instruction stringclasses 1
value | input stringlengths 6 8.98k | output stringlengths 5 3.11k |
|---|---|---|
Generate impression based on findings. | 38-year-old female. Status-post ACL reconstruction. Surgical tunnels in the distal femur and proximal tibia with a surgical button along the lateral femur consistent with postsurgical findings of ACL reconstruction. Tibiofemoral alignment is anatomic. Likely small knee joint effusion. | Post-surgical findings of ACL reconstruction. |
Generate impression based on findings. | Female 53 years old Reason: s/p lumbar spine fusion, evaluate construct History: see above Postsurgical changes from lumbar spine fusion extending from L3 through S1 is in near-anatomic alignment. There are postsurgical changes from laminectomy and interbody fusion.No acute fracture or malalignment. No evidence of hard... | Postsurgical changes without radiographic evidence of hardware complication. |
Generate impression based on findings. | Female 24 years old Reason: fx History: crush injury Three views of the left hand are provided. There is a fracture through the tuft of the fourth digit with minimal displacement. There is an additional fracture of the tuft of the fifth phalanx with minimal displacement. | Fractures of the tufts of the fourth and fifth distal phalanges as described above. |
Generate impression based on findings. | Follow-up of T3N0 left vocal cord squamous cell carcinoma, receiving CRT, s/p FHX completed on 2/8/13. There are post-treatment findings with diffuse stranding of the neck subcutaneous tissues and edema of the supraglottic larynx. However, the laryngeal cartilages appear to be intact and there is no evidence of measura... | Persistent post-treatment findings, but no evidence of measurable mass lesions or significant cervical lymphadenopathy. However, direct laryngoscopic examination may be useful for further evaluation of mucosal tumor that may otherwise be inapparent on CT. |
Generate impression based on findings. | Female, 46 years old. Left lower quadrant abdominal pain LIVER: The liver measures 16.2 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 common bile duct measures ... | Unremarkable examination. |
Generate impression based on findings. | Female, 36 years old. Reason: r/o abdominal abscess or pyelonephritis History: fever, UTI RIGHT KIDNEY: The right kidney measures 12.8 cm, with normal echogenicity. Physiologic fullness of the collecting system without significant hydronephrosis. No perinephric fluid or shadowing calculi.LEFT KIDNEY: The right kidney m... | 1. Physiologic fullness of the renal collecting systems without significant hydronephrosis.2. No perinephric fluid or shadowing calculi. |
Generate impression based on findings. | Female 52 years old Reason: pain History: pain Bone mineralization is normal. Alignment is near-anatomic. There is moderate medial compartment joint space narrowing in the left knee with small tricompartmental osteophytes.There is a small lucency involving the medial femoral condyle likely representing a subchondral cy... | Mild to moderate left knee osteoarthritis with a small joint effusion. |
Generate impression based on findings. | Images are limited by patient motion. There are numerous scattered punctate foci of diffusion hyperintensity, some of which demonstrate ADC hypointensity consistent with true diffusion restriction. These are scattered throughout both cerebral hemispheres as well as within the cerebellum bilaterally. The most conspicuo... | 1. Numerous scattered bilateral supratentorial and infratentorial punctate foci of diffusion hyperintensity, many of which represent true diffusion restriction. These likely represent foci of acute to subacute embolic infarcts. Underlying moderate chronic small vessel ischemic changes somewhat advanced for the patient'... |
Generate impression based on findings. | FractureVIEWS: Right wrist AP and lateral There is a healing distal radial fracture in near anatomic alignment. There is sclerosis at the fracture site reflecting interval healing. The overlying cast has been removed. | Healing distal radial fracture as described above. |
Generate impression based on findings. | Female 72 years old. Reason: right shoulder pain History: decreased ROM. Right hand ulnar drift and difficulty with extension. Three views of the right shoulder demonstrate tiny osteophytes at the glenohumeral joint indicating mild osteoarthritis. There are enthesopathic changes at the superolateral aspect of the humer... | 1. Findings suggestive of osteoarthritis of the right hand in the setting of prior inflammatory arthritis. 2. Mild osteoarthritis of the right shoulder. |
Generate impression based on findings. | Female 57 years old. Reason: left shoulder pain denies injury History: Three views of the left shoulder are provided. There are enthesopathic changes along the superolateral aspect of the humeral head. There are osteoarthritic changes at the glenohumeral joint with a possible subchondral cyst. Mild osteophytes are pres... | Mild osteoarthritis of the left shoulder. |
Generate impression based on findings. | Male 35 years old. Reason: pain. History: pain Four weight-bearing views of the right knee are provided. There is no joint space narrowing. There is no fracture, dislocation, or joint effusion. | Etiology of the patient's pain is not evident. |
Generate impression based on findings. | 60 year old female patient with asymmetry seen in the left breast on screening mammography presents for call back diagnostic mammogram and ultrasound. DIAGNOSTIC MAMMOGRAM: Three standard views of the left breast and a total of 4 spot compression views were performed digitally and reviewed with the aid of R2 CAD 9.3. T... | Focal asymmetry in the left upper outer breast most likely corresponds to an asymmetric island of fibroglandular tissue. Recommend 6 month follow up with diagnostic mammogram and ultrasound to ensure stability.BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at Short Interval (1-11 Months). |
Generate impression based on findings. | Female 72 years old Reason: dip djd History: pain Left index finger: Severe osteoarthritis affects the distal interphalangeal joint with bone on bone apposition and osteophytes. Moderate osteoarthritis affects the proximal interphalangeal joint. No acute fracture or malalignment.Right index finger: Severe osteoarthriti... | Severe distal interphalangeal joint osteoarthritis. |
Generate impression based on findings. | Evaluate fracture Three views of the right fifth digit reveal a comminuted fracture of the proximal phalanx fixed with two K wires. The PIP joint is held in flexion and the DIP joint is held in extension. No change from previous | Fracture of the phalanx unchanged from previous |
Generate impression based on findings. | Ms. Hanrahan is a 70 year old female with a personal history of left breast lumpectomy in 1997 treated with radiation and chemotherapy. She also has a history of benign stereotactic core biopsy of the left breast. She has no current breast related complaints. Three standard views of both breasts were performed digitall... | Stable postsurgical 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 - Diagnos... |
Generate impression based on findings. | Total knee arthroplasty Two views of the left knee reveal a total knee arthroplasty in anatomic alignment. No evidence of fracture-dislocation | Total knee arthroplasty in anatomic alignment |
Generate impression based on findings. | 65-year-old female with persistent nausea, vomiting, and dilated bowel loops. CHEST:LUNGS AND PLEURA: Calcified left lower lobe granulomata. No suspicious pulmonary masses or nodules. No focal consolidation, pleural effusions or pneumothorax.MEDIASTINUM AND HILA: Normal cardiac size without pericardial effusion. No med... | High-grade small bowel obstruction to the level of the left hemi-pelvis with ascites and severe proximal jejunal wall thickening which raises the possibility of bowel ischemia. The atypical positioning of the proximal jejunum in the right hemi-abdomen (partial malrotation) is not resulting in the obstruction but may be... |
Generate impression based on findings. | Female 67 years old Reason: bilateral knee pain History: bilateral knee pain Right knee: Bone mineralization is normal. There is severe joint space narrowing in the medial compartment with small tricompartmental osteophytes. There is moderate extensor compartment joint space loss. No acute fracture or malalignment. No ... | Severe bilateral knee osteoarthritis, left worse than right. Most pronounced in the medial compartment. |
Generate impression based on findings. | 38-year-old female. Evaluate for soft tissue foreign body (metal) prior to MRI. No radiopaque foreign body. Osseous structures are unremarkable. | No radiopaque foreign body. |
Generate impression based on findings. | Female 87 years old. Reason: Eval for OA. History: same Two views of the left hip demonstrate mild osteophyte formation indicating mild osteoarthritis. There is no fracture or dislocation evident. Arterial calcifications are noted. Four views of the lumbar spine demonstrate moderate multilevel degenerative disk disease... | Mild osteoarthritis of the hip and moderate degenerative disk disease as described above. |
Generate impression based on findings. | Female 79 years old Reason: evaluate R TKA History: s/p R TKA 6 weeks ago Three views of the right knee demonstrate hardware components of a total right knee arthroplasty device situated in near-anatomic alignment. Status post removal of the staples and joint drain. There is heterotopic bone formation along the posteri... | Total right knee arthroplasty as detailed above. |
Generate impression based on findings. | 64 year old female. Superficial infection. Evaluate for right third digit osteo. Market soft tissue swelling of the distal index finger with soft tissue defect/wound at the tip. There is cortical erosion and fragmentation of the 2nd terminal tuft consistent with osteomyelitis. Again seen is amputation of the distal thi... | Findings consistent with osteomyelitis of the index finger terminal tuft. Associated marked soft tissue swelling and soft tissue defect/wound of the finger tip. |
Generate impression based on findings. | Reason: History of metastatic breast cancer on treatment. Compare to prior imaging, evaluate for response and extent of disease. History: History of metastatic breast cancer on treatment. Compare to prior imaging, evaluate for response and extent of disease. CHEST:LUNGS AND PLEURA: Bibasilar scarring/atelectasis. Scatt... | 1.Stable right breast mass.2.Slight interval decrease in size of extensive lymphadenopathy.3.Diffuse osseous and hepatic metastases, not significantly changed.4.Bilateral fissural nodularity is unchanged and may represent early lymphatic involvement. 5.No new sites of disease. |
Generate impression based on findings. | 56 years, Female, Reason: History of metastatic breast cancer on treatment. Compare to prior imaging, evaluate for response and extent of disease. History: History of metastatic breast cancer on treatment. Compare to prior imaging, evaluate for response and extent of disease.. Multiple foci of increased uptake througho... | Stable osseous metastases. |
Generate impression based on findings. | 50 years old Male. Reason: new diagnosis of sarcoma. History: new diagnosis of sarcoma. RADIOPHARMACEUTICAL: 12.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 104 mg/dL. Today's CT portion grossly demonstrates multiple masses in the left proximal thighs and the floor of the pelvis. There is bony destructi... | 1.Hypermetabolic masses in the left upper thigh and floor of the pelvis, consistent with the patient's diagnosis of sarcoma.2.Bony metastasis in the left pelvis, and L2 and L4 vertebral bodies.3.Multiple small left inguinal lymph nodes with increased metabolic activity, suspicious for nodal metastasis.4.Nonspecific foc... |
Generate impression based on findings. | 63 years, Male, Reason: 63 with melena of unknown source. looking for source History: GIB. Angiographic phase is unremarkable. Normal physiologic radiotracer distribution is seen throughout the abdomen. There is no abnormal focus of activity. | Negative Meckel's scan. |
Generate impression based on findings. | Ms. Basic is a 49 year old female presenting for a routine diagnostic mammogram. She has no current breast related complaints. 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 ... | Benign calcifications seen bilaterally. 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 Mammog... |
Generate impression based on findings. | Female, 43 years old.Surgery lasting greater than 8 hours. Counts are correct per service. Dilated loops of bowel are noted within the abdomen, which are nonspecific. No suspicious radiopaque foreign object is identified. Surgical clips are noted in the right upper quadrant. Multiple skin staples are present. | No suspicious radiopaque foreign object is identified.These findings were discussed by telephone with Dr. Lee, the attending surgeon, on 4/16/15 at 15:44. |
Generate impression based on findings. | 63 years, Female. Reason: 63 F s/p ex lap now w SOB, nausea r/o aspiration, PNA, obstruction History: nausea, SOB Nonobstructive bowel gas pattern. Again seen are surgical staples, surgical clips, and suture in place, unchanged. Interval removal of surgical drain. There is retrocardiac opacity, better characterized on ... | 1. Nonobstructive bowel gas pattern.2. Retrocardiac opacity, better characterized on recent chest radiograph. Infection or aspiration could be considered in the correct clinical setting. |
Generate impression based on findings. | Reason: eval for clot/vegetation at line tip Color and spectral Doppler were performed on inflow and outflow vasculature. The tip of the left PICC was identified. There is no evidence of clot. Blood flow within the left subclavian vein and left brachiocephalic vein is normal. | No evidence of clot at the PICC tip.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 73 year old female with a history of small bowel obstruction. Status post NG tube placement. Persistent dilated loops of small bowel, suggestive of a partial small bowel obstruction. Interval placement of NG tube with the tip projecting at the level of the antropyloric region of the stomach. No evidence of pneumatosis ... | Interval placement of NG tube with the tip projecting at the level of the antropyloric region of the stomach. Persistent findings suggestive of partial small bowel obstruction. |
Generate impression based on findings. | Intra-operative CT of the head. This is a limited intra-operative stealth CT demonstrating an external frame with pins in place. There are prior post-operative changes related to a right-sided craniotomy with evidence of extensive areas of hypoattenaution in the right frontal and temporal lobes. There are also hypoatte... | Limited intraoperative CT with redemonstration of remote post-operative changes in the right frontal and temporal lobes. Assessment for tumor is otherwise limited on this study. Please refer to the separate brain MRI report for additional details.I personally reviewed the Images and/or procedure with the Resident/Fello... |
Generate impression based on findings. | 65 years, Male, Reason: metastatic prostate cancer, evaluation of disease during treatment w/investigational agent. please complete PCWG2 form History: metastatic prostate cancer. Increased uptake in the thoracic spine is likely degenerative. No new foci of increased uptake to suggest osseous metastases. | No evidence of osseous metastasis. |
Generate impression based on findings. | Ms. Mellos is a 38 year old female with a personal history of left breast lumpectomy in 2013 for IDC treated with radiation and chemotherapy. She has a family history of breast cancer in a maternal aunt, diagnosed at the age of 60. She has no current breast related complaints. Three standard views of both breasts with ... | Stable postsurgical 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 - Diagnos... |
Generate impression based on findings. | Reason: r/o fracture History: limp, trauma to legs on 4/10/15VIEWS: Left ankle AP oblique lateral (3 views), left tibia/fibula AP lateral (2 views), right tibia/fibula AP lateral (2 views), right ankle AP oblique lateral (3 views) 4/16/15 15:28 No definite fracture or malalignment of bilateral ankles and tibia/fibula. ... | No fracture or malalignment. |
Generate impression based on findings. | 48 -year-old male with history of AML, follow up CT prior to stem cell transplant LUNGS AND PLEURA: New areas of clustered micronodular with tree in bud component most prominent in the left lower lobe but also present to a milder extend in the right middle and lower lobes (series 5, images 105, 173 and 187) are noted. ... | 1. New scattered areas of clustered micronodules with tree in bud component suggestive of bronchiolitis probably related to aspiration or infection.2. Right middle lobe nodule decreased in size presumably benign. |
Generate impression based on findings. | FractureVIEWS: Left wrist AP and lateral There are fractures involving the distal radius and ulna with minimal dorsal angulation of the distal fracture fragments. The overlying cast obscures fine bony detail. | Distal forearm fractures as described above. |
Generate impression based on findings. | FractureVIEWS: Right wrist AP and lateral There are transverse fractures involving the distal radius and ulna with minimal dorsal angulation of the distal fracture fragment. The overlying cast obscures fine bony detail. | Distal forearm fractures as described above. |
Generate impression based on findings. | Patella instability Examination of the images reveals a hypoplastic trochlear groove. 3 cm above the joint line the groove is less than 3mm. In addition the tibial tuberosity trochlear groove distance is abnormally high, being measured at 29 mm. These findings are consistent with patella instability | Patella instability |
Generate impression based on findings. | 52 years old Male. Reason: to assess for lymphoma and sarcoid. History: Polyradiculopathy. RADIOPHARMACEUTICAL: 10.6 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 101 mg/dL. Today's CT portion grossly demonstrates multiple calcified nodules in the right lung and calcified lymph nodes in the right hilum and... | 1.No definite evidence of FDG avid tumor.2.Abnormal FDG uptake in the skin/subcutaneous tissue in the right thigh and left lower leg, which is most likely due to inflammatory change. However, melanoma cannot be excluded. Suggest clinical correlation. |
Generate impression based on findings. | 84 year-old female with fall, AMS. History of Stage IV adenocarcinoma of the right lung with metstases to the brain, bone s/p RT, Head: There is no evidence of intracranial hemorrhage, mass effect or cerebral edema. The known metastatic lesions demonstrated on the prior MRI are not appreciable on this exam. Mild perive... | 1. No evidence of acute intracranial hemorrhage or skull fracture. The known metastatic lesions demonstrated on the prior MRI are not appreciable on this exam.2. Multilevel degenerative spondylosis of the cervical spine, but no evidence of acute fracture.3. Nonspecific lucency within the dens, which may represent infla... |
Generate impression based on findings. | Patient with enlarged thyroid and palpable nodularity to right thyroid lobe. Patient with shortness of breath. Please evaluate. The thyroid gland is not particularly enlarged and no thyroid nodules are not discernible. There is no tracheal narrowing. There is no evidence of significant cervical lymphadenopathy based on... | The thyroid gland is not particularly enlarged and there is no evidence of tracheal narrowing or thyroid nodules. Likewise, no cervical lymphadenopathy is apparent. |
Generate impression based on findings. | 34-year-old male. Pain. Right foot: Pes planus deformity. Mild osteoarthritis of the first MTP joint. Moderate osteoarthritis of the talonavicular joint.Left foot: Pes planus deformity. Mild osteoarthritis of the first MTP joint. Moderate osteoarthritis of the talonavicular joint.Right ankle: Ankle mortise is intact. N... | Pes planus deformity. Osteoarthritis. |
Generate impression based on findings. | 38-year-old female. Pain at volar third or fourth MCPs with finger swelling. Assess pain with no injury. No fracture or dislocation. No focal erosion. | Unremarkable hand radiograph. |
Generate impression based on findings. | Retained foreign object evaluation with multiple surgical teams involved in the surgery.VIEW: Abdomen AP 4/16/15 at 1449 and 1505 There are two abdominal radiographs performed for evaluation of possible retained foreign object. Note that the instrument counts are correct at the end of the procedure. The earlier abdomin... | Radiopaque density at the lumbar level as described above which is seen in the earlier abdominal radiograph but not reproducible in the second radiograph likely to be external in location. Finding was communicated to Dr. Mak on 4/16/15 at 1520 hrs. |
Generate impression based on findings. | 70 year-old female. Edema. Evaluate for gas. Markedly soft tissue swelling of the foot and ankle. Foci of low density are seen in the soft tissues mostly in the dorsal aspect of the foot, likely representing air. Bones are diffusely demineralized but without destructive osseous changes to indicate osteomyelitis. Mild o... | Marked diffuse soft tissue swelling likely with foci of air mainly in the dorsal soft tissues of the foot. No radiographic evidence of osteomyelitis. |
Generate impression based on findings. | There is a C4-C5 anterior cervical discectomy and fusion with an intervertebral device. There is also anterior cervical discectomy and fusion of C5 through C7 with intervertebral disc grafts at C5-C6 and C6-C7, with partial osseous fusion at these levels. There is no evidence of fracture. The vertebral column alignmen... | 1. Postoperative findings related to C4-5 anterior cervical discectomy and fusion with a cage device as well as anterior cervical discectomy and fusion of C5 through C7 with intervertebral disc spacers at C5-C6 and C6-C7, with partial osseous fusion at these levels. 2. Mild degenerative cervical spondylosis with mild s... |
Generate impression based on findings. | Reason: h/o laryngeal ca and CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Biapical fibrosis secondary to radiation appear stable. Pulmonary nodule posterior right apex is unchanged.Mild paraseptal emphysema. Nonspecific, ill-defined focus of ground glass within the left lower lobe (4... | No evidence of metastatic disease.Multiple collateral veins in the setting of near complete SVC occlusion. |
Generate impression based on findings. | Ms. Levy is a 77 year old female presenting with right medial breast pain for the past one month. The pain is brought on with straining and coughing. Patient denies a discrete mass, overlying skin changes, or nipple discharge. She has no family history of breast cancer. Three standard views of both breasts were perform... | Benign intramammary lymph nodes of the right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. All results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: NS -... |
Generate impression based on findings. | 76-year-old male with altered mental status. There is no evidence of intracranial hemorrhage or mass. There is patchy hypoattenuation of the periventricular white matter which is nonspecific but may represent age indeterminate small vessel ischemic disease. The grey-white matter differentiation appears to be otherwise ... | No evidence of intracranial hemorrhage. However, non-contrast CT is insensitive for the detection of non-hemorrhagic acute infarct. |
Generate impression based on findings. | 84 year old female presents with trauma. Evaluate for acute abnormality. ABDOMEN:LUNG BASES: Focal consolidation within the left lower lobe is nonspecific. Mild basilar atelectasis. No pleural effusions. Normal cardiac size without pericardial effusion.LIVER, BILIARY TRACT: Normal hepatic morphology and enhancement wit... | 1. No acute intra-abdominal process. No acute fracture is identified.2. 1 cm hyperattenuating right renal lesion is incompletely characterized, stable since 2014; may represent a small renal cell carcinoma. Surveillance ultrasound and/or cross-sectional imaging is recommended if clinically warranted.3. Non-specific foc... |
Generate impression based on findings. | Cardiac surgeryVIEW: Chest AP and abdomen AP ET tube tip below thoracic inlet and above the carina. Right internal jugular central line with tip at the right brachiocephalic vein. There are epicardial pacer leads and mediastinal drain in the midline. Left chest tube in place. There is a surgical clip in the left medias... | Postoperative exam as described above. |
Generate impression based on findings. | 40 year-old female. Compression injury 5 weeks ago. Continued pain and limited ROM. No fracture or dislocation. | No significant abnormality. |
Generate impression based on findings. | Reason: 82 yo M with hx of CAD, prostate Ca, pAF, BiV ICD, admitted with new L lower lung opacification and R costophrenic nodule on CXR, needing further evaluation History: L back pain, shortness of breath LUNGS AND PLEURA: Scattered calcified pulmonary micronodules compatible with prior granulomatous disease. Small r... | 1.Large left loculated subpulmonic pleural effusion. Small right pleural effusion. Overlying bilateral compressive atelectasis. 2.Mediastinal and upper abdominal enlarged lymph nodes.3.No cardiophrenic lymphadenopathy. Radiographic finding correlates with epicardial fat.4.Severe atherosclerotic disease. |
Generate impression based on findings. | 31 year old female with lung nodule LUNGS AND PLEURA: Previously referenced 2 mm right upper lobe nodule has resolved. No suspicious pulmonary nodules or masses. 5 mm right upper lobe nodule adjacent to vascular structures ( series 5, image 86) unchanged presumably benign. Right lower lobe nodule (series 5, image 162) ... | Previously reference right upper lobe nodule has resolved. Additional lung nodules unchanged most likely benign. |
Generate impression based on findings. | OLT, screen for HCC LIVER: Transplanted liver measures 12.6 cm. Hepatic cyst, measuring 0.9 x 0.7 x 0.5 cm, and accounting for differences in technique this is likely unchanged. No focal solid liver lesion seen. GALLBLADDER, BILIARY TRACT: No intrahepatic or extrahepatic biliary duct dilatation.PANCREAS: Not well seen ... | Patent hepatic transplant vasculature. |
Generate impression based on findings. | Evaluate pneumothoraxVIEW: Chest AP Left upper extremity PICC and left central line again noted. Right internal jugular central line has been removed. NG tube tip in the stomach. There is a surgical drain in the right upper quadrant. Midline skin staples are again noted. Cardiothymic silhouette cannot be evaluated. Lef... | Left lung opacity has increased and may reflect a combination of atelectasis and pleural effusion. |
Generate impression based on findings. | 43-year-old female. Patient with SLE on chronic prednisone. Pain. Evaluate for fracture. Lumbar spine: Six lumbar type vertebrae are again designated. Lumbar spine alignment is anatomic. Again seen is hypertrophy of the right transverse process of L6, indicating partial sacralization. The right transverse process of L1... | Mild right hip osteoarthritis. No significant acute abnormality in the lumbar spine. |
Generate impression based on findings. | Frontal sinus: There is partial opacification of the right frontal ethmoidal recess. The frontal sinus and left frontoethmoidal recess is clear.Anterior ethmoids: The anterior ethmoid air cells are clear.Maxillary sinuses: There is mild mucosal thickening in the left maxillary sinus. There is trace mucosal thickening ... | 1. No significant sinus inflammatory changes with only minimal scattered disease as detailed above. Patent bilateral ostiomeatal units.2. Mild-moderate leftward nasal septal deviation with small bony spur which abuts the neck of the left middle turbinate. |
Generate impression based on findings. | Female 76 years old Reason: Evaluate for progression of metastatic disease; compare to previous scan History: None CHEST:LUNGS AND PLEURA: Bilateral, multiple new lung nodules. An index nodule measures 11 x 9 mm image number 30, series number 6. Previously measured index nodule measures 7 by 4 mm on image number 51, se... | Interval development of new small lung nodules.Interval increase in the size of the hyperdense pelvic soft tissue mass.Left adrenal lesion is stable.Index precarinal nodule is smaller. |
Generate impression based on findings. | vomitingVIEWS: abdomen AP (1 views) 4/16/15 13:55 G tube in place. Stool in the descending colon and sigmoid colon. No bowel obstruction. No pneumatosis or pneumoperitoneum. | Normal examination. |
Generate impression based on findings. | Male 67 years old; Reason: ho of ILD, left inguinal hernia History: right scrotal swelling, no hernia RIGHT TESTIS: The right testis measures 5.2 x 2.4 x 2 .9 cm, with homogeneous echotexture. A small right hydrocele is noted.LEFT TESTIS: Left testis measures 4.9 x 2.3 x 3 .1 cm, with homogeneous echotexture.RIGHT EPID... | 1. Unilateral right-sided varicocele is identified. CT abdomen and pelvis is recommended for further evaluation to exclude abdominal/pelvic adenopathy or other obstructing process.2. A subcentimeter left testicular echogenic focus is of uncertain clinical significance. Additional punctate focus of increased echogenicit... |
Generate impression based on findings. | 25-year-old male. Left navicular fracture. Interval removal of the dorsal fragments/heads of the two screws traversing the healing navicular fracture. The remaining fragments of the two screws are unchanged in position from prior exam. Mild osteoarthritis of the talonavicular joint. | Interval removal of the heads of the two screws traversing the navicular bone. |
Generate impression based on findings. | There has been complete resolution of previously seen adjacent ring-enhancing lesions in the left medial occipital lobe, with resolution also of the associated vasogenic edema. There is minimal residual ill-defined FLAIR hyperintensity in location of the prior metastases, likely post-treatment related. The previously ... | 1. Interval complete resolution of previously seen ring enhancing metastatic lesions in the medial left occipital lobe, with only very minimal residual FLAIR abnormality.2. Additional nodular focus in the left middle temporal gyrus is no longer appreciated.3. No new foci of enhancement seen. |
Generate impression based on findings. | Female 58 years old Reason: ongoing iron deficiency anemia with negative cscope and egd. evaluate for other gi source of bleeding History: iron deficiency anemia ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: HepatomegalySPLEEN: No significant abnormality notedPANCREAS: No significant abnorma... | No CT findings to explain patient's source of GI bleeding. |
Generate impression based on findings. | Female 65 years old Reason: renal mass or stone? History: L sided pain ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URET... | Right renal lower pole complex cyst with high density content and calcified walls. Further evaluation with renal mass protocol MRI is recommended to excluded renal cell carcinoma. |
Generate impression based on findings. | 58-year-old female. History of fracture 3rd metatarsal. Assess healing and alignment. Third metatarsal mid diaphyseal fracture in anatomic alignment. There is callus formation consistent with healing. | Healing third metatarsal fracture. |
Generate impression based on findings. | Male 56 years old Reason: Eval for OA History: Pain Bone mineralization is normal. Alignment is anatomic. The joint spaces are normal. Tiny osteophytes in the lateral and extensor compartment.No acute fracture or malalignment. | Minimal osteoarthritis. |
Generate impression based on findings. | Abdominal distentionVIEW: Abdomen AP There is a gastrostomy tube in place. The right central line is in place. Multiple dilated loops of bowel with retained contrast not significantly changed. No pneumatosis or pneumoperitoneum. Minimal patchy atelectasis in the left lower lobe. | Abnormal dilated loops of bowel not significantly changed from prior study. |
Generate impression based on findings. | Male, 49 years old. AKI Evaluate for hydronephrosis. RIGHT KIDNEY: Right kidney measures 11.7 centimeters, with normal cortical echotexture. Multiple simple renal cysts are identified. The largest in the right upper lobe measures 4.0 x 3.1 x 3.3 cm. No perinephric fluid, shadowing calculi, or hydronephrosis.LEFT KIDNEY... | No hydronephrosis or perinephric fluid identified. |
Generate impression based on findings. | 73 years old Female. Reason: new lung mass- staging of lung cancer. History: new lung mass. RADIOPHARMACEUTICAL: 14.1 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 99 mg/dL. Today's CT portion grossly demonstrates a large mass in the left upper lobe. Additional solid nodules in the left upper lobe and righ... | Hypermetabolic tumor in the right lung across right upper lobe and lower lobe, with central necrosis, consistent with the lung cancer.Satellite nodule in the right upper lobe, consistent with tumor.Stable mild hypermetabolic lymph nodes in the right lung hilum and mediastinal right paratracheal region, which are nonspe... |
Generate impression based on findings. | 83 years, Female, Reason: as above History: pt with lung cancer and enlarging new nodule on RML, ck for activity.RADIOPHARMACEUTICAL: 6.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 104 mg/dL. Today's CT portion grossly demonstrates a new right middle lobe nodule and increased size in right lower lobe no... | 1.Resolution of hypermetabolic L2 lesion.2.New hypermetabolic right middle lobe nodule, suspicious for metastases.3.Increased size in right lower lobe nodule, suspicious for metastases. |
Generate impression based on findings. | Postoperative changes are seen from right frontotemporal craniotomy. Images are now limited by streak artifact from intervally placed aneurysm clips along the expected location of previously seen distal right M3 and right MCA bifurcation aneurysms. Minimal subarachnoid blood products are likely present in the superior... | Expected postoperative changes following right MCA bifurcation and distal right M3 aneurysm clipping, without evidence of acute intracranial hemorrhage within streak artifact limitations. Likely trace postoperative subarachnoid blood products along the right superior sylvian fissure. |
Generate impression based on findings. | Evaluate for resolution of intracranial hemorrhage. There are postoperative findings related to right pterional craniotomy. There is unchanged extensive encephalomalacia in the right cerebral hemisphere with associated Wallerian degeneration and ex vacuo dilation of the right lateral ventricle. There is no evidence of ... | 1. Extensive right cerebral hemisphere encephalomalacia, but no evidence of acute intracranial hemorrahge.2. Persistent sinonasal polyposis. |
Generate impression based on findings. | 80 years, Female, Reason: evaluate extent of disease History: new maxilary sinus SCC.RADIOPHARMACEUTICAL: 13.1 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 140 mg/dL. Today's CT portion grossly demonstrates large mass centered in the left maxillary alveolar ridge with invasion of the left maxillary sinus,... | 1.Large hypermetabolic left maxillary alveolar ridge lesion consistent with squamous cell carcinoma on biopsy.2.Large necrotic left level 2 node with several surrounding smaller cervical nodes likely represent metastases. |
Generate impression based on findings. | Male 39 years old Reason: right knee pain History: knee pain Right knee: Bone mineralization is normal. Alignment is anatomic. The joint spaces are normal. No joint effusion. No acute fracture or malalignment. There are tiny extensor compartment osteophytes.Left knee: Bone mineralization is normal. Alignment is anatomi... | Minimal extensor compartment osteoarthritis |
Generate impression based on findings. | Male, 66 years old. Reason: Cryptogenic cirrhosis, increasing abdominal girth, eval vascular patency, eval for ascites History: cirrhosis GRAYSCALELIVER: The liver measures 15.6 cm, atrophic, with coarse echotexture, and no focal lesion.GALLBLADDER, BILIARY TRACT: No intrahepatic or extrahepatic biliary ductal dilatati... | 1. Technically difficult study. 2. Blunted hepatic venous waveforms, may be seen with venoocclusive disease.3. Mildly elevated velocities through the TIPS as described above. No intrashunt aliasing seen to suggest definite stenosis. Left and right portal veins not well assessed. Correlation with patient's clinical hist... |
Generate impression based on findings. | Female 90 years old Reason: pubic ramus fractures History: fractures There are fractures of the right superior and inferior pubic rami with callus formation. There is ongoing healing of the right sacral alar fracture. Alignment is not significantly changed.The bones are diffusely demineralized.IVC filter is in place | Healing right superior, infrapubic rami fractures and right sacral alar fracture. |
Generate impression based on findings. | 64 years, Female, Reason: evaluate for lytic lesion History: lesion sternum. Increased uptake within the sternum and proximal left clavicle corresponds to destructive lesion on CT and is suspicious for metastases. No additional lesions are evident. | Sternal and left clavicular lesions corresponding to findings on CT are suspicious for a metastases. No additional lesions present. |
Generate impression based on findings. | Female 44 years old Reason: OA? History: weight bearing knee pain, remote history of power lifting Bone mineralization is normal. Alignment is anatomic. The joint spaces are appropriate for age. No acute fracture or malalignment.No osteophytes are evident to indicate osteoarthritis. | No significant osteoarthritic changes. |
Generate impression based on findings. | Female 56 years old Reason: Pt s/p Manipulation under Anesthesia of L Knee s/p TKA History: Flexion increased Components of a total left knee arthroplasty device is situated in near-anatomic alignment. No acute fracture or malalignment.The distal quadriceps tendon is indistinct with a few calcifications and thickening ... | Left knee arthroplasty as above. |
Generate impression based on findings. | Male 50 years old Reason: shoulder pain and clicking History: as above There is severe joint space narrowing with near bone-on-bone apposition. There are inferomedial humeral head osteophytes, lucencies in the glenoid indicating subchondral cysts with osteophytes.No acute fracture or malalignment. AC joint is anatomic ... | Moderate to severe right shoulder osteoarthritis. |
Generate impression based on findings. | Female 52 years old Reason: Hallux valgus (acquired) History: Two orthopedic screws affix the first tarsometatarsal joint with reduction of the hallux valgus. No hardware complication is evident.Mild osteoarthritis affects the first MTP joint. The medial sesamoid is bipartite. | Postsurgical changes as detailed above. |
Generate impression based on findings. | Female 76 years old Reason: r/o DJD, gout History: right foot pain. hx of gout The bones are demineralized.There is mild hallux valgus deformity with mild to moderate osteoarthritic changes at the first MTP joint. No acute fracture or malalignment. The bones are demineralized. No definite findings of gout. Mild osteoar... | Osteoarthritic changes as detailed above. |
Generate impression based on findings. | Female, 61 years old. Reason: ?kidney stones History: hyperparathyroidism RIGHT KIDNEY: The right kidney measures 11.0 cm, with normal echotexture. No shadowing calculi or hydronephrosis. No perinephric fluid.LEFT KIDNEY: The left kidney measures 10.4 cm, with normal echotexture. No shadowing calculi or hydronephrosis.... | No renal stone or hydronephrosis. |
Generate impression based on findings. | Male 72 years old Reason: pain History: pain Two views of the left hip: Two views of left hip shows bone mineralization is normal. Alignment is anatomic. There is mild joint space narrowing. No acute fracture or malalignment.AP view of the pelvis shows moderate osteoarthritic changes at the symphysis pubis, lower lumba... | Osteoarthritic changes as detailed above. |
Generate impression based on findings. | Female 100 years old Reason: right distal humerus fracture History: right distal humerus fracture The bones are demineralized.There is a complete transcondylar fracture of the distal humerus with medial displacement of the distal fracture fragment. There is malunion at the fracture site. | Distal humerus fracture as above. |
Generate impression based on findings. | Male 59 years old Reason: b/e djd of hips left hips worsening l hip pain. History: Right hip: Components of a total right hip arthroplasty device are situated in near-anatomic alignment without radiographic evidence of hardware complication. There is subtle lucency surrounding the distal tip of the femoral prosthesis h... | 1.Severe left hip osteoarthritis.2.Total hip arthroplasty device as detailed above |
Generate impression based on findings. | Male 50 years old Reason: knee pain History: pain Right knee: Bone mineralization is normal. Alignment is anatomic. The joint spaces are normal. No acute fracture or malalignment. No joint effusion. There are tiny developing osteophytes.Left knee: Bone mineralization is normal. Alignment is anatomic. The joint spaces a... | Minimal osteoarthritic changes. |
Generate impression based on findings. | Reason: evaluate for bleed History: worst headache of life. There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. There is a prominent retrocerebellar CSF space. Otherwise, the ventricles are normal in size and configuration. There is no midline shift... | No evidence of acute intracranial hemorrhage. |
Generate impression based on findings. | Female 40 years old Reason: pain in right hip x weeks. worse with walking. hx obesity History: pain Bone mineralization is normal. There are early osteoarthritic changes in the superior acetabulum.No acute fracture or malalignment. | No acute fracture or malalignment. |
Generate impression based on findings. | Female 71 years old Reason: s/p reverse total shoulder arthroplasty History: as above Status post resection of a left humeral fracture. The humeral prosthesis is intact.The glenoid component shows a gap between the glenosphere and the base plate which may positional.Interscalene block and drain are in place. | Reverse total left shoulder arthroplasty as detailed above. |
Generate impression based on findings. | Status post left total knee arthroplasty Components of a total knee arthroplasty device are situated in near-anatomic alignment without radiographic evidence of hardware complication. Skin staples, a drain and foci of gas density in the soft tissues reflect recent surgery. | Postoperative changes of total knee arthroplasty. |
Generate impression based on findings. | Status post right TKA Components of a right total knee arthroplasty device are situated in near-anatomic alignment without radiographic evidence of complication. Skin staples, a drain and foci of gas in the soft tissues reflect recent surgery. | Postoperative changes of total knee arthroplasty. |
Generate impression based on findings. | Left side headache. 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 paranasal sinuses and mastoid air cells are clear. The skull and scalp s... | No evidence of acute intracranial hemorrhage, mass, or paranasal sinus disease. |
Generate impression based on findings. | Trauma to the 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. There are subcentimeter osteomas in the frontoethmoid recesses. There is partially-... | No evidence of acute intracranial hemorrhage or skull fracture. |
Generate impression based on findings. | Right side weakness and fall. There are postoperative findings related to bilateral pterional craniotomies. There are multiple aneurysm clips in the expected locations of the distal internal carotid arteries bilaterally and the left middle cerebral artery. Extensive streak artifact from these clips limits the evaluatio... | Multiple clipped cerebral aneurysms and extensive left cerebral hemisphere encephalomalacia attributable to a chronic left middle cerebral artery territory infarct, but no evidence of acute intracranial hemorrhage within the limits of metal artifact. However, non-contrast CT is insensitive for the detection of non-hemo... |
Generate impression based on findings. | Fall, confusion. History of stroke. Head: There is no evidence of acute intracranial hemorrhage or mass. There is unchanged encephalomalacia in the right temporal lone and insula, as well as the corona radiata. The ventricles are unchanged in size and configuration. There is no midline shift or herniation. The imaged p... | 1. No evidence of acute intracranial hemorrhage or skull fracture.2. Chronic right middle cerebral artery territory infarct. However, non-contrast CT is insensitive for the detection of non-hemorrhagic acute infarct.3. No evidence of cervical spine fracture or spondylolisthesis.4. Posterior disc protrusion at C4-5 asso... |
Generate impression based on findings. | Intraoperative planning CT. There is a stereotactic head frame in position without apparent complications. The left cerebellar hemisphere and right temporal lobe lesions are more conspicuous on the prior MRI. Aerodigestive track tubes are present. | Intraoperative CT with stereotactic frame in position. The left cerebellar hemisphere and right temporal lobe lesions are more conspicuous on the prior MRI. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.