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Generate impression based on findings. | Anosmia. There are multiple bullet fragments embedded in the soft tissues of the left face, and left orbit, and anterior maxillofacial skeleton, including the anterior nasal septum and anterior maxillary bones. The other paranasal sinuses and nasal cavity are clear, including the olfactory recesses. There is mild S-sha... | Stigmata of gunshot wound to the maxillofacial region without evidence of sinonasal opacification. Although the imaged intracranial structures appear to be grossly unremarkable, evaluation of the olfactory apparatus is limited on CT. |
Generate impression based on findings. | Male, 54 years old. Reason: h/o thyroid cancer s/p RAIx3, XRT neck History: thyroid cancer RIGHT LOBE: Status post thyroidectomy. No focal lesion in the thyroid bed.LEFT LOBE: Status post thyroidectomy. No focal lesion in the thyroid bed.ISTHMUS: Status post thyroidectomy. No focal lesion in the thyroid bed.PARATHYROID... | Status post thyroidectomy without evidence of recurrent or metastatic disease. |
Generate impression based on findings. | T2N3 right tonsil squamous cell carcinoma status post CRT in 2002 who presented with a second primary of the midline soft palate with extension onto the tonsil and base of tongue. Neck: There are post-treatment findings in the neck with developing hypoattenuation and what appears to be soft tissue defects in the region... | 1. Post-treatment findings in the neck with developing hypoattenuation and what appears to be soft tissue ulceration in the region of the right glossotonsillar sulcus and retromolar trigone with periosteal reaction along the medial aspect of the right mandibular ramus, which may represent osteoradionecrosis and/or infe... |
Generate impression based on findings. | History of left breast biopsy in 2008 showing atypical lobular hyperplasia. History of breast cancer in maternal aunt, paternal aunt and paternal cousin. History of ovarian cancer in paternal aunt. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchy... | 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: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 48-year-old male with history of head and neck cancer. Status post chemoradiation therapy. CHEST:LUNGS AND PLEURA: Stable mild apical scarring. Few scattered pulmonary micronodules are not changed in size or number. Mild basilar subsegmental atelectasis. No new or suspicious pulmonary nodules or masses. No focal consol... | No interval change or evidence of metastatic disease. |
Generate impression based on findings. | Female, 53 years old. Reason: AKI eval for obstruction History: AKI RIGHT KIDNEY: The right kidney measures 11.2 cm, without focal lesion, hydronephrosis, or shadowing calculus.LEFT KIDNEY: The lower pole of the left kidney is obscured by overlying bowel gas. No focal lesion, hydronephrosis, or shadowing calculus.URINA... | 1.No evidence of hydronephrosis.2.Splenomegaly and a moderate to large amount of ascites are noted. |
Generate impression based on findings. | 33-year-old female with irregular menses and infertility. Scout AP film of the pelvis was normal. Opacification of the uterine cavity revealed a slightly anteverted uterine cavity without mucosal irregularity or filling defects in the uterine cavity. Incidental note is made of an arcuate uterus, a normal anatomic varia... | Normal uterine cavity and patent fallopian tubes. |
Generate impression based on findings. | 47 year old female who has a complaint of thickening within the left breast upper outer quadrant. Family history of breast carcinoma in her paternal grandmother. MAMMOGRAM: Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously den... | Multiple simple left breast cysts. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram... |
Generate impression based on findings. | Reason: eval ngt History: ngt NG tube tip terminates in the prepyloric antrum. Residual contrast in the bowel from recent CT scan. Multiple fluid-filled loops of bowel compatible with small bowel obstruction are better evaluated on recent CT abdomen.The pelvis is excluded from the field-of-view. Surgical clips are note... | NG tube terminates in the distribution of the prepyloric antrum. |
Generate impression based on findings. | Clinical question: Rule out ICH status post trauma last week. Signs and symptoms: Somnolence, nausea/vomiting. Nonenhanced head CT:There is no evidence of an acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, v... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Reason: esophageal fistula noted on esophagram/ SBFT requested to r/o evidence of Crohn's History: as above Scout radiograph showed a nonobstructive bowel gas pattern. Amorphous calcification in the pelvis may relate to uterine fibroids.Transit time to the colon was 45 minutes. Fluoroscopic evaluation showed normal muc... | Normal examination of the small bowel and proximal colon. No evidence of Crohn's disease of the small bowel. |
Generate impression based on findings. | 3 year old female patient with a humerus fracture.VIEWS: Left elbow AP and lateral (2 views) 4/14/2015 Cast material obscures fine bone detail.There is the suggestion of periosteal reaction along the distal humerus on the lateral view. Alignment is anatomic. An elbow joint effusion is present. | Healing supracondylar fracture. |
Generate impression based on findings. | 70 year-old female with history of breast cancer and right hip pain. Evaluate No abnormal osseous foci are identified to indicate metastatic disease. In the region of the pelvis, no osseous explanation for patient's hip pain.Again noted are foci of increased activity in the upper cervical vertebral body and left aspect... | No evidence of osseous metastatic disease. |
Generate impression based on findings. | 75-year-old male who presents for second opinion regarding new diagnosis of right lateral tongue border invasive squamous cell carcinoma status post excision biopsy with (+) margins. Evaluate extent. Evaluate for lymphadenopathy. Streak artifact from dental amalgam somewhat limits evaluation. There is a 1.3 x 1.0 cm mu... | 1. A mass that measures up to 1.3 cm in the right lateral posterior tongue is compatible with squamous cell carcinoma.2. No evidence of significant cervical lymphadenopathy. 3. A subcentimeter hypoattenuating focus in the left basal ganglia may represent a lacunar infarct of indeterminate age. Further evaluation via a ... |
Generate impression based on findings. | 59 year old female status post right lumpectomy in 2014 for invasive ductal carcinoma and DCIS, presents today for routine follow up. No current breast complaints. No family history of breast cancer. Three standard views of both breasts, and two spot indication views of the right breast lumpectomy bed, were performed d... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 1 year old male patient with a tibia fracture.VIEWS: Left tibia/fibula AP and lateral (2 views) 4/14/2015 Cast material obscures fine bone detail.The proximal tibial fracture is in anatomic alignment. There is sclerosis about the proximal tibia. | Healing proximal tibial fracture. |
Generate impression based on findings. | Male 68 years old; Reason: mantle cell lymphoma History: mantle cell lymphoma, re-evaluation CHEST:LUNGS AND PLEURA: Bullous emphysematous disease seen.MEDIASTINUM AND HILA: Moderate calcified coronary artery disease. Hypoattenuated appearance of intracardiac blood pool suggests underlying anemia.CHEST WALL: Right ches... | 1. Improvement in retroperitoneal and pelvic lymphadenopathy. 2. Improved splenomegaly. |
Generate impression based on findings. | Reason: Asses for rectocele History: constipation rectal pain There is prompt opacification of the rectum, sigmoid, and descending colon, with normal static morphology. There is significant amount of retained stool within the colon, despite sufficient prep, consistent with colonic inertia.Trial straining showed appropr... | 1.No fluoroscopic evidence of rectocele.2.Significant residual stool despite sufficient prep, consistent with colonic inertia.3.While straining on the fluoroscopy table failed to yield any passage of contrast, post-restroom images demonstrated near-complete evacuation, with mild residual. |
Generate impression based on findings. | 56 years, Female. Reason: eval for SBO History: h/o prior SBO from pelvic abscess, now has Nausea, vomiting, abdominal distension, and diarrhea. No acute cardiopulmonary process is identified. Nonobstructive bowel gas pattern. Moderate stool burden. No evidence of free intraperitoneal air. Surgical clips project in the... | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Bilateral hip pain Two views of the left hip are provided. Mild osteoarthritis affects the hip. Small foci of heterotopic ossification in the soft tissues of the left buttock appear similar to those seen on the prior study.Two views of the right hip reveal minimal osteoarthritic changes, essentially within normal limit... | Minimal-mild osteoarthritic changes. |
Generate impression based on findings. | Male 53 years old; Reason: eval ventral hernia and fascia, muscle History: ventral hernia ABDOMEN:LUNG BASES: Interval resolution of pleural effusions.LIVER, BILIARY TRACT: Status post hepatic transplant. 1.4-cm enhancing focus in the periphery of the right lobe (3:23) is nonspecific, and not definitively seen on prior... | 1.Large predominantly right ventral hernia as described above with no obstruction.2.1.4-cm enhancing lesion in the liver is indeterminate, and can be further characterized with MRI if indicated. |
Generate impression based on findings. | 83-year-old male with history of down trending hemoglobin CHEST:LUNGS AND PLEURA: Interval increased interstitial markings and slightly increased pleural effusions, which is nonspecific but most likely due to pneumonitis possibly from therapy.Left lower lung spiculated nodule (4/37) measures 3 x 1 .8 cm, unchanged from... | 1.Large right retroperitoneal hematoma, with additional smaller hematomas as described above.2.Pulmonary masses and nodules are again noted, without significant interval change.3.Increased interstitial predominant opacities and increased size of small bilateral pleural effusions, nonspecific but may be seen in pneumoni... |
Generate impression based on findings. | Pain There is a slight rightward curvature of the lumbar spine as well as mild hyperlordosis. Anterior wedging of L1 and T12 appears similar to the prior study. Severe degenerative disk disease affects T12/L1 and L1/L2. Moderate degenerative disk disease affects L2/3 and L4/5. Moderate facet joint osteoarthritis affect... | Chronic vertebral body compression deformities and degenerative arthritic changes as described above. |
Generate impression based on findings. | History of left lumpectomy for IDC followed by radiation and chemotherapy in 1997. History of benign right breast biopsy. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pa... | Stable post-surgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagn... |
Generate impression based on findings. | Stage IIIc colon cancer status post colectomy 2013 followed by chemotherapy completed February 2014. Now with new brain metastasis. Restaging exam.RADIOPHARMACEUTICAL: 9.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 91 mg/dL. Today's CT portion grossly demonstrates a left cerebellar craniotomy defect. Ri... | 1.Progression of hypermetabolic metastases including involvement of the brain, mediastinum, upper abdomen, and left humeral head. Multiple new pulmonary parenchymal hypermetabolic foci may represent additional metastatic progression versus inflammation.2.Additional findings very suspicious for bilateral hip AVN, new fr... |
Generate impression based on findings. | Female, 46 years old. Abdominal pain. LIVER: The liver measures 12.9 cm, with homogeneous echotexture. A 2.0 x 1.5 x 1.9 cm hypoechoic lesion is identified in the left hepatic lobe, likely a cyst. No other focal lesion.The main portal vein is patent, with normal hepatopetal flow.GALLBLADDER, BILIARY TRACT: No intrahepa... | No acute abnormality to account for the patient's abdominal pain. |
Generate impression based on findings. | Male 58 years old Reason: Evaluate for aortic dissection History: chest pain radiating to back CHEST:LUNGS AND PLEURA: Left lower lobe bronchial wall thickening with scarring/atelectasis, associated ground glass which favors aspiration, possible aspiration pneumonia.MEDIASTINUM AND HILA: Mildly enlarged left hilar lymp... | 1.No evidence of aortic dissection.2.Left lower lobe ground glass opacity likely secondary to aspiration, possible aspiration pneumonia. |
Generate impression based on findings. | 14 year old male patient with wrist fracture.VIEWS: Right wrist PA and lateral (2 views) 4/14/2015 Cast material obscures fine bone detail.There is a fracture of the distal radial metaphysis and probably a fracture of the distal ulnar metaphysis as well. The distal fracture fragments are in near anatomic alignment. | Distal radius and ulna fractures. |
Generate impression based on findings. | 48 years, Male. Reason: left kidney stone, s/p ESWL History: left kidney stone Nonobstructive bowel gas pattern. A moderate amount of stool is noted throughout the colon. Right upper quadrant surgical clips in place. The previously described left renal calculus is not definitively visualized on today's exam. The lung b... | The previously described left renal calculus is not definitively visualized on today's exam. |
Generate impression based on findings. | Reason: previous irregular menses, history of chlamydia. evaluate uterine contour and tubal patency History: history of irregular menses Scout AP film of the pelvis was normal. Opacification of the uterine cavity revealed a normally oriented uterine cavity without mucosal irregularity or filling defects in the uterine ... | Normal uterine cavity and patent fallopian tubes. |
Generate impression based on findings. | Female 89 years old; Reason: 89 y/o female with pancreas ca on chemo. please compare to prior CHEST:LUNGS AND PLEURA: No dominant lung lesion. Nonspecific reticular changes in the lung bases and along the fissures.MEDIASTINUM AND HILA: Chest wall port terminates in the SVC.Heart size is mildly enlarged. No pericardial ... | 1.Stable exam. |
Generate impression based on findings. | Female 63 years old; Reason: Pancreas Cancer: Restaging History: n/a CHEST:LUNGS AND PLEURA: Left lower lobe pulmonary nodule measures 5 mm (image 66 series 5) previously, 3 mm. Pleural spaces are clear. The central airways are patent.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. There are calcif... | 1.Slight increase in the size of the left lower lobe pulmonary nodule, upper abdominal soft tissue mass.2.New ascites with several new peritoneal nodularity highly suspicious for peritoneal carcinomatosis. |
Generate impression based on findings. | 45-year-old male with history of multiple myeloma presents for restaging evaluation.RADIOPHARMACEUTICAL: 12.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 107 mg/dL. Today's CT portion grossly demonstrates linear atelectasis/scarring at both lung bases. There are innumerable lytic and some sclerotic foci ... | Interval resolution of prior moderate to markedly hypermetabolic lesions throughout the axial and appendicular skeleton. No significantly FDG avid tumor activity currently. |
Generate impression based on findings. | Gunshot wound.VIEWS: Left knee AP/lateral (two views) 04/14/15 Small joint effusion is present. The medial aspect of the medial condyle cortex is disrupted and there appear to be lucencies extending into the medial condyle. | Nondisplaced fracture of the medial condyle of the femur. |
Generate impression based on findings. | 61 year-old male with a 50 pack year smoking history presenting for lung cancer screening. LUNGS AND PLEURA: Moderate upper lung paraseptal emphysema and cystic lung changes of the mid and lower lungs. Scattered pulmonary micronodules. Minimal basilar subsegmental atelectasis. No suspicious pulmonary nodule or mass. No... | Micronodules with no suspicious nodules or masses.Lung-RADS: Category: 1 (Negative: No nodules and definitely benign nodules)RECOMMENDATION: Continue annual screening with LDCT in 12 months. |
Generate impression based on findings. | 68 year-old female. Status post RSA. Evaluate implant position. Reverse ball-and-socket total shoulder arthroplasty device in anatomic alignment. No radiographic evidence of hardware complication. Chronic deformity of the acromioclavicular joint presumably reflects prior surgery. Heterotopic ossification inferior to th... | Reverse ball-and-socket total shoulder arthroplasty device. |
Generate impression based on findings. | Right: The external auditory canal is patent. The middle ear and mastoid air cells are well-pneumatized and clear. The ossicular chain is intact. The inner ear structures are unremarkable. The facial nerve describes a normal course. The jugular bulb and carotid canal are intact, although the jugular bulb appears to be... | Unremarkable temporal bone anatomy for the purposes of cochlear implantation planning. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Female 45 years old; Reason: metastatic colon ca History: metastatic colon ca CHEST:LUNGS AND PLEURA: Left lower lobe pulmonary nodule measures 7 x 6 mm (image 81/series 5), previously, 6 x 4 mmMEDIASTINUM AND HILA: Chest wall port terminates at the cavoatrial junction.CHEST WALL: No significant abnormality noted.ABDOM... | 1.Slight increase in the size of the left lower lobe pulmonary nodule which appears more solid. |
Generate impression based on findings. | 56-year-old female with history of right hydronephrosis and left renal cysts. Evaluate for bilateral renal function, specifically on the right The posterior abdominal radionuclide angiogram demonstrates prompt, symmetrical perfusion of the kidneys. Sequential renal images show the kidneys to be of normal size. There is... | 1.Mild to moderately dilated right pelvicalyceal system but with rapid washout and no evidence of current obstruction.2.Minimal asymmetrically decreased left renal parenchymal function which may be secondary to parenchymal defects representing cysts. |
Generate impression based on findings. | Left ankle fracture.VIEWS: Left ankle AP/lateral/oblique (3 views) 04/14/15 Two screws remain in place in the distal fibula. The K wire tracks in the medial malleolus are noted. The fractures are almost completely healed. Soft tissue swelling surrounds the ankle. Demineralization is noted. | Continued healing of fractures of the medial malleolus and fibula. |
Generate impression based on findings. | Male 82 years old Reason: evaluate for degenerative changes, compare to 2011 History: neck pain Evaluation of the cervical spine is limited by inability to optimally position patient. Evaluation of the lower cervical spine is also limited on the lateral view by overlying anatomy.There is demineralization of the bones. ... | Limited study as described above showing severe degenerative changes of the cervical spine appear similar to prior study allowing for differences in patient positioning. Other findings as above. |
Generate impression based on findings. | 45-year-old female with dysphagia. Evaluate for gastroparesis Visually there was significant and rapid gastric emptying. Using anterior and posterior geometric means, residual gastric activity at the following postprandial intervals was calculated as follows:30 mins: 35.7 % of peak activity (normal >70 %)1 hour: 21.3 %... | No evidence of gastroparesis. In fact, findings raise the question of abnormally rapid gastric emptying. |
Generate impression based on findings. | 60 year-old female with history of right cerebellar brain metastasis status post resection and SRS. Surveillance MRI. Surgery 10/2014. Post treatment findings related to suboccipital right craniotomy and right cerebellar tumor resection are redemonstrated. Few foci of nodular enhancement surrounding the resection cavit... | 1.Marked interval growth of a solid, enhancing right posterior neck mass-like lesion. Differential diagnosis includes growing tumor deposit as well as benign etiology such as an organizing hematoma, possibly infected given the significant associated inflammation. 2.Post treatment findings related to craniectomy and rig... |
Generate impression based on findings. | 66-year-old male with history of type I aortic dissection and axillary femoral bypass. Angiography: There has been surgical repair of a type A dissection with a interposition graft between the native sinus of Valsalva and they distal aortic arch. There is a small linear tract of contrast measuring 6 mm extending from t... | 1. Status post type A dissection repair with interposition graft between the native sinus of Valsalva and distal ascending aorta. Small linear tract of contrast arising from the right aspect of the distal anastomosis extending inferiorly to continue with the false lumen likely represents a small residual dissection.2. ... |
Generate impression based on findings. | 67-year-old male with history of prostate cancer, rising PSA who presents for evaluation for progression. No abnormal osseous foci are identified to indicate metastatic disease. Focus of increased activity at T9/10 vertebral body levels is correlated with the CT examination and consistent with degenerative changes. Add... | No evidence of bone metastases. |
Generate impression based on findings. | 35-year-old male with history of sarcoma. Evaluate tumor progression. LUNGS AND PLEURA: Multiple pulmonary nodules/masses are again seen demonstrating interval increase in size.Reference right middle lobe nodule measures 2.3 x 1.8 cm (series 5 image 39) compared to 1.5 x 1.5 cm previously.Left lower lobe superior segme... | Multiple pulmonary metastases demonstrating interval increase in size. No new sites of disease. |
Generate impression based on findings. | Female, 65 years old, with spinal stenosis status post cervical laminoplasty. Findings are demonstrated compatible with cervical laminoplasty from C3 through C7. The posterior neural arches have been canted towards the right which results in a decompression of the spinal canal. Since the prior examination, bone graft m... | 1. Expected findings status post cervical laminoplasty. At least partial osseous incorporation of the bone graft material is seen within the left laminotomy defects at C4 and C6.2. Persistent degenerative findings as above. |
Generate impression based on findings. | 4-month-old former 29 to 30 week gestational age patient with respiratory distress.VIEW: Chest AP (one view) 04/14/15, 1415 Endotracheal tube tip is between thoracic inlet and carina. Feeding tube tip is in the stomach. Left central line has its tip at junction of brachiocephalic veins.Right upper lobe opacities persis... | Persistent upper lobe opacities. Elevation of left hemidiaphragm. |
Generate impression based on findings. | 80 year-old male with history of renal cell carcinoma with back pain who presents for evaluation. No abnormal osseous foci are identified to indicate metastatic disease.There are foci of increased activity throughout the lumbar spine which correspond with degenerative osteophytes. Distortion of the right kidney consist... | No evidence of bone metastases. Extensive degenerative changes of the lumbar spine. |
Generate impression based on findings. | Three day old former 27 week gestational age patient with abdominal distention.VIEWS: Chest and abdomen AP (two views) 04/14/15, 1424 Endotracheal tube tip is at thoracic inlet. Feeding tube tip is in gastric body. Umbilical venous line has its tip at level of left hepatic vein.Pneumomediastinum composed of two compone... | Persistent pneumomediastinum. Decreased lung opacities. Increased bowel dilation. |
Generate impression based on findings. | Female 72 years old. Reason: eval fractures. History: R sided pain and hip pain s/p fall Two views of the right ribs are provided. There is mild deformity of the lateral aspect of the right sixth rib but no evidence of acute fracture. Degenerative disk disease affects the thoracic spine. Osteoarthritis affects the shou... | No acute fracture evident. Other findings as described above. |
Generate impression based on findings. | Nine month old male patient with pain and swelling. Question of distal radius/ulnar fractureVIEWS: Right wrist PA, oblique, lateral (3 views) 4/14/2015 There is a buckle fracture of the distal radius and oblique fracture of the distal ulna with dorsal angulation of the distal fracture fragment. Soft tissue swelling is ... | Fractures of the distal radius and ulna. |
Generate impression based on findings. | Lung cancer initial treatment management. Left upper lobe mass and enlarged right hilar lymph nodes.RADIOPHARMACEUTICAL: 11.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 89 mg/dL. Today's CT portion grossly demonstrates an approximately 2 cm spiculated nodular in the left upper lobe. A large approximatel... | 1.Markedly hypermetabolic left upper lobe mass, highly suspicious for malignancy, likely primary lung cancer.2.Enlarged markedly hypermetabolic right lower paratracheal and to a lesser extent right hilar lymph nodes, highly suspicious for contralateral mediastinal metastases.3.No FDG avid metastatic disease elsewhere. ... |
Generate impression based on findings. | Recurrent sinusitis despite sinus surgery; chronic left sided facial pain/pressure. There are subtle findings related to sinonasal surgery. There is moderate mucosal thickening and opacities in the bilateral maxillary sinuses, infundibulae, anterior and posterior ethmoid air cells, and nasal cavity. There is also mild ... | Persistent inflammatory changes predominantly in the maxillary and ethmoid sinuses and nasal cavity. Bilateral concha bullosa and mild osteitis of the right middle turbinate. |
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. The previously seen circumscr... | 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. | 2-year-old female patient with a supracondylar fracture.VIEWS: Left elbow AP and lateral (two views) 4/14/2015 Cast material obscures fine bone detail. Interval removal of three K wires affixing the distal humerus. Periosteal reaction is noted about the distal humerus. Alignment is anatomic. | Healing supracondylar fracture. |
Generate impression based on findings. | History of fall, abrasion posterior scalp Head: There is a right frontal parenchymal hematoma measuring approximately up to 9 mm with associated mild vasogenic edema. There is what appears to be extra-axial extension of the hemorrhage into the overlying subarachnoid space. The ventricles are normal in size and configur... | 1. Small left occipital scalp hematoma and a subcentimeter contre-coup anterior right frontal intraparenchymal hematoma with associated probable subarachnoid hemorrhage.2. Multilevel moderate to severe degenerative changes of the cervical spine without evidence of acute fracture or subluxation.3. A right suprahyoid nod... |
Generate impression based on findings. | 65-year-old female with history of melanoma of the skin presents for evaluation of response to therapy.RADIOPHARMACEUTICAL: 10.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 85 mg/dL. Today's CT portion grossly demonstrates a left upper lobe subsolid pulmonary nodule, unchanged in size. Multiple sharply m... | 1. No evidence of progression of melanoma. Interval resolution of the punctate left distal lower extremity focus laterally. Stable to decreased cutaneous left leg foci anteromedially which may be inflammatory versus conceivably mild stable tumor. No additional FDG avid findings suspicious for metastatic disease.2. Left... |
Generate impression based on findings. | Female 61 years old. Reason: s/p L basilar joint arthroplasty. History: as above Three views of the left thumb and three views of the left hand are provided. Mild osteoarthritis affects the basilar joint as well as the interphalangeal joint of the thumb.Minimal osteoarthritic changes affect the DIP joints of the finger... | Mild osteoarthritis as described above. |
Generate impression based on findings. | 59 years, Male. Reason: evaluate G tube placement History: s/p EGD Gastrostomy balloon projects over the gastric body, with the tip appearing just proximal to the ligament of Treitz, not significantly changed. Multiple gas-filled loops of small and large bowel are suggestive of ileus. The lower pelvis is excluded from ... | Gastrostomy tube tip appears to terminate just proximal to the ligament of Treitz. Bowel gas pattern is suggestive of ileus. |
Generate impression based on findings. | Male 42 years old. Reason: 5th mc fx. History: as above Three views of the right hand are provided. There is a fracture through the fifth metacarpal neck with mild volar angulation of the distal fracture fragment. There is also a fracture of the head/neck of the fourth metacarpal with mild volar angulation of the dista... | Fourth and fifth metacarpal fractures as described above. |
Generate impression based on findings. | 86 year old female with history of bladder cancer status post cystectomy and ileal conduit. Evaluate for recurrence. ABDOMEN:LUNG BASES: Scattered pulmonary micronodules.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS... | 1. No specific evidence of recurrence or metastatic disease.2. Mild improvement of pelvic fluid collection. |
Generate impression based on findings. | 52-year-old male with headaches. Evaluate for etiology. There is no evidence of intracranial hemorrhage, mass or edema. There is colpocephalic appearance of the ventricles secondary to a largely absent corpus callosum, which is noted incidentally. The genu of the corpus callosum is present while the body, splenium, and... | 1.No findings to account for headaches.2.Incidental note is made of partial agenesis of the corpus callosum. |
Generate impression based on findings. | Male 29 years old; Reason: evaluate for palpable abnormality to right testicle History: as above RIGHT TESTIS: The right testis measures 4.3 x 2.0 x 3.0 cm, with homogeneous echotexture, and no focal lesion.LEFT TESTIS: The left testis measures 4.3 x 2.8 x 2.3 cm, with homogeneous echotexture, and no focal lesion.RIGHT... | No mass lesion or other acute abnormality identified. |
Generate impression based on findings. | Age: 65 years. Sex : Female. Reason for study: Reason: head and neck cancer post crt. 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 obtai... | The exam was positive for penetration and positive for aspiration. |
Generate impression based on findings. | Female 77 years old Reason: pain History: pain There is a dextroscoliosis of approximately 30 degrees. Severe degenerative disk disease at L2-L3 with moderate degenerative disk disease at L1-L2, L3-L4 and L4-L5. Moderate/severe facet joint osteoarthritis particularly affects the lower lumbar spine with grade 1 anteroli... | Degenerative arthritic changes of the lumbar spine appear similar to those on prior study. |
Generate impression based on findings. | 46 your old male with history of thoracic aortic aneurysm. CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: The ascending aorta measures approximately 3.9 cm in its largest diameter. No lymphadenopathy. No pericardial effusion. No aortic dissection.CORONARY ARTERY CALCIFICATION: None.CHEST ... | Ascending aorta measures 3.9 cm as above. |
Generate impression based on findings. | 40 year old female patient with history of retroareolar right breast abscess that was surgically excised in 2010 presents with nipple tenderness and occasional right breast swelling. MAMMOGRAM:Three standard views of both breasts with 2 spot compression views of the right retroareolar area were performed digitally and ... | Areolar thickening and hypoechoic, hypervascular area in the retroareolar region that may represent a chronic inflammatory/infectious process. Recommend patient schedules a surgical consultation.BIRADS: 2 - Benign finding.RECOMMENDATION: B - Surgical Consultation. |
Generate impression based on findings. | 5-year-old male with history of 2 febrile seizures, now every few week episodes of feeling "alone" followed by staring and mouth movements. Evaluate for cortical dysplasia or other possible seizure focus. There is diffuse prominence of the perivascular spaces, including a few within the corpus callosum. No evidence of ... | 1.No evidence of any structural abnormality. No acute intracranial findings.2.Diffuse prominence of the perivascular spaces, including a few within the corpus callosum. Prominent perivascular spaces are most commonly an incidental finding of no clinical significance. In rare instances, they have been associated with th... |
Generate impression based on findings. | 4-year-old male patient with ulnar fracture.VIEWS: Left forearm AP and lateral (two views) 4/14/2015 Cast material obscures fine bone detail. There is redemonstration of a transverse fracture of the proximal ulna with callus formation. Alignment is near anatomic. | Healing proximal ulnar fracture. |
Generate impression based on findings. | Female 69 years old Reason: RA elbow History: dec ROM and pain Two views of the right elbow show narrowing of the elbow joint with osteophyte formation consistent with rheumatoid arthritis and secondary osteoarthritic changes. There is soft tissue swelling about the elbow and more focal soft tissue prominence on the do... | Findings consistent with stated diagnosis of rheumatoid arthritis as described above. |
Generate impression based on findings. | Male 44 years old. Arm numbness. Chronic history of back pain. Rule out disk herniation. Six views of the cervical spine are provided. The cervicothoracic junction is not well seen on the lateral views. There are small anterior vertebral body osteophytes at C5/C6. The intervertebral disk spaces are preserved. There is ... | Mild degenerative arthritic changes as described above. Disk herniation and foraminal narrowing can be better evaluated with MRI if clinically warranted. |
Generate impression based on findings. | Clinical question: Rule out VPS malfunction. Signs and symptoms: Vomiting and increased lethargy. Nonenhanced head CT:Ventricle is enlarged and measures at 21.2 mm in transverse axis compared to prior study measurements of 16.There is also significant interval increase size of the supratentorial ventricular system. The... | Interval increased size of ventricular system (more significantly supratentorially) since prior exam. |
Generate impression based on findings. | 75 years, Female. Reason: r/o dilated loops of bowel, concern for c. dif History: rising WBC, temps, worsening hemodynamics despite cefepime Exam is limited secondary to motion. Enteric tube projects over the gastric body. Multiple lines, tubes, and support tubing project over the chest and upper abdomen. Dilated loop ... | Focally dilated loop of bowel in the central abdomen may represent focal ileus. |
Generate impression based on findings. | 7 year old male patient with radius and ulna fractures.VIEWS: Right forearm AP and lateral (2 views) 4/14/2015 There are transverse fractures of the distal radius and ulna. Periosteal reaction is present. There is approximately one half shaft width displacement of both the distal fracture fragments, appearing similar t... | Healing distal radius and ulna fractures. |
Generate impression based on findings. | Male, 26 years old. Reason: assess for fatty liver/other abnl- intermittently elevated LFTs, hypertrigltceridemia History: none LIVER: The liver measures 13.9 cm, with mildly heterogeneous echotexture, and no focal lesion.The main portal vein is patent, with normal hepatopetal flow.GALLBLADDER, BILIARY TRACT: No intrah... | 1.Hypoechoic abnormal contour at the head of the pancreas is nonspecific and should be further evaluated with dedicated cross-sectional imaging.2.Mildly heterogeneous liver echotexture and moderate ascites. 3.Mild cortical heterogeneity of the transplanted kidney. |
Generate impression based on findings. | Following a discussion of the procedure with the patient and/or family, including its risks, benefits, alternatives and steps to prevent infection, informed written consent was obtained and documented in the patient's chart. The time-out form was completed to confirm patient identity and side/type of procedure. All op... | Successful fluoroscopically guided injection of the midcarpal joint for CT wrist arthrogram. Findings consistent with a scapholunate ligament tear. |
Generate impression based on findings. | 75-year-old male status post intubation and NG tube placement. The pelvis is incompletely included in the field of view. Interval repositioning of NG tube with the tip projecting at the level of the antrum of the stomach. Gaseous distention of loops of small bowel, and colon without evidence of obstruction. Streaky ret... | Interval repositioning of NG tube with the tip projecting at the level of the antrum of the stomach. |
Generate impression based on findings. | Reason: r/o VA shunt malfunction, r/o obstruction History: vomiting and increased lethargyVIEWS: Shunt series: Skull AP/lateral (two views), chest AP/lateral (two views), abdomen AP/lateral (two views) date Unchanged position of intracranial portion of the VA shunt system with tip in the SVC. The Strata valve is set in... | Extracranial VA shunt is intact. |
Generate impression based on findings. | 73 year old female. Unable to stand on ankle, pain. Evaluate for fracture. Sideplate and screw affix a mildly deformed distal fibula, likely from remote trauma. Deformity of the posterior malleolus is likely also post-traumatic. No acute fracture or dislocation. Mild soft tissue swelling about the ankle. | Chronic deformity of the posterior malleolus and distal fibula with orthopedic fixation, likely from remote trauma. No acute fracture. |
Generate impression based on findings. | Male 49 years old. Reason: fx/dislocation/traumatic injury. History: pain s/p blunt trauma Five views of the lumbar spine are provided. There is severe degenerative disk disease at L5/S1. There also appears to be a chronic spondylolysis of L5 and a grade 2 anterolisthesis of L5. There is mild degenerative disk disease ... | Degenerative arthritic changes and chronic appearing L5 spondylolysis and spondylolisthesis without acute fracture. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts, with a total of 8 images obtained, were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. No suspicious masses, microcalcifi... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | 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 almost entirely fatty, unchanged in pattern and distribution. No suspicious masses, microcalcifications or areas of architectural di... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | Clinical question: Frontal headaches following endoscopic sinus surgery. Signs and symptoms: Headaches. Medtronic fusion sinus CT:Frontal sinuses are well pneumatized and without evidence of disease or change since prior exam.Ethmoid sinuses are well pneumatized without evidence of disease or interval change since prio... | 1.No evidence of sinusitis.2.Internal bilateral endoscopic functional sinus surgery and with patent bilateral sinonasal windows. |
Generate impression based on findings. | 16 year old male patient with a distal tibia and fibula fracture. VIEWS: Right ankle AP, oblique, lateral (3 views) 4/14/2015 A sideplate and screw device affixes the distal fibula. Two screws are noted within the distal fibula which are not within the sideplate. Periosteal reaction is noted about the distal tibia and ... | 1. Healing distal fibula and tibia fractures.2. Area of lucency along the medial aspect of the tibial metaphysis is similar to the prior study. |
Generate impression based on findings. | Female 60 years old Reason: source of RUQ pain? 60F with AML, fevers History: RUQ pain, tenderness on exam, fevers LIVER: Hepatomegaly 21.7-cm in length. No focal lesions.On the portal vein is hepatopedal, peak velocity .2 m/secGALLBLADDER, BILIARY TRACT: Gallbladder wall upper normal in thickness. Sludge in gallbladde... | Pericholecystic fluid and sludge in the gallbladder without hydrops. Favor ascites, hypoproteinemia etiologies rather than cholecystitis |
Generate impression based on findings. | Reason: assess for shunt malfunction History: patient with VP shunt now with headaches and increased ventricular sizeVIEWS: Shunt series: Skull AP/lateral (two views), chest AP/lateral (two views), abdomen AP/lateral (two views) 4/14/15 Extracranial portion of the shunt is disconnected at the level of C2/3. Stable righ... | Shunt malfunction with disconnection at the level of C2/3. |
Generate impression based on findings. | 4 day old female patient with UVC adjustment. Question of UVC tip.VIEW: Chest and abdomen AP (two views) 4/14/2015 at 1555 hrs Enteric tube tip is in the stomach. UVC tip is in the right atrium, slightly retracted from the prior study. The cardiothymic silhouette is normal. Hazy bilateral lung opacities are unchanged. ... | UVC tip is in the right atrium. |
Generate impression based on findings. | Reason: r/o pneumothorax History: birth, 0 days oldVIEW: Chest AP (one view) 4/14/15 16:03 NG tube tip in the stomach, one of the side port is at GE junction. Right medial chest is hyperlucent. Cardiothymic silhouette is normal. The aortic arch, cardiac apex and stomach are left-sided. | Hyperlucent right medial chest. Lateral/cross table lateral view is recommended for further evaluation. |
Generate impression based on findings. | 50 year-old female. Anterior knee pain below the patella. Evaluate for effusion. No fracture or dislocation. Small osteophytes and mild medial tibiofemoral compartment joint space narrowing consistent with osteoarthritis. Evaluation for interval progression of osteoarthritis cannot be performed as the prior study was d... | Osteoarthritis without evidence of fracture. Suggestion of a small joint effusion. |
Generate impression based on findings. | 35-year-old male. Pain. Evaluate for scapholunate ligament disruption and midcarpal instability. Intra-articular contrast injected into the midcarpal joint spilled into the radiocarpal joint through a widened scapholunate interval (measuring 6 mm), consistent with a scapholunate ligament tear. There was also abnormal e... | Findings consistent with tears of the scapholunate ligament and TFCC complex. |
Generate impression based on findings. | Small joint effusion is present. The medial aspect of the medial condyle cortex is disrupted and there appear to be lucencies extending into the more proximal portion of the medial condyle toward the fusing physis. No fracture is seen extending into the articular surface. | Nondisplaced fracture of the medial aspect of the medial condyle of the femur. No fracture is seen in the articular surface. |
Generate impression based on findings. | Female, 22 years old.Comments: Surgical Case Information | Procedure(s): Procedure(s): | KIDNEY TRANSPLANT | Operating Room: CDOR 17 CENTRAL | Surgeon(s) and Role: | * Yolanda Tai Becker, M.D. - Primary | * Mohan S. Gundeti, M.D. - Assisting | No suspicious radiopaque foreign object is identified. Surgical clips projec... | No suspicious radiopaque foreign object is identified. Nasogastric tube is only partially imaged, but appears to terminate in the gastric fundus, and should be advanced.These findings were discussed by telephone with Dr. Becker, the attending surgeon, on 4/14/15 at 16:17. |
Generate impression based on findings. | Traumatic injury: unwitnessed fall with head trauma and altered mental status. Head: There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. The imaged paranas... | 1. Small right frontal scalp hematoma, but no evidence of acute intracranial hemorrhage or skull fracture.2. Multilevel degenerative spondylosis of the cervical spine, but no evidence of acute fracture.3. Extensive dental disease. |
Generate impression based on findings. | Female, 51 years old.Multiple surgical teams. Rule out foreign body. Motion artifact degrades the examination. A surgical drain and clips project over the mid abdomen. NG tube tip projects below the level of the diaphragm. The side port terminates at the level of the diaphragm. No unexpected radiopaque foreign bodies a... | No unexpected radiopaque foreign bodies are identified. These findings were discussed with Dr. Eggener, the attending surgeon by phone at 4:25 p.m. on 4/14/2015. |
Generate impression based on findings. | Male, 64 years old. Reason: hydronephrosis History: urinary retention RIGHT KIDNEY: The right kidney measures 11.4 cm, with normal cortical echogenicity. Moderate hydroureteronephrosis. In the proximal right ureter there is a 3.3 x 2.4 x 1.5 cm ovoid non-shadowing echogenic structure with significant internal vasculari... | 1.Bilateral moderate hydroureteronephrosis. A 2 to 3-cm echogenic structure within the proximal right ureter is nonspecific, but given the internal vascularity, tumor is a primary consideration vs a clot or atypical appearance of a stone. Recommend dedicated cross-sectional imaging for further evaluation.2.Debris-fille... |
Generate impression based on findings. | Intracranial hemorrhage? Recent spontaneous epistaxis, on coumadin, and right-sided weakness. There is no evidence of acute intracranial hemorrhage. There is moderate periventricular and subcortical white matter hypoattenuation, which is non-specific but may represent small vessel ischemic disease. There is also an are... | 1. Moderate periventricular and subcortical white matter hypoattenuation, which is non-specific but may represent small vessel ischemic disease, but no evidence of acute intracranial hemorrhage. However, non-contrast CT is insensitive for the detection of non-hemorrhagic acute infarct.2. Packing material and hemorrhage... |
Generate impression based on findings. | 4 year old male patient with history of chylous pleural effusion. Evaluate pleural effusionVIEW: Chest AP (one view) 4/14/2015 at 1623 hrs. Right chest port catheter tips projects in the right posterior cardiophrenic sulcus. Right upper extremity PICC and left central line tips are in the superior atriocaval junction. ... | Moderate right pleural effusion, increased from the prior study. |
Generate impression based on findings. | 55-year-old male with history of unspecified nerve root and plexus disorder. CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: No significant abnormality notedCORONARY ARTERY CALCIFICATION: None.CHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: No significant abnormal... | No significant abnormality. |
Generate impression based on findings. | Female, 36 years old. Reason: Supraumbilical nodule, eval for mass in supraumbilical area History: supraumbilical nodule In the subcutaneous soft tissue of the anterior abdominal wall at midline, superior to the level of the umbilicus, there is a heterogenous hypoechoic structure measuring 1.9 x 0.9 x 2.0 cm. No signif... | A 1-2 cm hypoechoic lesion in the subcutaneous tissue superior to the umbilicus is nonspecific and may represent a small periumbilical hernia. Recommend CT for further evaluation. |
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