at 6 o'clock position in the left breast. With physical exam, no discrete mass was palpated. Focused ultrasound did not detect any abnormalities at the area of palpable concern. | No sonographic evidence for malignancy. BIRADS: 1 - Negative.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts with repeat left MLO view were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. No suspicious masses, microcalcifications or areas of archit... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.Mammography is optimally performed when prior studies are available to detect changes. If the patient's prior mammograms can be submitted, then an addendum to this re... |
Generate impression based on findings. | Reason: head and neck cancer, evaluate for treatment, please provide measurements. History: as above CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules and masses. No pleural effusions.MEDIASTINUM AND HILA: Small nonenlarged mediastinal lymph nodes. No significant mediastinal or hilar lymphadenopathy. Heart size i... | No evidence of metastases. |
Generate impression based on findings. | 25-year-old female with history of classical Hodgkin lymphoma status post two cycles of ICE chemotherapy, now with relapse. CHEST:LUNGS AND PLEURA: Subtle focal opacities in the left lobe dependently may be atelectasis, however this may be infectious/inflammatory in nature depending on the patient's clinical presentati... | Large anterior mediastinal mass which does not correspond to increased metabolic activity on today's PET scan, so this may represent necrotic tumor. No additional suspicious masses. |
Generate impression based on findings. | Female, 49 years old. Reason: to assess characteristics of L posterior cervical and supraclavicular lymph nodes noted on exam History: none Comparison to prior CT exam is difficult due to differences in modality and patient positioning.A palpable left supraclavicular lymph node measures 2.2 x 1.7 x 3.3 cm, increased fr... | Enlarged cervical lymph nodes as detailed above, including a supraclavicular lymph node which is increased from the prior CT exam dated 12/18/14 (although comparison between ultrasound and CT suboptimal). |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microcalcifications or ar... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 45 year old with palpable lump in the left axilla Three standard views of both breasts with three 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, unchanged in pattern and distribution. A lobulated mass with sugg... | No mammographic or sonographic evidence of malignancy. A sebaceous cyst in the left axilla. Simple cysts in the left breast. Sebaceous cyst should be managed clinically. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: C - Clinical Correlation Needed. |
Generate impression based on findings. | 63-year-old female presenting for annual diagnostic examination. No current breast related complaints. No family history breast carcinoma. Family history of uterine carcinoma in her maternal aunt, diagnosed at the age of 78. History of right breast cyst aspiration in 2002 and benign left breast biopsy in 2002. Three st... | 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. | Reason: eval for PE History: SOB, tachycardia, h/o DVT PULMONARY ARTERIES: Technically adequate. No acute pulmonary embolus.LUNGS AND PLEURA: Elevation of the left hemidiaphragm, unchanged, with left lingular and lower lobe atelectasis. No suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HIL... | No pulmonary embolus. PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Reason: eval for obstruction or slowing through enteral stent History: abdominal pain, emesis, h/o enteral stent for gastric adenocarcinoma. Scout radiograph of the abdomen showed a pyloroduodenal stent projecting over the right upper quadrant. An air-fluid level is noted in the stomach. Surgical clips again visualized... | 1.Incomplete filling of the pyloroduodenal stent which may be secondary to debris or neoplastic invasion.2.Mucosal irregularity of the distal stomach, which is nonspecific.3.Nonobstructive adhesive disease is likely affecting the distal duodenum. |
Generate impression based on findings. | Female 58 years old Reason: PAIN History: PAIN Two views of the left hip are provided. There is mild osteoarthritis affecting the left hip.A single AP view of the pelvis is provided. There is osteoarthritis of both hips. Mild osteoarthritis affects the sacroiliac joints bilaterally. A transitional lumbar vertebra is no... | Osteoarthritis and other findings as described above. |
Generate impression based on findings. | Male 58 years old. Reason: Eval for inflammatory or erosive arthritis. History: pain Three views of the right hand demonstrate narrowing of the radioulnar articulation with small osteophytes. There is uniform narrowing of the radiocarpal and mid-carpal joints with small osteophytes affecting the wrist. There is soft ti... | Arthritic changes which appear predominantly degenerative in etiology. However, some findings including uniform narrowing of the right wrist articulations, soft tissue swelling adjacent to the second MCP joint on the right hand, and possible chronic remodeling of the left ulnar styloid raise the possibility of an under... |
Generate impression based on findings. | Male 44 years old. Reason: Evaluate for osteo. History: concern for osteo Three views of the right foot are provided. There is osteolysis of the fifth proximal and middle phalanges with small foci of gas density about the MTP joint compatible with osteomyelitis. There is also osteolysis along the lateral aspect of the ... | Osteomyelitis as described above.Findings were discussed by telephone with the clinical service, Meggan Forbes, APN, at 4:30 p.m.. on 4/13/2015. |
Generate impression based on findings. | 9 year old male patient with prior hernia repair. Question of hydrocele. RIGHT TESTIS: The right testis is normal in echogenicity. It measures 2.3 x 1.8 x 0.5 cm. Flow is detected on color and spectral Doppler imaging.LEFT TESTIS: The left testis is normal in echogenicity. It measures 1.7 x 1.4 x 0.9 cm. Flow is detect... | Unusual appearing right hydrocele with ribbon-like material causing mass effect on the right testis. |
Generate impression based on findings. | Female 57 years old. Reason: RA, OA. History: same Three views of the right hand are provided. There is osteoarthritis affecting the interphalangeal joints, most severe at the DIP joints. We see no erosions or specific radiographic finding of rheumatoid arthritis. Three views of the left hand are provided. There is ost... | Arthritic changes as described above that appear predominantly degenerative in etiology. |
Generate impression based on findings. | Female 71 years old. Reason: IPG change evaluation. History: SCS IPG change There is a spinal cord stimulator device with a new generator which is situated posterior to the left ilium. The wires enter the spinal cord at the level of L2 and terminate at the level of T9/T10. There is moderate to severe degenerative disk ... | Spinal cord stimulator and degenerative arthritic changes of the lumbar spine as described above. |
Generate impression based on findings. | Reason: head and neck cancer evaluate for treatment, please prvoide measurements. CT neck:There is a 25x42mm sagittal dimension right nasopharyngeal mucosal space mass which is unchanged since the prior exam.There is a 19 x 24 mm axial dimension heterogeneously enhancing mass adjacent to the right jugular vein and righ... | 1.Stable right nasopharyngeal tonsillar mass presumably representing the patient's known history of squamous cell carcinoma of the nasopharyngeal tonsillar associated with stable level 2 lymphadenopathy.2.No evidence for brain metastases. |
Generate impression based on findings. | 87 year old female with hip pain, concern for femur fracture. Evaluation of fine detail is limited by factors related to portable technique. I see no fracture. Mild osteoarthritis affects the hip. | Limited study showing no femoral neck fracture. If there is strong clinical concern for femoral neck fracture then MRI may be considered for further evaluation. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microca... | 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. | 72-year-old male with a history of esophageal carcinoma. Status post esophagectomy with gastric pull up. Scout radiograph of the chest showed no abnormal pulmonary opacities, or pleural effusions. NG tube tip projects at the level of the right diaphragm, likely within the gastric pull up. Right surgical drain tip proje... | No evidence of anastomotic leak, as clinically questioned. |
Generate impression based on findings. | Pain. Follow-up fracture. Evaluation of fine detail is limited by overlying bandage/splint. There is a comminuted but predominantly spiral fracture of the distal fibula extending to the level of the tibiotalar joint, with mild posterior angulation and displacement of the distal fracture fragment. There is also a vertic... | "Trimalleolar" ankle fracture as described above. |
Generate impression based on findings. | 60-year-old female. Pain. Right shoulder: No fracture or dislocation. Severe osteoarthritis of the glenohumeral joint, similar to prior. High riding humeral head consistent with chronic rotator cuff tear.Left shoulder: Postsurgical findings of left hemi-arthroplasty device in near anatomic alignment without radiographi... | Left hemiarthroplasty device and severe right glenohumeral joint osteoarthritis. |
Generate impression based on findings. | 25-year-old male with R facial numbness, L leg numbness and R eye blurry vision. Demyelination vs. malignancy vs. infection. The following scattered white matter T2/FLAIR hyperintense lesions are present, a few of which are oriented radially with respect to the ventricles: Largest is located in the right middle cerebel... | Scattered primarily white matter lesions, as above. While one lesion may be larger, the rest are stable or decreased in size. These findings may be seen with demyelinating disease, however they remain nonspecific. Other inflammatory etiologies may also be considered. |
Generate impression based on findings. | Elbow stiffness and pain. Evaluate for osteoarthritis. Moderate to severe osteoarthritis affects the elbow, with osteophyte formation. There is slight elevation of the distal humeral fat pads suggesting a joint effusion. | Osteoarthritis. |
Generate impression based on findings. | 70-year-old male. SI joint pain. Evaluate for SI joint arthritis. Hip pain. Evaluate for fracture. Sacroiliac joints: No significant joint space narrowing or evidence of fusion.Pelvis and bilateral hips: No fracture or dislocation. Minimal osteoarthritis of the bilateral hips with tiny osteophytes, similar to prior exa... | No significant abnormality of the SI joints. Minimal osteoarthritis of the hip joints. |
Generate impression based on findings. | Right hip pain.VIEWS: Pelvis AP/frog leg (two views) 04/13/15 The round, smooth femoral heads are well directed into normally formed acetabula. No fracture is identified. | Normal examination. |
Generate impression based on findings. | Central line placementVIEW: Chest AP Left subclavian central line with tip in the SVC. Cardiothymic silhouette normal. Cardiac apex and stomach left-sided. Patchy atelectasis left lower lobe. No pleural effusion or pneumothorax. | Left subclavian central line with tip in the SVC. |
Generate impression based on findings. | 64-year-old female presents for annual diagnostic examination. Complaint of right nipple pruritus one month ago, which has since resolved. Family history of breast carcinoma in her mother at age 74 and maternal grandmother in her 40s. Three standard views of both breasts were performed digitally and reviewed with the a... | 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. | Right femur trauma and hip pain.VIEWS: Right femur AP/lateral (two views) 04/13/15 The femur is normal in appearance. No fracture is identified. | Normal examination. |
Generate impression based on findings. | Right knee pain.VIEWS: Right knee AP/lateral/oblique (3 views) 04/13/15 A joint effusion is not present. The bones are normal in appearance. No fracture is identified. | Normal examination. |
Generate impression based on findings. | HypercarbiaVIEW: Chest AP NG tube tip at the GE junction. Central line with tip at the IVC. Cardiothymic silhouette normal. Diffuse lung atelectasis bilaterally not significantly changed. There is a small left-sided pleural effusion. Marked body wall edema present. | Diffuse atelectasis bilaterally with small left pleural effusion. |
Generate impression based on findings. | Reason: assess for reflux, hiatal hernia History: excessive mucus in throat, globus sensation and vomiting/choking Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions.Double contrast evaluation of the esophagus and gastric cardia/fundus revealed a small hiata... | Small hiatal hernia, mild motor abnormality, and gastroesophageal reflux, as above. |
Generate impression based on findings. | 35-year-old male. Left leg pain, history of lesion in left fibula. Evaluate for fracture/interval change. Radiolucent expansile lesion in the proximal fibular diaphysis, not significantly changed. No new fracture is identified. | Radiolucent lesion in the proximal fibula, not significantly changed, likely benign with etiologies including enchondroma or fibrous dyplasia. |
Generate impression based on findings. | 84 years, Female. Reason: eval for stool impaction History: constipation Gastrostomy tube in place. Gastrostomy tube T-tacs in place. Nonobstructive bowel gas pattern. Residual contrast is noted within the rectum. Average stool burden. Vascular calcifications of aorta and its branches. Streaky right basilar opacity mos... | Nonobstructive bowel gas pattern. Average stool burden. |
Generate impression based on findings. | 64 year old male. Status post left humerus IM rod for pathologic fracture due to metastatic lung cancer. Evaluate for complications. Again seen is an intramedullary rod and screw device affixing a pathologic fracture through a lytic lesion of the proximal humeral diaphysis in near anatomic alignment. No radiographic ev... | Orthopedic fixation of a pathologic fracture of the proximal humerus, as above. |
Generate impression based on findings. | Male, 54 years old. Reason: rising transaminases, please exclude stone LIVER: The liver measures 19.8 cm, with diffusely increased echogenicity, and no focal lesion.The main portal vein is patent, with normal hepatopetal flow.GALLBLADDER, BILIARY TRACT: No intrahepatic or extrahepatic biliary ductal dilatation. The com... | 1.Cholelithiasis without evidence of acute cholecystitis.2.Increased hepatic echogenicity may be related to hepatic steatosis/parenchymal dysfunction. Hepatosplenomegaly.3.Mild fullness of the right lower pole collecting system is nonspecific. |
Generate impression based on findings. | Extensive motion artifact limits evaluation. Fat saturation is also inhomogeneous.PHARYNX/LARYNX: There is medial deviation of the left true cord, consistent with known vocal cord paralysis. There is also thickening of the left aryepiglottic fold. The nasopharynx, oropharynx, and hypopharynx are unremarkable. The lary... | 1. Extremely limited exam secondary to motion artifact. No definite focal mass along the expected course of the left recurrent laryngeal nerve, with evidence of left vocal cord paralysis as clinically known. A CT of the neck may be of benefit for further evaluation as clinically warranted as hopefully motion artifact w... |
Generate impression based on findings. | 75 years, Male. Reason: 75yo M w/ OG tube now re advanced History: as above The pelvis is incompletely included in the field-of-view. Interval repositioning of the NG tube the tip projecting at the level of the body of the stomach. The side-port terminates just below the level of the GE junction and needs to be advance... | NG tube side port terminates at the level of the GE junction and needs to be advanced. |
Generate impression based on findings. | Restaging tonsillar cancer status post surgery and chemoradiation, completed January 2015.RADIOPHARMACEUTICAL: 10.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 107 mg/dL. Today's CT portion grossly demonstrates a mucus retention cyst or polyp in the right maxillary sinus. Postsurgical changes seen in the... | 1.Interval resolution of previous suspicious hypermetabolic right neck lesion. There are new right neck foci more anteriorly which correspond with muscles of mastication are considered more likely benign than progression of tumor.2.New hypermetabolic axillary lymph nodes, more notably on the right, which are of some su... |
Generate impression based on findings. | Female, 51 years old. Eval liver and gallbladder for stones. RUQ pain, jaundice LIVER: The liver measures 15.6 cm, with homogeneous echotexture, and no focal lesion.The main portal vein is patent, with normal hepatopetal flow.GALLBLADDER, BILIARY TRACT: No intrahepatic or extrahepatic biliary ductal dilatation. The com... | 1.No evidence of cholelithiasis or cholecystitis.2.Bilateral renal atrophy related to chronic kidney disease. |
Generate impression based on findings. | 30 year-old female. Right great toe osteomyelitis? LVAD, neutropenic status has AML chemo. Persistent fevers. No destructive osseous changes or cortical erosion in the great toe to indicate osteomyelitis. No focal fluid collection. | No evidence of osteomyelitis. |
Generate impression based on findings. | Female 77 years old Reason: HIP ARTHROPLASTY REVISION (Right HIP) Single view of the pelvis obtained in the operating room at time stamped 10:56 shows the stem of the femoral component of a total hip arthroplasty device, the neck of which overlies the lateral aspect of the acetabular cup. | Preliminary components of a total hip arthroplasty as described above. |
Generate impression based on findings. | 93 year-old female with history of abdominal pain. Evaluate for liver abscess. Evaluation of the solid organs is limited by lack of intravenous contrast.ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Previously described hypoattenuating liver lesions are not well visualized on today's noncont... | Limited exam due to lack of intravenous contrast, however regarding the clinical query no convincing evidence of hepatic abscess is seen. Pancreatic and renal masses, and additional right lower quadrant cystic collection as above. |
Generate impression based on findings. | 21 months old, Male, Reason: view for interval change in SDH History: blunt force trauma from MVC causing SDH Again seen is a hyperattenuating left cerebral convexity subdural hematoma that measures up to 5 mm in width, previously measuring up to 5 mm. There are differences in patient positioning. The hematoma on the p... | 1. Expected redistribution of acute left cerebral convexity subdural hematoma with stable maximal thickness, although now more focal in left frontal area, with unchanged trace midline shift to the right.2. Subdural hematoma along the dorsal clivus is decreased in size. |
Generate impression based on findings. | Diaphragmatic hernia repair. Where are chest tube tips?VIEW: Chest crosstable lateral (one view) 04/13/15, 1459 Right chest tube has its tip located posteriorly. Left chest tube tip is in the projection of the anterior trachea. Umbilical arterial line tip is at T11. Umbilical venous line has its tip at junction of IVC ... | Hydropneumothorax, it is difficult to say whether this is on the left, on the right, or bilateral. |
Generate impression based on findings. | Reason: r/o aspiration History: coughing/ choking with feedEXAMINATION: Oropharyngeal motility study 4/13/15 Dana Sussman, speech and language therapist, supervised the examination.2 minutes 15 seconds of fluoroscopy was used.Increased oral transit time, positive piece meal deglutition. Decreased lingual coordination a... | Positive for aspiration.Please see the speech and language therapist's report for feeding recommendations. |
Generate impression based on findings. | 15 year old male patient with neurogenic bladder. Follow-up scan. Note the examination is limited by patient anatomic characteristics and positioning.BLADDER Wall Thickness: Normal Contents: Distended and contains debris. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: Not o... | Grade 4 right-sided hydronephrosis, similar to the prior study. *SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4: Grade 3 and parenchyma... |
Generate impression based on findings. | 10 month old female with splenomegaly. Question of portal vein flow. Doppler Findings: Color and spectral Doppler were performed on inflow and outflow vessels.The main portal vein is patent with hepatopetal flow measuring approximately 0.08 m/sec. The right and left portal veins are patent with hepatopetal flow measuri... | Patent portal veins with hepatopetal flow. The right hepatic vein is not visualized on this examination. |
Generate impression based on findings. | 81-year-old female. Status post excision of left forearm tumor/XRT with suspected deep infection. Evaluate for change. Extensive dystrophic calcifications and osseous deformity with fusion of the radial and ulnar diaphysis, similar to prior exam. Diffuse soft tissue atrophy. Linear lucency in the proximal ulnar diaphys... | Deformity of the radius and ulna with extensive dystrophic calcifications consistent with post-treatment effect, not significantly changed. |
Generate impression based on findings. | Female 63 years old. Reason: eval LT humerus History: pain Three views of the left shoulder are provided. Again seen is a comminuted fracture of the proximal humerus involving the surgical neck and greater tuberosity with fracture fragments in near anatomic alignment. There is callus formation about the fracture line i... | Healing proximal humerus fracture. |
Generate impression based on findings. | Female 66 years old. Reason: hx of BL knee osteoarthritis. History: hx of BL knee osteoarthritis Four views of the right knee are provided. There is moderate to severe osteoarthritis affecting the right knee, particularly the medial tibiofemoral compartment. This appears similar to the study from 2013 but has progresse... | Osteoarthritis of both knees as described above. |
Generate impression based on findings. | Female 56 years old. Reason: pain left posterior back, paraspinous/ribs- point tenderness. History: pain left posterior back, paraspinous/ribs- point tenderness, concern for fracture vs lytic lesion. Three views of thoracic spine demonstrate mild to moderate multilevel degenerative disk disease with mild thoracic scoli... | 1.Degenerative disk disease of the thoracic spine.2.No rib fracture is evident. There is a small lucent focus in the posterolateral aspect of the left ninth rib which may represent a benign rib lesion such as fibrous dysplasia or simply overlying bowel gas. |
Generate impression based on findings. | Male 52 years old; Reason: Pt is a 52 yo male w/ hx of follicular lymphoma; pre-allo sct evaluation CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Multiple tiny mediastinal and axillary lymph nodes.CHEST WALL: Right chest wall port seen with tip in distal SVC.ABDOMEN:LIVER, BILIARY TRACT... | 1. Ill-defined soft tissue attenuation seen in right lower quadrant, extending to and encasing right external iliac vessels, suspicious for lymphomatous involvement although posttreatment scarring also a consideration. Comparison to prior imaging if available would be helpful. Asymmetrically atrophic right kidney and r... |
Generate impression based on findings. | 18 year old female patient with strep throat. Question of pneumonia.VIEWS: Chest AP and lateral (2 views) 4/13/2015 The aortic arch, cardiac apex, and stomach are on the left. The cardiac silhouette size is normal. There is left lower lobe atelectasis. No pleural effusion or pneumothorax. The colon is distended with ai... | No specific evidence of infection. |
Generate impression based on findings. | 68-year-old female. Pain. Alignment is anatomic. Moderate degenerative disk disease of L5-S1. Minimal degenerative arthritic changes at the other lumbar levels. Lower lumbar level facet joint osteoarthritis. Vertebral body heights are maintained.Right hip: No fracture or dislocation. Minimal osteoarthritis. Vascular ca... | Osteoarthritis and degenerative disk disease. |
Generate impression based on findings. | 55 year old female. Pain. For fracture. Again seen is a fracture of the greater tuberosity of the humeral head in anatomic alignment. The fracture line is indistinct indicating interval healing. | Healing greater tuberosity fracture. |
Generate impression based on findings. | 19 year-old female. Distal tibial posteromedial pain. Evaluate for stress fracture. No fracture or significant abnormality is identified. | No evidence of a fracture. |
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