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Generate impression based on findings. | 12 year old male patient with pediatric trauma. Question of fracture and pneumothorax.VIEWS: Chest AP (1 view), cervical spine AP and lateral (two views), pelvis AP (one view) 4/19/2015 No acute cervical fracture is evident. No prevertebral soft tissue swelling. Alignment is anatomic. There is mild adenoid hypertrophy.... | No acute fracture is evident. |
Generate impression based on findings. | Female 61 years old Reason: s/p fall History: s/p fall Three views of the right hand demonstrate moderate osteoarthritis affecting the interphalangeal joints and the basilar joint. Osteophytes at the second and fifth metacarpal heads raising the possibility of CPPD arthropathy although there is no chondrocalcinosis. Os... | 1. Moderate osteoarthritis affects the interphalangeal joints and basilar joint.2. Osteophytes at the second and fifth metacarpal heads raising the possibility of CPPD arthropathy although there is no chondrocalcinosis. 3. Other findings as described above. |
Generate impression based on findings. | Reason: head and neck cancer for tumor assessment History: as above CT neck:Some infiltration of fat planes along the right neck is likely treatment related. It is stable compared to prior exams.Within the suprahyoid neck on the basis of size criteria for lymphadenopathy no lymphadenopathy is appreciated. Within the in... | 1.No evidence for local recurrence or neck lymphadenopathy on the basis of CT size criteria for lymphadenopathy2.No evidence for brain metastases. |
Generate impression based on findings. | 71 year old female with basal cell carcinoma of left upper chest/neck, open wound 10 x 5 cm. LUNGS AND PLEURA: Postsurgical changes of right upper lobectomy. Loculated right apical pleural fluid collection with associated pleural thickening unchanged. Calcified left lung micronodules consistent with healed granulomatou... | 1. Open wound in the left chest wall with soft tissue thickening and sclerosis in the underlying left clavicular diaphysis is unchanged. 2. New punctate micronodule in periphery of right base is nonspecific but is much more likely inflammatory than metastatic, though continued follow up is recommended. It is too small ... |
Generate impression based on findings. | Male 34 years old; Reason: left flank pain with hx of kidney stone History: left flank pain radiating into groin ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS... | 1. No hydronephrosis. Nonobstructing punctate right intrarenal stones.2. Postoperative sequela related to left-sided hernia repair. |
Generate impression based on findings. | Increased work of breathingVIEW: Chest AP and abdomen AP Tracheostomy tube in place. Right lower extremity PICC with tip in the right atrium. G-tube in place. Cardiothymic silhouette normal. Patchy atelectasis in the right upper lobe and left lower lobe. No pleural effusion or pneumothorax. Multiple dilated loops of bo... | Multiple dilated loops of bowel in the right hemi-abdomen not significantly changed. |
Generate impression based on findings. | 12 year old male patient with right lower extremity fracture secondary to crush injury. VIEWS: Right tibia/fibula AP and lateral (2 views) 4/19/2015 Splint material obscures fine bone detail. There is a transverse fracture through the mid/distal fibular diaphysis with approximately 4 mm of medial displacement of the di... | Tibia and fibula fractures. |
Generate impression based on findings. | Female 82 years old Reason: foot pain History: foot pain The bones are demineralized. There is moderate/severe osteoarthritis at the first metatarsophalangeal joint with hallux valgus. Moderate osteoarthritis affects the tarsometatarsal articulations at the Lisfranc joints. No fracture or malalignment. Amorphous calcif... | 1. Calcium hydroxyapatite deposition at the fifth metatarsophalangeal joint suggestive of calcific capsulitis.2. Osteoarthritis as described above. |
Generate impression based on findings. | Female 85 years old Reason: right thigh pain History: right thigh pain Moderate osteoarthritis affects the the right hip. A small 4-mm calcific focus is again noted along the superior femoral neck which may represent a small intra-articular body. Moderate osteoarthritis affects the right knee joint and there is a small... | Osteoarthritis and other findings as described above. |
Generate impression based on findings. | Blunt trauma to the abdomen. Evaluate for visceral injury. ABDOMEN:LUNG BASES: There is minimal left lower lobe atelectasis.LIVER, BILIARY TRACT: Normal contrast enhancement of the liver without evidence of a focal lesion.SPLEEN: The spleen is normal in appearance.PANCREAS: The pancreas is normal in appearance without ... | No specific evidence of solid or hollow viscus organ injury. |
Generate impression based on findings. | Male 18 years old Reason: pain on the medial aspect after fallen onto bent knee 2 days ago History: pain No fracture or malalignment. No significant joint effusion. | No fracture or malalignment. |
Generate impression based on findings. | FractureVIEWS: Left wrist AP and lateral There is buckle fracture involving the metaphysis of the distal radius in near anatomic alignment. There is soft tissue swelling about the wrist joint. The overlying cast obscures fine bony detail. | Buckle fracture distal radius as described above. |
Generate impression based on findings. | Trauma with swellingVIEWS: Left fifth finger AP lateral oblique Fracture of the distal portion of the proximal phalanx of the left fifth finger. The distal fracture fragment is angulated in the volar direction. There is surrounding soft tissue swelling. | Distal proximal phalanx fracture of the left fifth finger. |
Generate impression based on findings. | Reason: 56 yo F with stage IIb/IIIa lung adenocarcinoma of LUL s/p chemoRT and lobectomy in June 2013 for routine surveillance History: none CHEST:LUNGS AND PLEURA: Postsurgical changes of a left upper lobectomy. Left lower lobe posttreatment changes, unchanged. Scattered pulmonary micronodules, including a cluster of ... | Stable postsurgical and posttreatment changes at the left lung. New subtle left pleural nodularity and small left pleural effusion, raising the question of metastatic disease. Short-term follow up recommended. |
Generate impression based on findings. | FractureVIEWS: Right foot AP and lateral There are healing fractures involving the first and second metatarsals in near anatomic alignment. There are sclerosis and periosteal reaction reflecting interval healing. The overlying cast has been removed. | Healing metatarsals fractures as described above. |
Generate impression based on findings. | There are postoperative findings related to left parietal craniotomy with left precuneus encephalomalacia and ex vacuo dilatation of the atrium of the left lateral ventricle. There is no evidence of intracranial hemorrhage, mass, or cerebral edema. There is mild periventricular white matter hypoattenuation (also invol... | Remote postoperative findings with no acute intracranial hemorrhage or mass-effect. CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction. |
Generate impression based on findings. | History of left lumpectomy for LCIS in 2001. Patient was on tamoxifen for 5 years. No new breast complaints. History of breast cancer in maternal grandmother. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandu... | 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. | History of left lumpectomy in 2002 for IDC and DCIS. Patient received radiation, chemotherapy and tamoxifen. No new breast 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, un... | 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.I personally reviewed the Images a... |
Generate impression based on findings. | Female 22 years old Reason: Eval for Fx History: Knee Pain s/p ACL Recon Osseous tunnel and anchor noted, reflecting prior ACL repair. A moderate joint effusion is present. No fracture or malalignment. | No fracture or malalignment. Moderate joint effusion. |
Generate impression based on findings. | 61-year-old female patient with calcifications in the right upper outer breast as seen on prior mammogram. History of breast cancer in her maternal grandmother. Three standard views and two spot magnification views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchy... | Stable benign calcifications in the right upper outer breast. Recommend bilateral diagnostic mammogram in 6 months. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Female 61 years old Reason: right knee pain History: right knee pain Moderate osteoarthritis affects the right knee with medial and lateral joint compartment narrowing and osteophytosis most marked in the lateral joint compartment. There is a joint effusion. | Moderate osteoarthritis. |
Generate impression based on findings. | Reason: head and neck cancer for tumor assessment History: as above CHEST:LUNGS AND PLEURA: Scattered punctate micronodules are stable and presumably benign. New pulmonary nodules. MEDIASTINUM AND HILA: No significant abnormality noted.CORONARY ARTERY CALCIFICATION: Moderate.CHEST WALL: Vertebral body hemangiomas, unch... | No evidence of metastatic disease. |
Generate impression based on findings. | InjuryVIEWS: Right wrist AP and lateral There is fusion of the lunate and triquetral bone unchanged from prior study. No acute fracture or dislocation. | No acute fracture or dislocation. |
Generate impression based on findings. | Reason: high risk for lung CA History: cough, significant tobacco history, unintentional weight loss LUNGS AND PLEURA: Mild upper lobe predominant centrilobular and paraseptal emphysema. Left lower lobe bronchiectasis and bronchial wall thickening with mucus impaction and airspace opacities, increased compared to prior... | 1.No suspicious pulmonary nodules or masses. Low dose screening CT is recommended in one year.2.Interval increase in left lower lobe bronchiectasis, bronchial thickening, mucus impaction, and airspace opacities.3.Basilar opacities may represent mild basilar fibrosis and dependent atelectasis.4.The previously identified... |
Generate impression based on findings. | Female 50 years old Reason: left knee pain History: left knee pain Moderate osteoarthritis affects the left knee with medial joint space narrowing. The bones are demineralized. There is no joint effusion. | Moderate osteoarthritis. |
Generate impression based on findings. | Reason: fall this AM with lac to temporal area History: fall CT head:The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized por... | 1.No evidence for cervical spine fracture2.No evidence for acute intracranial hemorrhage mass effect or edema.3.Normal to low degenerative changes present in the cervical spine with mild to moderate degrees of spinal stenosis suspected at the C3-4, C4-5 and 6 - 7 as detailed above. Additionally there is multilevel encr... |
Generate impression based on findings. | Female 71 years old Reason: hip pain 2 months s/p fall History: as above There is joint space narrowing, osteophytosis, and subchondral sclerosis consistent with moderate osteoarthritis. No fracture or malalignment. | Moderate osteoarthritis. No fracture or malalignment. |
Generate impression based on findings. | Male 30 years old Reason: ankle pain 10 days s/p twisting. Pain and bruising under lateral malleolus. tenderness over distal fibula History: as above Mild soft tissue swelling over the lateral malleolus. No fracture, malalignment or joint effusion. | Soft tissue swelling over the lateral malleolus but no fracture or malalignment. |
Generate impression based on findings. | There is persistent minimal lucency through the right body of the mandible representing healing nondisplaced fracture without change in alignment, and small amount of callus formation without change. The fracture line extends to the apex of the right mandibular canine tooth as noted before. There are multiple addition... | 1.Healing right mandible body fracture without significant change. 2.Healed left subcondylar fracture. |
Generate impression based on findings. | Reason: Change in masses? History: Thyroid cancer metastatic to lungs LUNGS AND PLEURA: Left apical fibrosis, likely post radiation in etiology, unchanged. Bilateral pulmonary nodules compatible with metastases have increased in size compared to prior. For reference right lower lobe module measures 13 mm and series 4 i... | Interval increase in size of numerous pulmonary metastases. No new sites of disease. |
Generate impression based on findings. | TMJ pain There are moderate degenerative changes at the right temporomandibular joint with flattening of the mandibular condyle and some mild sclerosis and osteophyte formation. Mild degenerative findings are also evident at the left temporomandibular joint.There is a small mucus retention cyst in the right maxillary s... | 1. Moderate degenerative arthritic changes of the right temporomandibular joint.2. Interval placement of maxillary implant hardware.3. Unchanged partial opacification of the left mastoid air cells, which is nonspecific but may represent mastoiditis. I personally reviewed the Images and/or procedure with the Resident/Fe... |
Generate impression based on findings. | Male 56 years old Reason: 56M with rectal cancer s/p LAR/DLI c/b anastomotic leak managed wtih IR drain. please re-eval collection for possible drain removal History: ascess s/p IR drainage. please re-eval collection ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Subcentimeter hypodense lesio... | Significant interval decrease in the size of the perirectal abscess. |
Generate impression based on findings. | FractureVIEWS: Right elbow AP and lateral The alignment of the humerus, radius and ulna are anatomic. The overlying cast obscures fine bony detail. There is a faint lucency at the olecranon and may represent a nondisplaced fracture. | Faint lucency at the olecranon and may represent a nondisplaced fracture. |
Generate impression based on findings. | Reason: AMS, status strokes History: AMS There is redemonstration of hematoma located in the left anterior temporal lobe and extending along the insular cortex and left inferior frontal lobe cortical white matter which remains stable since the prior exam.There is redemonstration of a continued evolution of infarctions ... | 1.Examination is relatively stable compared to the prior exam with continued evolution of a left frontal and temporal hematoma as well as infarctions in the left parietal lobe , temporal lobe and occipital lobe.2.There is redemonstration of encephalomalacia in the cerebellar hemispheres |
Generate impression based on findings. | Male 67 years old Reason: s/p reverse TSA History: s/p reverse TSA Components of a reverse ball-and-socket right total shoulder arthroplasty in near anatomic alignment without evidence of hardware complication. A small amount of heterotopic bone is again noted along the lateral aspect of the joint. A vascular stent is ... | 1. Reverse total shoulder arthroplasty.2. A radiopaque foreign body is projected over the proximal arm on a single view which may represent a fragment of stent material. It is uncertain if this is within the patient's soft tissues. |
Generate impression based on findings. | 34-year-old male. Pain and swelling after exercise, has been training for a marathon. Evaluate for fracture. No fracture or dislocation. Small osteophytes at the anterior talonavicular joint consistent with mild osteoarthritis. | Osteoarthritis. No fracture is evident. |
Generate impression based on findings. | 66 year old male with h/o SGL ca and CRT, compare to previous CHEST:LUNGS AND PLEURA: Right punctate perifissural micronodule measuring 4mm (image 112/293 high res) is increased versus prior, at which time it measured <1 mm. Based on appearance and location it is most likely an intrapulmonary lymph node though since it... | 1. Right punctate perifissural micronodule 4mm is increased versus prior, at which time it measured <1 mm. Based on appearance and location it is most likely an intrapulmonary lymph node though since it is larger, continued follow up is recommended to exclude growth. It is too small for reliable PET or needle biopsy. 2... |
Generate impression based on findings. | Female 63 years old Reason: hx of low grade Ta urothelial carcinoma, evaluate for metastatic disease History: see above ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Subcentimeter, nonspecific hypodense lesions in the liver, too small to accurately characterize but are most likely cysts.SPLE... | Right lower quadrant collection and fat stranding adjacent to the tip of the appendix. An abscess secondary to perforated appendicitis is a diagnostic possibility.Nonspecific small retroperitoneal and iliac lymph nodes. |
Generate impression based on findings. | 63 years, Male. Reason: Dobbhoff History: Dobbhoff Interval replacement of the Dobbhoff tube, now with the tip in the distribution of the gastric fundus. The pelvis is excluded from the field-of-view. Nonobstructive bowel gas pattern. Please refer to concomitant chest radiograph for detailed thoracic findings. | Interval replacement of Dobbhoff tube, with tip in the region of the gastric fundus. |
Generate impression based on findings. | Female 28 years old Reason: pt fell on wet pavement with pain to diffuse lower knee History: knee pain Complex medial side plate fixation numerous screws appearing unchanged compared to prior study. No hardware complication. The fracture line is not well visualized, compatible with healing. There is a joint effusion bu... | 1. Joint effusion but no acute fracture or malalignment.2. Tibial fracture hardware fixation is unchanged. |
Generate impression based on findings. | Reason: Dobbhoff placement History: above Dobbhoff tube tip appears in the distribution of the the left lung base, likely placed through left main bronchus. Nonobstructive bowel gas pattern. Please refer to concomitant chest radiograph for detailed thoracic findings. | Dobbhoff tube tip in the left lung base. At the time of dictation, follow-up films have been obtained, and tube has been removed. |
Generate impression based on findings. | Reason: NGT placement History: above NG tube tip appears in the distribution of the gastric fundus, with the side-port at the level of the gastroesophageal junction, recommend advancing. Multiple dilated loops of small bowel, suggestive of postoperative ileus. Midline skin staples are noted. Please refer to recent ches... | NG tube tip in the distribution of the gastric fundus, with the side-port at the gastroesophageal junction, recommend advancing 7 cm. |
Generate impression based on findings. | Reason: confirm ngt History: ngt NG tube tip in the proximal gastric fundus, with the side-port at the level of the gastroesophageal junction, recommend advancing. Bowel gas pattern is unremarkable. Midline skin staples are noted. Please refer to concomitant chest radiograph for detailed thoracic findings. | NG tube side port at the level of the gastroesophageal junction, recommend advancing at least 7 cm. |
Generate impression based on findings. | 59-year-old male. Pain and swelling status post fall. Mild chronic deformity of the distal femur, which is affixed by a sideplate and screws, likely related to remote trauma. No acute fracture is identified. Vascular calcifications in the medial soft tissues of the thigh. Moderate to severe osteoarthritis affects the k... | Orthopedic fixation of a chronic mild deformity of the left femur, most likely post-traumatic. No acute fracture is identified. |
Generate impression based on findings. | 102 years, Female. Reason: eval progression of SBO History: as above Interval removal of nasogastric tube. Persistent dilatation of the small bowel, not significantly changed when compared to prior. Stool is again noted distally within the rectosigmoid colon. Chronic-appearing fibrotic changes of the lung bases are par... | Persistent dilatation of the small bowel, grossly unchanged. |
Generate impression based on findings. | Age: 77 years. Sex : Female. Reason for study: Reason: evaluate for aspiration History: dysphagia. 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 obtained. T... | The exam was negative for penetration and negative for aspiration. |
Generate impression based on findings. | 40 year-old male with worsening LFTs and abdominal distention. Rule out biliary disease and portal hypertension. Grayscale ultrasound:LIVER: Note is made of hepatomegaly. The liver measures 19.8 cm in length. Coarsened liver echotexture. Note is made of a 2.3 x 3.4 x 3.5 cm simple cyst in the left lobe of the liver. Th... | Coarsened liver echotexture is nonspecific but can be seen in chronic liver disease. Hepatomegaly without evidence of suspicious focal mass lesion. |
Generate impression based on findings. | 75 year old female with metastatic breast cancer on treatment, compare to previous CHEST:LUNGS AND PLEURA: Interval decreased in loculated right pleural effusion with irregular pleural thickening compatible with known metastatic disease. High density consistent with talc pleurodesis. There is adjacent compressive atele... | Interval decrease in loculated right pleural effusion with irregular pleural thickening. Fluid in the minor fissure obscures the previously noted pulmonary nodules/lymph nodes. No new sites of disease. |
Generate impression based on findings. | Male 72 years old; Reason: hx of bladder cancer s/p radical cystectomy, evaluate for metastatic disease with delayed imaging ABDOMEN:LUNGS BASES: Incompletely imaged moderate to marked calcified coronary disease. Visualized lung bases demonstrate no suspicious lung nodule. However, evaluation suboptimal due to respirat... | 1. Interval cystectomy. Right-sided ileostomy seen.2. New from prior study is mesenteric fat stranding and nodularity at site of small bowel anastomosis in right abdomen. Lymph nodes measure up to 0.8 cm. Moderate wall thickening seen near level of the anastomosis as well. Findings likely postoperative in etiology but ... |
Generate impression based on findings. | Male 49 years old. Reason: r/o acute process. History: foot pain. Three views of the right foot demonstrate no evidence of acute fracture or malalignment. There is minimal degenerative change at the first metatarsophalangeal joint. | No acute fracture or dislocation. |
Generate impression based on findings. | Ms. O'Neal submitted outside mammograms dated 5/12/2014 and 12/11/2012, from Cerner Imaging. Submitted outside studies were compared to the current mammogram dated 03/24/2015. The breast parenchyma is composed of scattered fibroglandular density. Left chest ICD partially obscures the left axilla. There is re-identifica... | Stable benign calcifications in the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually, due next in March 2016.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 61-year-old male. AML. History of fall. Please evaluate for fracture. No fracture or dislocation. Minimal osteoarthritis of the first MTP joint. Mild soft tissue swelling of the forefoot. | No fracture is identified. Minimal osteoarthritis. |
Generate impression based on findings. | Ms. O'Neal submitted outside mammograms dated 5/12/2014 and 12/11/2012, from Cerner Imaging. Submitted outside studies were compared to the current mammogram dated 03/24/2015. The breast parenchyma is composed of scattered fibroglandular density. Left chest ICD partially obscures the left axilla. There is re-identifica... | Stable benign calcifications in the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually, due next in March 2016.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 54 year old female with history of breast carcinoma. Evaluate for systemic disease. CHEST:LUNGS AND PLEURA: Scattered pulmonary micronodules, some of which are calcified. Bibasilar scarring.MEDIASTINUM AND HILA: Scattered mediastinal and hilar lymph nodes are seen, with a reference AP window lymph node (3/30) measuring... | 1.Left breast asymmetric soft tissue, consistent with given history of left breast cancer. Left axillary adenopathy. 2.Scattered small mediastinal and hilar lymph nodes, nonspecific with reference measurements above.3.No definite lytic or sclerotic skeletal lesions, however refer to report from today's bone scan for mo... |
Generate impression based on findings. | 4-year-old female patient with fever, low oxygen saturations. Question of pneumonia.VIEWS: Chest AP/lateral (two views) 4/20/2015 The cardiothymic silhouette size is large. There is patchy opacity in the right lung on a background of chronic lung disease. There is right lower lobe bronchiectasis. No pleural effusion or... | Patchy atelectasis on a background of chronic lung disease. |
Generate impression based on findings. | Patient undergoing posterior spinal fusion VIEWS: Lumbosacral spine AP (1 view) 4/20/15 10:45, Lumbosacral spine AP (1 view) 4/20/15 9:55 Intraoperative prone imaging. T12, L1, L2, and L3 posterior pedicle screws in place. Curvilinear opacities representing Ray-tec sponges project over the lower thoracic spine in the s... | T12, L1, L2, and L3 posterior pedicle screws in place. Ray-tec sponges project over the lower thoracic spine. |
Generate impression based on findings. | 69-year-old female. Medial foot pain. No fracture or dislocation. Mild osteoarthritis affects the first MTP joint. Small plantar heel spur. | Mild osteoarthritis. No fracture is evident. |
Generate impression based on findings. | XR ESOPHOGRAM, 4/20/2015 9:23 AM Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions.Double contrast evaluation of the esophagus and gastric cardia/fundus revealed mild dilatation of the esophagus, without morphologic abnormalities of the mucosal surfaces. La... | 1.Moderate esophageal dysmotility with diffuse tertiary waves, which results in transient retention of barium while in the prone position.2.Mild dilatation of the esophagus, without evidence of stricture or narrowing.3.Transient retention of barium pill.4.No evidence of gastroesophageal reflux.5.Laryngeal penetration, ... |
Generate impression based on findings. | 10 week old female patient with hydronephrosis. Follow up scan. BLADDER Wall Thickness: Normal Contents: Distended and normal. Distal Ureter -- SFU Grade** Right: 2 Left: 0 Ureteral Jets Right: Not observed Left: Not observedKIDNEYS Cortical Echogenicity: Normal Medullary Echogenicity: Normal Pelvicaliceal ... | Duplicated right renal collecting system with grade 2 hydronephrosis and grade 2 hydroureter of the upper pole moiety.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all... |
Generate impression based on findings. | 69-year-old female. Evaluate right shoulder reverse surgery, postop. Interval placement of hardware components of a right reverse shoulder arthroplasty device in anatomic alignment without radiographic evidence of hardware complication. Oblique fracture of humeral tuberosity/neck with interval callus formation consiste... | Right total reverse shoulder arthroplasty device. |
Generate impression based on findings. | FractureVIEWS: Left elbow AP and lateral (2 views) 4/20/15 10:48 Cast is off. Bones are in anatomic alignment. Fracture line not definitely identified. No joint effusion. | Bones in anatomic alignment. |
Generate impression based on findings. | Reason: bCC of left neck/chest History: above. Open wound There is a large ulcerated mass present superficial to the left clavicle measuring 62 mm in width and 6 mm superior inferior dimension. It extends down to the level of the clavicle. There is some thinning of the left clavicular cortex and some foci of erosion as... | 1.There is a superficial mass present at the level of the clavicle associated with erosion of the underlying clavicle. This is suspected to represent a neoplasm such as basal cell carcinoma. The possibility of a superimposed infection (possibly with osteomyelitis) cannot be excluded. The mass may be invading the left c... |
Generate impression based on findings. | InjuryVIEWS: RIght forearm AP lateral (2 views) 4/20/15 10:44 Overlying cast limits fine bone details. Probable olecranon fracture is obscured by overlying cast. Ulna and radius in anatomic alignment. | Ulna and radius in anatomic alignment |
Generate impression based on findings. | 26-year-old female. Wrist pain. Arm pain. Evaluate for joint derangement. Right elbow: No fracture, dislocation, or joint effusion.Left elbow: No fracture, dislocation, or joint effusion.Right wrist: No fracture, malalignment, or significant abnormality to explain the patient's pain.Left wrist: No fracture, malalignmen... | Unremarkable radiographs of the elbows and wrists. |
Generate impression based on findings. | There is no evidence of intracranial hemorrhage, mass, or cerebral edema. There is a normal variant cavum septum pellucidum et vergae. The ventricles and basal cisterns 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... | No acute intracranial hemorrhage or mass effect. MRI is more sensitive for evaluation of seizure foci. |
Generate impression based on findings. | Female 62 years old; Reason: Metastatic breast cancer, on systemic therapy. Restaging exam. Evaluate for response to therapy and extent of disease. History: Metastatic breast cancer with pleural and bone mets. CHEST:LUNGS AND PLEURA: Emphysema. Stable 4 mm left upper lobe pulmonary nodule, image 28 series 4. Stable loc... | 1. Stable exam as above. |
Generate impression based on findings. | 59-year-old male. Pain. Evaluate for fracture. Increased sclerosis along the metaphysis of the lateral distal radius consistent with a healing nondisplaced fracture. Mild deformity of the distal ulnar diaphysis, likely from remote trauma. Triscaphe and basilar joint osteoarthritis, similar to prior study. | Healing distal radius fracture. |
Generate impression based on findings. | 11 year old male patient with injury.VIEWS: Right middle finger AP and lateral (2 views) 4/20/2015 There is a transverse fracture of the head of the middle finger middle phalanx with slight radial displacement of the distal fracture fragment. Soft tissue swelling is noted about the finger. | Middle finger middle phalanx fracture. |
Generate impression based on findings. | 73 year old female with a history of a left breast lumpectomy in the late 1990s. Patient received adjuvant radiation. Family history of breast cancer in her sister. Three standard views of both breasts and 2 spot magnification views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma... | 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. | InjuryVIEWS: Left wrist AP and lateral No acute fracture or dislocation. No soft tissue swelling about the wrist joint. | Normal examination. |
Generate impression based on findings. | 6-year-old female patient with fever, frank pus from tube following placement. Chest tube placed on 4/19 for treatment of persistent empyema. Evaluate for possible abscess. LUNGS AND PLEURA: A posterolateral right-sided chest tube is in place with the tip directed superiorly at the level of the 4-5 ribs.The right upper... | 1. Right upper and lower lobes are largely destroyed and replaced by aerated complex fluid.2. Right hydropneumothorax. |
Generate impression based on findings. | FractureVIEWS: Left tibia and fibula Again noted an oblique fracture of the distal tibia with minimal posterior displacement of the distal fracture fragment not significantly changed. The alignment is not significantly changed. The overlying cast obscures fine bony detail. | Fracture of the distal tibia not significantly changed. |
Generate impression based on findings. | 79 year old female with left palpable mass. Family history of breast cancer in daughter diagnosed at age 57. BILATERAL DIAGNOSTIC MAMMOGRAM: Three standard views of both breasts, additional left XCC view, and 3 spot compression views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchym... | Suspicious palpable mass in the left breast and enlarged left axillary lymph node. Patient to see Dr. Chhablani in clinic next week.BIRADS: 5 - Highly suggestive of malignancy.RECOMMENDATION: T - Take Appropriate Action - No Letter. |
Generate impression based on findings. | 26-year-old male. Three weeks ago bike accident (right foot inversion/rolling injury). Resulting soft tissue swelling, pain with weight bearing. Mild soft tissue swelling over the lateral malleolus. No fracture or dislocation is evident. | Mild soft tissue swelling without evidence of a fracture. |
Generate impression based on findings. | Female 32 years old. Reason: left hip and knee pain. History: left hip and knee pain Four weight-bearing views of the left knee demonstrate no fracture or dislocation. The left knee is unremarkable in appearance without significant osteoarthritis.Three views of the left hip demonstrate no fracture or dislocation. There... | Several lucencies in the anterosuperior aspect of the left femoral neck which may represent synovial herniation pits, which are a normal variant. These can be associated with femoral acetabular impingement. |
Generate impression based on findings. | 78-year-old male. Low back pain with tenderness to palpation in the lumbar area. Alignment is anatomic. Severe degenerative disk disease at L5-S1 with vacuum disk phenomenon and marked joint space narrowing. Mild degenerative arthritic changes affect the other lumbar levels. Well-corticated ossific density at the right... | Degenerative disk disease, as above. |
Generate impression based on findings. | Female 76 years old; Reason: pain at site of previous adrenalectomy and hernia repair in left abdomen History: as above ABDOMEN:LUNGS BASES: Visualized lower lung fields demonstrate multiple micronodules, stable to decreased in size. For example, 4 mm right lower lobe lung nodule on image 16 series 5, previously measur... | 1. Incompletely imaged large sliding type hiatal hernia with intrathoracic stomach visualized, greater amount of stomach located above level of hemidiaphragms than on prior study, patient at risk of gastric strangulation and volvulus.2. Mild interval increase in size of partially exophytic right lower pole renal lesion... |
Generate impression based on findings. | Female 41 years old Reason: 41 y.o. F with HPT. Please assess for parathyroid adenomas History: HPT There is physiologic distribution of the radiopharmaceutical. Seen only on the delayed planar images there are two small foci of radiotracer activity in the regions of the inferior lobes of the thyroid bilaterally. This ... | Increased radiotracer activity in location of the inferior thyroid lobes bilaterally which may reflect underlying adenomas. |
Generate impression based on findings. | Female 64 years old. Reason: s/p ORIF. History: s/p ORIF Three nonweightbearing views of the right ankle demonstrate a side plate with multiple screws affixing the distal fibula and two orthopedic screws fixing the medial malleolus, both in anatomic alignment. There is no evidence of hardware complication. The fracture... | Orthopedic fixation of ankle fractures as described above. |
Generate impression based on findings. | Female 37 years old Reason: hydronephrosis History: hydronephrosis The posterior abdominal radionuclide angiogram demonstrates prompt perfusion uptake, and excretion from the left kidney. There is delayed perfusion, uptake, and excretion from an enlarged right kidney. Uptake within the right kidney is asymmetrically in... | 1.Obstruction of the right kidney, more in the superior right renal collecting system.2.Minimal radiotracer uptake in the inferior pole of the right kidney indicating poor residual parenchymal function. 3.Normal renal perfusion, function, and morphology of the left kidney. 4.Relatively preserved renal splint function. |
Generate impression based on findings. | Opacification is present within a few superiorly located right mastoid air cells. The bilateral external auditory canals, middle ear cavities and the left mastoid air cells are completely clear. There is no evidence for congenital atresia of the external auditory canals or middle ear cavities. The scuta and ossicles a... | Opacification is present within a few superiorly located right mastoid air cells. Otherwise negative high-resolution CT scan of the temporal bones. Specifically, there are no CT findings to explain the patient's chronic left ear pain. |
Generate impression based on findings. | Female 48 years old. Bilateral knee pain with altered gait. Four nonweightbearing views of the left knee demonstrate minimal osteophyte formation consistent with minimal degenerative change. There is no fracture or dislocation. Four nonweightbearing views of the right knee demonstrate minimal osteophyte formation consi... | Minimal osteoarthritis of the bilateral knees. Please note that the radiographs of the bilateral knees are nonweightbearing which may underestimate the degree of osteoarthritis. |
Generate impression based on findings. | Reason: cardiomyopathy, rule out coronary artery disease History: cardiomyopathy, rule out coronary artery diseaseMEDICATIONS: Regadenoson, Aminophyllin, Acyclovir, Lisinopril, Metformin, Metoprolol, Posaconazole, Tamsulosin First Pass PerfusionDuring hyperemia, no perfusion defects were present. The fixed perfusion de... | 1. No perfusion/ "ischemia" present during hyperemia.2. Mid lateral transmural myocardial infarction.3. Normal LV size with decreased systolic function (LVEF 43%).4. Normal RV size and systolic function (RVEF 49%).5. Persistent consolidation in the superior segment in the right lower lobe. There is internal high signal... |
Generate impression based on findings. | Female 63 years old Reason: hx of labral tear History: same Left hip: Joint space narrowing, subchondral sclerosis and osteophyte formation consistent with moderate osteoarthritis.Pelvis: Mild osteoarthritis affects the right hip. Degenerative changes affect the lower lumbar spine. | Osteoarthritis as described above. |
Generate impression based on findings. | Calvarial changes are consistent with the provided history craniofacial reconstruction including osteotomy sites as well as indwelling hardware. The ventricles and sulci are unchanged in size without evidence of dilatation or compression. There are no masses, mass effect or midline shift. There is no evidence for intr... | 1.Calvarial changes are consistent with the provided history craniofacial reconstruction including osteotomy sites as well as indwelling hardware. 2.No CT evident abnormality to explain the patient's symptoms. |
Generate impression based on findings. | Male 19 years old Reason: L scaphoid fracture s/p ORIF History: as above Headless cannulated screw fixation of a scaphoid body fracture in near-anatomic alignment without evidence of hardware complication. The fracture line is less clearly visible suggestive of healing. There is widening of the scapholunate interval su... | 1. Healing scaphoid fracture.2. Widening of the scapholunate interval suggestive of scapholunate dissociation. |
Generate impression based on findings. | Male, 61 years old, with paresthesias. Spinal alignment is anatomic. Vertebral body height and morphology are normal. No destructive osseous lesions or fractures are seen.C2-3: Facet hypertrophy. Mild posterior disk bulging. Mild spinal canal stenosis. No significant foraminal narrowing.C3-4: Facet hypertrophy. Loss of... | Multilevel cervical spondylosis with areas of spinal canal stenosis ranging from mild to at least moderately severe, and foraminal narrowing ranging from mild to severe. |
Generate impression based on findings. | Male 57 years old Reason: 57 y/o rectal ca. last chemo 2013. Compare to prior scan in 2014 History: See above CHEST:LUNGS AND PLEURA: Left lower lobe calcified nodule is unchanged.MEDIASTINUM AND HILA: Index prevascular lymph node is unchanged measuring 9-mm in diameter image number 30, series number 4. Other small med... | No significant change from previous study. |
Generate impression based on findings. | Male 77 years old Reason: colon cancer on chemotherapy evaluate for interval change History: colon cancer CHEST:LUNGS AND PLEURA: Bilateral metastatic disease. Index left upper lobe lesion is slightly smaller measuring 5.7 x 5.5 cm on image number 30, series number 3.More inferior located lung lesion measures 3.6 by 3.... | Minimal interval decrease in the size of some of the index lung lesions. Otherwise stable exam. |
Generate impression based on findings. | Female 29 years old Reason: primary hyperoxaluria, assess for kidney stone progression History: hyperoxaluria ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No sig... | Left renal and bladder stones.Stable left adnexal cystic lesion. Further evaluation with pelvic ultrasound in 3 months is recommended. |
Generate impression based on findings. | There is no evidence of intracranial hemorrhage, mass, or cerebral edema. There is an age indeterminate infarct in the right corona radiata which is new from prior exam. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. There is an atelectatic and opacifie... | 1.Age indeterminate infarct in the right corona radiata which is new from one month ago, suspected to be subacute. CT is insensitive for early detection of acute nonhemorrhagic cerebral infarction. If there is continued clinical concern for acute ischemia, MRI would be recommended.2.No acute intracranial hemorrhage or ... |
Generate impression based on findings. | Female 61 years old Reason: met melanoma please comapre to previous imaging to assess disease status History: met melanoma CHEST:LUNGS AND PLEURA: Biapical scarring.MEDIASTINUM AND HILA: No significant abnormality notedCORONARY ARTERY CALCIFICATION: None.CHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIAR... | No evidence of recurrent or metastatic disease. |
Generate impression based on findings. | Reason: surveillance, s/p bilateral mca aneurysms with craniotomies for clipping History: headache Brain CTA: The patient is status-post bilateral craniotomies for middle cerebral artery aneurysm clip placement. Immediately proximal to the left sided aneurysm clip there is an enhancing tubular structure which is partia... | 1.Status post bilateral middle cerebral artery aneurysm and clip placement. Findings raise the question of a residual aneurysm rest versus vessel along the left MCA bifurcation. This is stable since the 7/25/13 exam. Comparison with a prior conventional arteriogram of the left internal carotid artery or a preoperative ... |
Generate impression based on findings. | 48-year-old female on warfarin experiencing headache with vertigo The ventricles and sulci have normal size and configuration. There is no acute intracranial hemorrhage or extraaxial collection. The gray-white matter differentiation is maintained. There is no focal parenchymal lesion or CT evidence of acute territorial... | 1.No acute intracranial hemorrhage. 2.Stable moderate vascular calcification of the bilateral internal carotid arteries.3.Paranasal sinuses and mastoid air cells are clear apart from an unchanged small mucous retention cyst/polyp in a left ethmoid air cell. |
Generate impression based on findings. | Male 46 years old Reason: staging exam History: prostate cancer PROSTATE, SEMINAL VESICLES: No significant abnormality noted.BLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: No significant abnormality notedBONES, SOFT TISSUES: No significant abnormality notedOTHER:... | Unremarkable study. |
Generate impression based on findings. | Female 59 years old Reason: 59 F with metastatic neuroendocrine tumor, please eval for interval change since prior CT. History: none ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Segment 4 lesion is slightly increased in size and now measures 1.7 by 1.4-cm on image number 18, series number 6... | Slight interval increase in the size of the hepatic metastases lesions.Interval drainage of the right vulvar cystic lesion. Clinical correlation is recommended.Stable right renal artery aneurysm. |
Generate impression based on findings. | Female 36 years old Reason: Triple phase liver colorectal cancer s/p subtotal colectomy and chemo with suspicious liver and lung lesions please assess and compare to prior imaging, History: as above CHEST:LUNGS AND PLEURA: Geographic areas of lucency which could be due to air trapping, similar to prior exam. Small, non... | Interval development of right adnexal and midline pelvic cystic lesions. Ovarian cystic neoplasm cannot be excluded. Further evaluation with transvaginal ultrasound is recommended.Lung lesions are stable.No focal lesions are seen the liver.Right nephrolithiasis. |
Generate impression based on findings. | Reason: evaluate for hemorrhage History: fall, possible head trauma, left facial droop CT head:The CSF spaces are appropriate for the patient's stated age with no midline shift. Periventricular and subcortical white matter hypodensities of a moderate degree are present. This was also present on the prior exam. Punctate... | 1.No evidence for cervical spine fracture. Mild anterior subluxation of C4 on C5 is suspected to be degenerative, however, the possibility that the there is associated acute ligamentous injury cannot be excluded and MRI of the cervical spine may be helpful in further evaluating.2.No evidence for acute intracranial hemo... |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous images History: none CHEST:LUNGS AND PLEURA: Punctate calcified and noncalcified micronodules are unchanged and presumably post inflammatory.MEDIASTINUM AND HILA: No significant abnormality noted.CORONARY ARTERY CALCIFICATION: CHEST WALL: No significant abnormality noted.ABD... | No evidence of metastatic disease. |
Generate impression based on findings. | The ventricles and sulci are normal in size. The cerebellar tonsils are in normal position. There are no masses, mass effect or midline shift. The pituitary gland is normal in size. There is no evidence for intracranial hemorrhage or acute cerebral, brainstem or cerebellar infarction. No diffusion-weighted abnormaliti... | Scattered sporadic mucosal thickening can be found within the paranasal sinuses. Otherwise, negative noncontrast brain MRI. Specifically, there are no MRI findings to explain the patient's seizure activity. |
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