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Generate impression based on findings. | Known bilateral cysts with history of bilateral cyst aspiration. History of breast carcinoma in mother, maternal aunt and maternal uncle. 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... | Bilateral benign calcifications with interval reduction in size of known left breast cyst. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - ... |
Generate impression based on findings. | Hypodensity is present within the white matter as well as bilateral external capsules without associated mass effect. The ventricles and sulci are normal in size. There are no masses, mass effect or midline shift. There is no evidence for intracranial hemorrhage or acute cerebral or cerebellar cortical infarction. The... | 1.No acute intracranial hemorrhage.2.Small vessel ischemic disease of indeterminate ages. If there is continued clinical concern for acute ischemia, MRI would be recommended. |
Generate impression based on findings. | Male 39 years old Reason: Eval for Fx History: Pain at MCP No fracture or malalignment. | Negative study. |
Generate impression based on findings. | History of TXN2BM0 squamous cell carcinoma involving the right parotid gland, CML, CLL, prostate cancer, and rectal caner. There are postoperative findings related to right parotidectomy with interval resolution of a fluid collection within the treatment bed. There is now diffuse ill-defined soft tissue in the treatmen... | 1. Interval evolution of post-treatment findings in the right parotid region with nonspecific soft tissue in the treatment bed, but no evidence of discrete measurable mass lesions.2. Diffuse cervical lymphadenopathy is likely related to leukemia and less likely represents metastatic disease from one of the other malign... |
Generate impression based on findings. | Reason: evaluate aneurysm clip History: s/p aneurysm clipping Brain CTA: Since the prior examination patient has undergone right sided craniotomy for second aneurysm clip placement along the distal right internal carotid artery. The previously noted aneurysm in this location is no longer identified.The patient is statu... | 1.The patient is status post recent placement of a second aneurysm clip along the distal right internal carotid artery. There are associated immediate postoperative changes as indicated above. Streak artifact may obscure a subtle residual.2.There is a 2.5mm x 2mm left carotid terminus aneurysm. 3.There is a 2mm left co... |
Generate impression based on findings. | Frequent sinusitis treated medically, sinus surgery 1/9/15. There are findings related to endoscopic sinus surgery, including left uncinectomy and partial ethmoidectomy. There is increased mucosal thickening in the left maxillary sinus with hyperattenuating secretions and opacification of the neo-infundibulum. There is... | 1. Findings related to endoscopic sinus surgery with increased inflammatory changes in the paranasal sinuses, particularly the left maxillary sinus, where there are chronic inspissated secretions versus possible accumulated fungal material.2. Interval septoplasty with minimal residual nasal septal deviation. |
Generate impression based on findings. | Reason: h/o HNC and CRT, compare to previous measurements History: none CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.No pleural effusions.MEDIASTINUM AND HILA: Right central venous catheter with its tip in the SVC.No hilar or mediastinal lymphadenopathy.Cardiac size is normal without evidence of a ... | Stable exam without evidence of metastatic disease. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Personal history of cervical cancer at age of 25. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. No suspicious masses... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | Male 30 years old Reason: eval for Fx, distal phalanx History: hx of fx A K wire enters the volar soft tissues of the index/second finger and abuts the cortex of the distal phalanx maintaining a comminuted distal phalanx fracture in near-anatomic alignment. There is overlying soft tissue swelling.There is an additional... | Second and third distal phalangeal fractures as described above. |
Generate impression based on findings. | Male 64 years old Reason: bilateral cervical lymph nodes with prior history of T cell lymphoma History: as above, please compare with last cycle. CHEST:LUNGS AND PLEURA: Index right lower lobe nodule is stable measuring 6 mm on image number 52, series number 4. Bibasilar atelectasis, calcification along the right later... | Slight interval increase in the size of the retroperitoneal lymph nodes and infiltrative soft tissue density extending from the pancreatic tail into the lesser sac anteriorly. No other significant change from previous study. |
Generate impression based on findings. | 52 year old with known right breast cancer who presents for ultrasound guided biopsy with clip placement in a suspicious right axillary node. Right ultrasound re-identified the target lymph node for biopsy. Bipolar maximum dimension was about 3 cm and marked non-hilar cortical blood flow was seen on color flow imaging.... | Successful ultrasound guided core biopsy of an abnormal right axillary lymph node. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: T - Take Appropriate Action - No Letter. |
Generate impression based on findings. | Abdominal distentionVIEW: Abdomen AP NG tube tip in the stomach. Contrast is noted opacifying the descending colon and rectum. Dilation of the bowel loops has improved from prior study. No pneumatosis or pneumoperitoneum. | Bowel gas pattern improved from prior study. |
Generate impression based on findings. | Female 69 years old; Reason: Patient s/p radical cystectomy and ileal conduit. Had postoperative pelvic fluid collection s/p IR drain. Eval for resolution of collection History: As above ABDOMEN:LUNGS BASES: Improved aeration in visualized lung bases.LIVER, BILIARY TRACT: Unchanged prominence of common bile duct, measu... | 1. Status post cystectomy and hysterectomy. Right pelvic approach percutaneous drainage catheter, tip located in right anterior pelvis. Surrounding soft tissue induration present. Located more midline and inferior to left of catheter tip is collection not significantly changed in size accounting for differences in tech... |
Generate impression based on findings. | Reason: 68yo female with Crohn's disease. Evaluate extent of disease History: abdominal pain Scout radiograph showed a nonobstructive bowel gas pattern with scattered air-fluid levels within the small bowel.Transit time to the colon was 50 minutes. Fluoroscopic evaluation showed normal mucosa throughout the small bowel... | 1.Normal examination of the small bowel, without evidence of inflammatory bowel disease.2.Ventral hernia, containing loop of transverse colon, without evidence of obstruction.3.Diverticulosis of the ascending colon. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in distribution. No suspicious masses, microcalcifications... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Male 56 years old. Reason: follow up. History: follow up Three views of the lumbar spine are provided. The previously seen left L4 transverse process fracture is not well seen on the current study secondary to overlying bowel gas. The AP view of the pelvis is provided. Again seen are fractures of the left superior and ... | Healing fractures as described above. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses. A benign left axillary lymph node is noted.No suspicious ma... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Male 65 years old Reason: eval for fracture or dislocation History: back pain Apparent sclerosis in the midportion of what we take to be the T11 vertebral body which is worrisome for an age indeterminant compression fracture. | Concern for T11 vertebral body compression fracture which is age indeterminate. Further evaluation with CT is recommended.Findings discussed by myself Dr. Ward with Dr. Sakari 04/20/15 at 4:24 p.m.. |
Generate impression based on findings. | Female 77 years old. Reason: L buttock tenderness. History: pain with sitting and standing over Left SI joint Three views of the bilateral sacroiliac joints are provided. The sacroiliac joints are unremarkable. There is severe joint space narrowing, subchondral sclerosis, and subchondral cyst formation consistent with ... | Severe osteoarthritis of the left hip. |
Generate impression based on findings. | Reason: screening History: none LUNGS AND PLEURA: Stable scattered micronodules.No suspicious pulmonary nodules or masses.Mild bronchial wall thickening.Calcified pleural plaque lung right hemidiaphragm.No pleural effusions. MEDIASTINUM AND HILA: No hilar or mediastinal lymphadenopathy.Cardiac size is normal without ev... | Stable exam. No suspicious pulmonary nodule or mass.Lung-RADS: Category: 1 (Negative: No nodules and definitely benign nodules)RECOMMENDATION: Continue annual screening with LDCT in 12 months. |
Generate impression based on findings. | Reason: pe? rv strain? History: seen on cmr PULMONARY ARTERIES: Technically adequate. No acute pulmonary embolus. No evidence of right heart strain.LUNGS AND PLEURA: Mild upper lobe predominant centrilobular and paraseptal emphysema. Right central bronchial wall thickening and peribronchovascular interlobular septal th... | 1.No acute pulmonary embolus. 2.Bronchial wall thickening, patchy air space and ground glass opacity and small right pleural effusion on background of emphysema. The findings are nonspecific and could be due to aspirate or infection. Given the patient's age and presumed smoking history, follow up to resolution is recom... |
Generate impression based on findings. | Male 10 years old. Reason: SH2 of middle phalanx MF. History: EVAL FX Three views of the left middle digit are provided. There is a small fracture fragment along the volar aspect at the physes of the middle phalanx of the left middle digit. The fracture fragment is unchanged in position compared to prior study. The fin... | Avulsion fracture of the middle phalanx of the left middle finger with fracture fragment unchanged in position. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microcalcifications or ar... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative. RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. No suspicious masses, microcalcifications or areas of architectural di... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSA - Screening Mammogram. |
Generate impression based on findings. | Female 77 years old. Reason: back pain with RLE radicular symptoms. History: as above Four views of the lumbar spine are provided. There is grade 1 anterolisthesis of L4 on L5. There are anterior osteophytes with mild degenerative disk disease at L4/5 and L5/S1. There are no fractures evident.Five views of the cervical... | Degenerative arthritic changes as described above. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Personal history of benign right breast biopsy. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. Lobulated focal asymmetry in the left ... | Lobulated focal asymmetry in the left retroareolar region may represent an ectatic duct. Recommend comparison with prior mammogram. Additional workup, including spot compression views and possible ultrasound, are recommended for further evaluation if priors are not available. BIRADS: 0 - INCOMPLETE; Need additional ima... |
Generate impression based on findings. | Male 15 years old. Reason: right knee pain. History: knee pain Two views of the right knee are provided. The fracture line through the posterior aspect of the tibial plateau is indistinct consistent with healing. The posterior tibial plateau is in anatomic alignment. A small osseous fragment is again noted superior to ... | Healing posterior tibial plateau fracture as described above. |
Generate impression based on findings. | Bilateral cervical nodes and history of T cell lymphoma. There has been interval increase in size of several cervical lymph nodes, particularly bilateral suprahyoid lymph nodes. For example, a right level 1 lymph node measures 12 x 20 mm, previously 7 x 16 mm, and a left level 2 lymph node measures 10 x 12 mm, previous... | Interval increase in size of multiple cervical lymph nodes, particularly bilateral suprahyoid lymph nodes, as well as increase in size of the bilateral submandibular glands may represent recurrent lymphoma. |
Generate impression based on findings. | Reason: s/p artificial urinary sphincter erosion repair, check for extravasation of urine from urethra History: s/p artificial urinary sphincter erosion repair, check for extravasation of urine from urethra A voiding urethra cystogram was performed in standard fashion and serial spot films were obtained. The cystogram ... | 1.Large diverticula-like outpouching of the inferior urethra, as above.2.Urethral-scrotal fistulization, with external communication.3.The distal penile urethra did not opacify.4.Incomplete filling of the urinary bladder secondary to continuous outflow via the urethral fistula. |
Generate impression based on findings. | Male 59 years old Reason: Restaging Pet Scan for locally advanced esophageal cancer. Pt recieved pre-op chemoradiotheraphy and finished on March 26, 2015 History: noneRADIOPHARMACEUTICAL: 14.6 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 79 mg/dL. Today's CT portion of the neck demonstrates no significant... | 1.Interval increase in length of uniformly hypermetabolic activity in the distal esophagus without increase in intensity. This likely represents post treatment change, however underlying tumor cannot be excluded.Diagnostic CTs of the chest, abdomen, and pelvis also performed at today's visit will be reported separately... |
Generate impression based on findings. | Male 18 years old. Reason: right hand small finger proximal phalanx fracture. History: s/p ORIF Three views of the right fifth digit are provided. A sideplate with multiple screws fixes an oblique fracture through the proximal phalanx of the right fifth digit in anatomic alignment. There is no evidence of hardware comp... | Orthopedic fixation of a fracture through the proximal phalanx of the right fifth digit. |
Generate impression based on findings. | Female 65 years old Reason: s/p L total shoulder History: as above Components of a reverse ball-and-socket left total shoulder arthroplasty in near anatomic alignment. Multiple wires projected over the chest may overly the patient. | Left total shoulder arthroplasty. |
Generate impression based on findings. | Multiple myeloma restaging.RADIOPHARMACEUTICAL: 15.0 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 97 mg/dL. Today's CT portion grossly demonstrates innumerable lucent lesions throughout the axial and appendicular skeleton. Redemonstrated healing left lateral eighth rib fracture. Small bilateral knee joint... | 1.New hypermetabolic lesions within the left iliac bone and L3 vertebral body compatible with disease progression. There is also interval increase in hypermetabolic activity in the C1 and T10 vertebra |
Generate impression based on findings. | Reason: Metastatic breast cancer with new onset chest pain and dyspnea, please do PE protocol CT chest History: see above PULMONARY ARTERIES: Technically adequate. No acute pulmonary embolus.LUNGS AND PLEURA: Multiple bilateral pulmonary nodules compatible with metastases have increased in size and number compared to p... | 1.No acute pulmonary embolus.2.Interval increase in pulmonary metastases, mediastinal lymphadenopathy, right level 2 axillary lymphadenopathy, and hepatic metastasis.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Respiratory insufficiencyVIEW: Chest AP Cardiothymic silhouette is enlarged. Cardiac apex and stomach left-sided. Minimal patchy atelectasis in the left upper lobe. No pleural effusion or pneumothorax. | Cardiomegaly with patchy atelectasis in the left upper lobe. |
Generate impression based on findings. | 19 year-old female. Pain with ambulation. Evaluate for fracture. No fracture, dislocation, or significant abnormality to explain the patient's pain. | No significant abnormality to explain the patient's pain. |
Generate impression based on findings. | Male 24 years old Reason: intrabdominal infection History: fever, abdominal pain ABDOMEN:LUNG BASES: Cardiomegaly. Bilateral small pleural effusions. Atelectasis.LIVER, BILIARY TRACT: Hepatomegaly. Mild periportal edema.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No... | Cardiomegaly and bilateral pleural effusions. Hepatomegaly.Mild wall thickening involving the colon segments there represent colitis. Significant interval improvement in the small bowel wall thickening. |
Generate impression based on findings. | FractureVIEWS: Right hand AP, oblique and lateral There is a healing fracture involving the neck of the fifth metacarpal. There are sclerosis and periosteal reaction reflecting interval healing. The alignment is near anatomic. No additional fracture noted. | Healing fracture involving the metacarpal as described above. |
Generate impression based on findings. | 49-year-old female. Right knee pain. Tibial spine sharpening and tiny patellar osteophytes indicate minimal osteoarthritis, though evaluation is limited given non-weight bearing views. No fracture or dislocation. | Osteoarthritis, as above. |
Generate impression based on findings. | 77-year-old female. Left foot pain, swelling. Hallux valgus deformity and moderate osteoarthritis of the 1st MTP joint. Transverse nondisplaced extra-articular fracture through the base of the 5th metatarsal. Mild diffuse soft tissue swelling. | Transverse nondisplaced fracture of the 5th metatarsal base. |
Generate impression based on findings. | 64-year-old female with history of metastatic pancreas cancer. CHEST:LUNGS AND PLEURA: Scattered pulmonary micronodules, nonspecific.MEDIASTINUM AND HILA: No significant abnormality noted.CORONARY ARTERY CALCIFICATION: Moderate.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIARY TRACT: Multiple heteroge... | Findings compatible with given history of pancreas cancer and liver metastases as above. |
Generate impression based on findings. | Female 24 years old Reason: 24 year-old female with LLQ abdominal pain, evaluate etiolgoy History: as above ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No signi... | No CT findings to explain patient's left lower quadrant pain. |
Generate impression based on findings. | Female 68 years old Reason: pancreas cancer boarderline resectable on chemotherapy follow up History: none CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: No significant abnormality noted.CORONARY ARTERY CALCIFICATION: None.CHEST WALL: No significant abnormality noted.ABDOMEN:LIVER, BILIA... | Slight interval decrease in the size of the patient's known pancreatic head mass with decreased soft tissue density around the hepatic arteries the level of the hepatic hilum.Multiple small hypodense and two hyperdense lesions in the liver. MRI of the liver may be helpful for further evaluation, if clinically indicated... |
Generate impression based on findings. | 16 year old male patient with history of second metacarpal fracture. Evaluate for fracture. VIEWS: Right hand PA and lateral (3 views) 4/20/2015 Redemonstration of a mid-diaphyseal fracture of the second metacarpal with callous formation. | Healing second metacarpal fracture. |
Generate impression based on findings. | 63 year-old female. History of vaso-occlusive crisis from thalassemia and prior index finger. Stiffness of joint. Diffuse soft tissue swelling of the index finger. No fracture, dislocation, or significant osseous abnormality. | Diffuse soft tissue swelling without a signifcant osseous abnormality. |
Generate impression based on findings. | 62 year old male with colon cancer metastatic to liver. CT scan here on 3/13/2015 new LUL lung lesion. Evaluate for change. LUNGS AND PLEURA: Left upper lobe now less solid and predominantly ground glass in appearance and measures 24 mm x 13 mm (series 4, image 40) previously 25 mm x 15 mm. Calcified punctate nodules c... | 1. Left upper mass is now small and less solid and was presumably inflammatory. However, follow up to resolution is recommended to exclude malignancy.2. Multiple low attenuation hepatic lesions are not completely evaluated. Some have the imaging appearance of hemangiomas, others do not and have definitively increased i... |
Generate impression based on findings. | Male 59 years old; Reason: Restaging esophageal cancer CHEST:LUNGS AND PLEURA: Small patchy basilar groundglass attenuation in right lower lobe, may reflect atelectasis but continued follow recommended.MEDIASTINUM AND HILA: Mild calcified coronary artery disease. Left-sided central venous catheter with tip near cavoatr... | 1. Distal mild to moderate circumferential esophageal wall thickening seen, no significant change from earlier study. 2. Small patchy basilar groundglass attenuation in right lower lobe, may reflect atelectasis but correlation with patient's clinical history/symptoms recommended to exclude early pneumonia/infectious et... |
Generate impression based on findings. | PainVIEWS: Left clavicle AP and axial No acute fracture or dislocation. | Normal examination. |
Generate impression based on findings. | 38-year-old female. Status post-ORIF distal tibial fracture. A side plate and screws affix a distal tibia fracture in anatomic alignment. There is a sideplate and single transsyndesmotic screw affixing the fibula to the tibia. No radiographic evidence of hardware complication. Small plantar heel spur. Moderate soft tis... | Orthopedic fixation of the distal tibial fracture. |
Generate impression based on findings. | Female 37 years old Reason: new gyn cancer - likely cervical, pt found out today History: weakness, vaginal bleeding ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS:... | Large pelvic mass arising from the cervix invading both adnexa and the uterus consistent with cervical cancer.Likely metastatic retroperitoneal lymph nodes. |
Generate impression based on findings. | PainVIEWS: Sacrum and coccyx AP and lateral No acute fracture or dislocation. | Normal examination. |
Generate impression based on findings. | Male 49 years old Reason: Crohn's disease eval for inflammation and stricture History: Abdominal pain, nausea, vomiting ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Diffuse fatty infiltration of the liver. No focal liver lesions. Patient's known biliary stricture is not well seen on today's... | Active short segment inflammation at the level of the ileocolonic anastomosis.Distended stomach and proximal duodenum. Upper endoscopy is recommended for further evaluation of the duodenum for possible Crohn's involvement. |
Generate impression based on findings. | 16 year old male patient with pain in pelvis without clear etiology. Question of tumor or inflammation.EXAMINATION: MR pelvis without and with IV contrast 4/20/2015 PELVIS:PROSTATE, SEMINAL VESICLES: No significant abnormality notedBLADDER: The bladder is distended. LYMPH NODES: No significant abnormality noted.BOWEL, ... | Wall enhancement of the rectosigmoid colon, ascending colon including the appendix, and distal ileum reflects inflammatory changes and can be seen with inflammatory bowel disease. |
Generate impression based on findings. | History of pneumonia with interstitial changeVIEWS: Chest AP and lateral Cardiothymic silhouette normal. Cardiac apex, aortic arch and stomach left-sided. Minimal peribronchial wall thickening with subsegmental atelectasis in the right lower lobe and left lower lobe. No pleural effusion or pneumothorax. | Bronchiolitis or reactive airway disease without pneumonia. |
Generate impression based on findings. | Reason: 62 y/o AML s/p SCT h/o of CHF, with new SOB History: new SOB LUNGS AND PLEURA: Minimal amount of debris within the trachea. Bibasilar scarring and/or linear atelectasis. Unchanged intrapulmonary lymph nodes along the fissures. No new or suspicious pulmonary nodule or mass. No focal consolidation, pleural effusi... | 1.No acute pulmonary process.2.Nonspecific lower cervical and mediastinal lymph nodes have slightly increased in size, although remain subcentimeter. |
Generate impression based on findings. | Female 41 years old; Reason: Persistent bowel wall thickening on 4/14 CT, now w/ worsening abdominal pain and cough with thick secretions, neutropenic patient History: Abdominal pain, cough, neutropenia CHEST:LUNGS AND PLEURA: Interval resolution of small right pleural effusion. Persistent moderate left-sided pleural e... | 1. Interval worsening of diffuse circumferential colonic wall thickening, appearance consistent with pancolitis, may be of infectious/inflammatory or neutropenic etiology. Mesenteric/peritoneal edema nodularity present.2. Persistent large abdominopelvic ascites.3. Minimal patchy airspace disease in visualized left uppe... |
Generate impression based on findings. | 24-year-old male with history of urinary tract infection. Evaluate for etiology. ABDOMEN:LUNG BASES: Scattered pulmonary micronodules, nonspecific.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: Hypoattenuating, nonenhancing splenic focus, measures 1.5 cm, nonspecific and may represent a cyst.PANCREAS: No... | No hydronephrosis, hydroureter or other significant abnormality to explain the patient's UTI. |
Generate impression based on findings. | Female 57 years old. Reason: left knee pain. History: left knee pain Four weight-bearing views of the left knee are provided. There is marked medial joint space narrowing with medial and lateral osteophyte formation indicating severe osteoarthritis. There is no fracture or dislocation. | Severe osteoarthritis of the left knee. |
Generate impression based on findings. | The right uterine artery was embolized using 700-900 micron Embospheres until near stasis was achieved. The post-embolization angiogram confirmed these findings.LEFT UTERINE ARTERY EMBOLIZATION | Successful after hours, on call urgent bilateral uterine artery embolization. No active bleeding was identified so the uterine arteries were embolized. If bleeding recurs, repeat angiography could be performed to assess other tumor vascularity in the pelvis. |
Generate impression based on findings. | Clinical question: ICH. Signs and symptoms: Headache and nausea Nonenhanced head CT:There is no detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces time gray -- white ma... | 1.Unremarkable nonenhanced head CT.2.Air-fluid levels within the left maxillary sinus. |
Generate impression based on findings. | general weakness, left side feeling weaker than right. No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The osseous structures are unremarkable. ... | No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | Clinical question: Intracranial lesion. Signs and symptoms: Status post fall; occipital hematoma. Nonenhanced head CT:There is no detectable acute posttraumatic intracranial or calvarial findings.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF and spaces and gray -- white matter differentiation.Un... | 1.No acute posttraumatic intracranial or calvarial findings.2.Midline and bilateral paramedian occipital subgaleal hematoma measuring 8 mm in thickness.3.Pansinusitis. |
Generate impression based on findings. | dizziness No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The osseous structures are unremarkable. The paranasal sinuses and mastoid air cells a... | No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | Clinical question: Evaluate ventricular size. Signs and symptoms Cone dental concern for increased head size and increased fussiness. Nonenhanced head CT: Examination demonstrate interval decreased size of the supra-and infratentorial ventricular system since prior study. Significant ventriculomegaly however still rema... | 1.Interval decreased size of lateral ventricular system since prior study.2.Residual ventriculomegaly the supra-and infratentorially.3.Stable position of right sided approach ventricular catheter with the tip in the left frontal horn.4.Interval resolution of peri-ventricular CSF exudate since prior exam.5.Patchy opacif... |
Generate impression based on findings. | headache, motor vehicle accident Head CT:No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The osseous structures are unremarkable. The paranasal ... | Normal head CT scan without contrast enhancement.Slightly straightened C spine alignment otherwise unremarkable. |
Generate impression based on findings. | left thalamic ICH follow up Evolution of the left thalamic ICH and IVH since prior exam. In particular, the size of ICH appears to be smaller and the surrounding edema appears to be lessen. The amount of the IVH also appears to be lessen.Midline shift toward right side remains grossly unchanged or slightly lessen.Ventr... | Interval improvement of left thalamic ICH and IVH extent as well as surrounding edema since prior exam.No change of slightly improved midline shift toward right side since prior exam.No evidence of new ischemic or hemorrhagic lesion on this scan. |
Generate impression based on findings. | hemorrhagic conversion of acute ischemic stroke Progression of midline shift toward right side, now measured about 7.4mm at the level of foramen of Monroe.The left MCA territorial and thalamic ischemic infarction with hemorrhagic conversion appear to slightly more conspicuous than prior exam.Right parietal lobe (post c... | 1. Interval progression of the left MCA and thalamic acute ischemic infarction with hemorrhagic conversion.2. No change of the right parietal lesion since prior exam. |
Generate impression based on findings. | Reason: h/o of metapneumovirus, new 02 requirement, look for new/ advance infection History: sob, cough, fevers LUNGS AND PLEURA: Interval increase in diffuse bronchial wall thickening, tree in bud opacities and bilateral lower lobe predominant airspace opacities. No pleural effusions.MEDIASTINUM AND HILA: Interval pla... | Interval increase in diffuse bronchial wall thickening, tree in the opacity and bilateral lower lobe predominant air space opacities compatible with atypical infection, such as patient's history of metapneumovirus. Recommend short term CT follow up to resolution. |
Generate impression based on findings. | 52-year-old with a focal asymmetry seen on screening mammogram. Family history of breast cancer in her sister at age 40. An ML view and spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small mas... | 1. Small cyst in the right outer breast. No mammographic or sonographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.2. Based on the patient's family history of brea... |
Generate impression based on findings. | Male 10 months old Reason: Evaluate for focal abnormality/interval change History: 10 m/o with DiGeorge syndrome and PS/DORV s/p repair now with tachypnea and increased work of breathingVIEWS: Chest AP/lateral (two views) 4/20/15 at 1639 hrs Cardiac silhouette size is enlarged but stable. Bite basilar opacities either ... | Multifocal opacities as described. |
Generate impression based on findings. | Female 17 years old Reason: Concern for fx History: abrasions, TTP lateral leg and over tibiaVIEWS: Left knee AP, lateral and oblique. Left ankle AP, lateral and oblique. Left fluid AP, lateral and oblique and left tibia-fibula AP, and lateral 4/20/15 (11 views) There is no evidence of fracture, malalignment, joint eff... | Normal examination. |
Generate impression based on findings. | Reason: ILD History: SOB LUNGS AND PLEURA: Diffuse basilar and posterior predominant dense ground glass and patchy airspace opacity, similar in distribution and degree to prior outside exam. Focal nodular opacities in the upper lobes with central cavitation may represent cavitary lesions. Diffuse bronchial wall thicken... | Diffuse basilar and posterior predominant dense ground glass and patchy airspace opacity, similar to prior outside exam. Possible upper lobe cavitary lesions. Constellation of findings suggest pulmonary hemorrhage, favoring vasculitis such as granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis)... |
Generate impression based on findings. | Male 18 years old. Reason: fracture. History: posterior elbow, and lateral hip pain post hit by car. Two views of the right hip are provided. There is no acute fracture or dislocation.A single view of the pelvis is provided. There is no acute fracture or dislocation.Two views of the right elbow provided. There is no jo... | No acute fracture or dislocation. |
Generate impression based on findings. | Female 14 years old Reason: 14 year old F with wrist injury and pain, unable to move the wrist History: unable to move wrist due to pain, numbness and tingling throughout the handVIEWS: Left wrist AP, lateral and oblique left forearm AP and lateral 4/20/15 (5 views) There is no evidence of fracture, malalignment, joint... | Normal examination. |
Generate impression based on findings. | Status post fall. L4/5 spine tenderness.VIEWS: Thoracic spine AP, lateral and swimmers view. Lumbar spine AP and lateral. Lateral view of the sacrum. 4/2015 (6 views) Vertebral body heights and disk spaces are maintained. No fracture or malalignment. No spondylolyses. Straightening of the thoracic kyphosis may be relat... | Straightening of the thoracic kyphosis as described. |
Generate impression based on findings. | Reason: r/o shunt malfunction History: increasing head size (per mom) and increased fussinessVIEWS: Shunt series: Skull AP/lateral (two views), chest AP/lateral (two views), abdomen AP/lateral (two views) 4/20/15 22:49 Right parietoccipital approach ventriculostomy tip adjacent to the midline, unchanged from prior stud... | No evidence of extracranial shunt malfunction. |
Generate impression based on findings. | Male 78 years old. Reason: r/o traumatic injury. History: shoulder pain Three views of the right shoulder are provided. There are osteophytes affecting the inferior glenohumeral joint and degenerative changes at the acromioclavicular joint. There is no acute fracture or dislocation. | No acute fracture or dislocation. |
Generate impression based on findings. | blunt head trauma There is scanty subarachnoid space hemorrhage on the left superior temporal sulcus anterior aspect without evidence of adjacent parenchymal abnormality. Scalp hematomas on the left high parietal and left temporo-occipital areas are seen without evidence of underlying skull fractures. The ventricles, s... | Scanty subarachnoid space hemorrhages on the left superior temporal sulcus anterior aspect without evidence of parenchymal lesion. Brain MRI can be considered for further evaluation for brain parenchymal change.Scalp swellings without evidence of underlying skull fracture as described above. |
Generate impression based on findings. | PICC placement. Ulcerative colitis.VIEW: Chest AP (one view) 04/20/15, 1725 Right upper extremity PICC tip is at junction of superior vena cava and right atrium.Cardiothymic silhouette is normal. No focal lung opacity is seen. | PICC tip at junction of superior vena cava and right atrium. |
Generate impression based on findings. | Female 62 years old. Reason: eval for fx. History: wrist pain and shoulder pain Three views of the right wrist are provided. There is soft tissue swelling along the radial aspect of the the distal radius. There is no underlying fracture or dislocation. Vascular calcifications are noted.Three views of the right shoulder... | Fracture of the proximal right humerus as described above. |
Generate impression based on findings. | 36 year old female with sob, tachy, hx of clots. Evaluate for PE. PULMONARY ARTERIES: No evidence of pulmonary embolism. Main pulmonary artery caliber within normal limits. No evidence of right heart strain.LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. Mild basilar dependent atelectasis. No pleural effus... | No evidence of pulmonary embolism. No findings to account for the patient's symptoms. PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | 5-month-old former 27 week gestational age patient with short gut, chronic lung disease, and chylothorax. Is there improvement in pleural effusion?VIEW: Chest AP (one view) 04/21/15, 0421 Feeding tube tip is in proximal gastric body. Lower extremity central line tip is at junction of inferior vena cava and right atrium... | Continued bilateral pleural effusion |
Generate impression based on findings. | Reason: lung infiltrate History: SOBVIEWS: Chest PA/lateral (two views) 4/21/2015 0:53 Cardiothymic silhouette is normal. Mild peribronchial wall thickening. Streaky retrocardiac opacities compatible with atelectasis. No pleural effusions or pneumothorax. | Bronchiolitis/reactive airway disease pattern. |
Generate impression based on findings. | Reason: evaluate right apical lung lesion History: history apical lung lesion on CT 3/16/15 from OSH, now completed antibiotics (history of HNC-squamous cell carcinoma) LUNGS AND PLEURA: Right apical cavitary lesion measures approximately 29 x 22 mm (series 4 image 17), previously 35 x 23 mm (series 4 image 12) on outs... | Right apical cavitary lesion has decreased in size with increased cavitation compared to prior outside examination, favoring an infectious etiology post treatment. However, malignancy/metastasis cannot be excluded. Recommend continued short term followup or consider bronchoscopy if clinically indicated. No new pulmonar... |
Generate impression based on findings. | 4-month-old male status post ex lap and resection near G-tube site, evaluate for interval changeVIEW: Chest and abdomen AP (two view) 3 months, Male, Reason: Post op, evaluate for post op interval changes History: Pt s/p ex lap; resection near Gtube site, primary re anastamosis. Cardiothymic silhouette is normal. Diffu... | Multiple distended bowel loops have improved. Slightly improved right upper lobe atelectasis. |
Generate impression based on findings. | Reason: septic joint, dislocation, scfe History: 4yoF acute onset pain behind b/l knees today, inability to ambulate todayVIEWS: Pelvis AP frog leg (2 views), right knee AP lateral (2 views), left knee AP lateral (2 views) 4/21/15 Pelvis: Femoral epiphysis are appropriately directed towards well developed acetabula. No... | Normal hips and knees. |
Generate impression based on findings. | Status post fracture.VIEWS: Right wrist AP lateral 4/21/15 at 0 05 hours. (Two views) Cast material obscures fine bone detail. Radial fracture with minimal dorsal angulation is unchanged in alignment. | Distal radial fracture change in alignment after casting. |
Generate impression based on findings. | 70 years old, Male, History: fall, on xaralto Head CT: There is a large left frontoparietal subgaleal hematoma measuring approximately 17 mm in maximum width. There is no evidence of intracranial hemorrhage or mass. There is chronic right occipital lobe PCA distribution encephalomalacia appearing similar to prior exam.... | 1. Oblique nondisplaced fracture of the anterior arch of C1 on the left extending into the left lateral mass of C1.2. Fracture of the transverse process of C2 on the right involving the right vertebral foramen.3. Large left frontoparietal subgaleal hematoma.4. No evidence of intracranial hemorrhage, mass, or cerebral e... |
Generate impression based on findings. | 35 year old female with left chest wall pain, characterize location of bullet for possible surgery. LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. Mild dependent atelectasis. No pleural effusion or pneumothorax. MEDIASTINUM AND HILA: Normal sized heart with no pericardial effusion. No mediastinal or hilar... | Bullet fragment located posteriorly between the left 11th and 12th ribs with streak artifact limits adequate evaluation of the adjacent structures however appears to be lodged in the posterior flank wall with no evidence of osseous or intraperitoneal injury. |
Generate impression based on findings. | Male 70 years old Reason: elbow contusion/pain after fall History: elbow contusion after fall No fracture or malalignment. No joint effusion. Enthesophytes identified along the lateral epicondyle. Well corticated punctate densities projected over the lateral aspect of the joint may represent tiny intra-articular loose ... | No fracture or malalignment. Other findings as described above. |
Generate impression based on findings. | Male, 59 years old.Trigger: missing hemostat and small needle. Again seen is a right-sided ureteral stent and multiple surgical clips projecting over the right hemiabdomen and pelvis. A left approach surgical drain projects in the right hemiabdomen. Expected postoperative pneumoperitoneum. Interval placement of enteric... | No suspicious radiopaque foreign object is identified.These findings were discussed by telephone with Dr. Roggin, the attending surgeon, on 4/20/15 at 7:42 pm by the RROC. |
Generate impression based on findings. | Male, 59 years old.Trigger: Multiple surgical teams. Right-sided ureteral stent and multiple surgical clips project over the right hemiabdomen and pelvis. There is a left approach surgical drain terminating in the right hemiabdomen. Ventral hernia coils project in the pelvis. No suspicious radiopaque foreign object is ... | No suspicious radiopaque foreign object is identified.These findings were discussed by telephone with Dr. Roggin, the attending surgeon, on 4/20/15 at 18:23 by the RROC. |
Generate impression based on findings. | Wrist pain after fall.VIEWS: Right wrist AP, lateral and oblique. Right forearm AP and lateral 4/20/15 (5 views) Transverse fracture of the distal metaphyses of the right radius with dorsal angulation. | Right radius fracture as described. |
Generate impression based on findings. | Male 24 years old Reason: assess for avulsion of bone, fb History: cut finger cooking Gauze material overlying the tuft of the index finger obscures bone detail and also limits evaluation for foreign body. Within this limitation there is no fracture however it is impossible to rule out foreign body. | Within the limitations of this study no fracture is identified however it is not possible to exclude radiopaque foreign body due to gauze overlying the area of interest. |
Generate impression based on findings. | Reason: bowel obstruction History: diarrhea; abd distensionVIEW: Abdomen AP (one view) 4/21/15 1:29 Mildly disorganized bowel gas pattern. Few mildly distended loops of bowel in the upper abdomen. No definite bowel obstruction. No pneumoperitoneum or pneumatosis. | Nonspecific bowel gas pattern. |
Generate impression based on findings. | Male 44 years old Reason: OM? gas? History: ulcers Heterogeneous appearance to the bones consistent with history of sickle cell disease and bone infarction. Skin irregularity along the lateral aspect of the left ankle compatible with ulceration. No subcutaneous emphysema. No cortical erosion to suggest osteomyelitis. N... | 1. Skin irregularity consistent with ulceration. No radiographic evidence of osteomyelitis. 2. Other findings as above. |
Generate impression based on findings. | Four day old male with P. aerobic and sequence and severe micrognathia and increased oxygen requirementVIEW: Chest AP (one view) 4/21/15 Cardiothymic silhouette is normal. Aortic arch, cardiac apex and stomach are left-sided.Minimal diffuse lung haziness. No focal pulmonary opacities, effusions or pneumothoracesNG tube... | Minimal diffuse lung haziness without focal opacity. NG tube sidehole at the GE junction. |
Generate impression based on findings. | Reason: r/o fractures - old and new History: 4 yo M with c/for physical abuse. Extensive bruising.EXAMINATION: Skull AP/lateral, cervical spine AP/lateral, thoracolumbar spine AP/lateral, right humerus AP, left humerus AP, right forearm AP, left forearm AP, right hand PA, left hand PA, chest AP, ribs right oblique/left... | No fracture is identified. |
Generate impression based on findings. | AMS. Evaluate perfusion. There is no evidence of intracranial hemorrhage. The evolving likely subacute infarct in the right corona radiata extending into the interlaminar right internal capsule demonstrates stable minimal mass effect upon the right lateral ventricle. The ventricles and basal cisterns are otherwise with... | 1. Mild evolution of the subacute right corona radiata to right internal capsule infarct, without gross correlative abnormality identified on limited perfusion images.2. Unchanged subcentimeter hypoattenuating focus in the right centrum semiovale, likely representing an additional age-indeterminate infarct, likely embo... |
Generate impression based on findings. | 48-year-old male with history of left-sided abdominal pain. Evaluate for obstruction. ABDOMEN:LUNG BASES: Moderate dependent atelectasis. No pleural effusions. No pericardial effusion. Pacemaker leads are noted.LIVER, BILIARY TRACT: Status post cholecystectomy with mild biliary ductal dilatation, unchanged. No suspicio... | 1. No specific findings to account for the patient's left sided abdominal pain. 2. Stable post-operative changes of the stomach and small bowel without evidence of obstruction.3. Other chronic findings appearing similar to prior. |
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