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Generate impression based on findings. | SDH evacuation. AMS. The initially-seen left frontotemporal subdural hemorrhage has been evacuated via a left parietal craniotomy. There remain minimal residual blood products along the left cerebral convexity, similar to prior. No new acute hemorrhage is identified. The drainage catheter has been removed. The expected... | 1.Minimal unchanged residual blood products along the left cerebral convexity, without new acute hemorrhage.2.Unchanged hemorrhage along the falx cerebri and tentorium cerebelli.3. Unchanged size of the ventricular system. |
Generate impression based on findings. | Female 14 years old Reason: eval for joint derangement History: wrist massVIEWS: Right wrist AP, lateral and oblique 4/24/15 (3 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | 40 year-old presents for further evaluation of bilateral findings from screening. An ML view and spot compression views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. Potentia... | No mammographic evidence of malignancy. Benign morphology mammographic masses in the left breast are present. A short-term follow-up mammogram is recommended in 6 months to ensure stability of these typically benign findings. As long as the patient's physical examination remains normal, left unilateral diagnostic mammo... |
Generate impression based on findings. | 66 year old male with SOB. Evaluate bleb for pneumothorax. LUNGS AND PLEURA: Severe bullous emphysema bilaterally. Large left pneumothorax. The right lung expansion and size of bullae has improved. Postsurgical changes on the right.Bilateral endobronchial valves, unchanged.No new or suspicious nodules or masses.MEDIAST... | 1.Large left pneumothorax.2.Severe bullous emphysema. |
Generate impression based on findings. | 61-year-old female patient with known left breast cyst. 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 fibroglandular density, unchanged in pattern and distribution. The previously noted partially obscured subcentimet... | 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. | Male, 59 years old, status post MVC. Head:The cerebral and cerebellar hemispheres and brainstem are normal in attenuation and morphology. No intracranial hemorrhage or abnormal extra-axial fluid is seen. There is no evidence of mass effect or parenchymal edema. The ventricular system is normal in size and morphology. T... | 1.No acute intracranial abnormality.2.No cervical spine fracture or traumatic dislocation. |
Generate impression based on findings. | Reason: Evaluate for structural lesion or etiology of hoarseness, specifically History: Hoarseness, hypophonia, recurrent aspiration and likely paralyzed L vocal cord There is a 10 x 11 mm axial dimension mass located at the lower left jugular chain at the level of the thyroid gland.Within the suprahyoid neck on the ba... | 1.Right hilar lung lesion and right upper lobe lesion are suspicious for neoplasia or infection but incompletely evaluated by this exam. Please refer to CT of the chest for further comments. Because these lesions are only partially included on this exam they are not adequately evaluated by this exam alone.2.There is a ... |
Generate impression based on findings. | Male 82 years old Reason: shoulder pain Mild osteoarthritis affects the glenohumeral joint and acromioclavicular joint. A 1.8 cm density projected over the inferior glenohumeral joint may represent a loose body within the joint however it was present and is not significantly changed compared to a prior chest radiograph... | 1. Mild osteoarthritis. 2. Possible loose body within the joint. |
Generate impression based on findings. | 71-year-old female patient newly diagnosed right breast DCIS presents for needle localization bracketing. On review of the prior studies, two biopsy clips (anterior and posterior) were identified in the right lower outer breast with post biopsy changes and a focal asymmetry immediately posterolateral to the posterior b... | Successful needle localization bracketing of the right breast clips and focal asymmetry.BIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | 83 year old male. Tophi in the right olecranon bursa. Evaluate for gouty erosions. Left elbow: Moderate osteoarthritis with osteophytes and joint space narrowing of the radiocapitellar and ulnotrochlear articulations. No erosions are evident.Right elbow: Fullness of the soft tissues posterior to the olecranon consisten... | 1. Multiple erosions in the hands suspicious for gouty erosions, on background of extensive osteoarthritis.2. Osteoarthritis in the elbows and feet with no evidence of erosions. |
Generate impression based on findings. | Reason: eval for possible paraduodenal hernia History: abdominal pain Scout radiograph showed a nonobstructive bowel gas pattern. Transit time to the colon was 45 minutes. Fluoroscopic evaluation showed normal mucosa throughout the small bowel, with no ulcers, sinus tracts, fistulae, or adhesions. No separation of bowe... | Normal examination of the small bowel and proximal colon. |
Generate impression based on findings. | There are post-operative findings related to a right frontal burr hole and craniotomy for resection of a right frontal lobe cavernous malformation. The resection cavity is unchanged in size, but contains more hyperattenuating material which may reflect mild interval bleeding. The thin rim of hypoattenuation likely rep... | Right frontal lobe cavernous malformation resection, with minimally increased hyperattenuation within the resection cavity, likely representing slow accumulation of blood products. |
Generate impression based on findings. | Status post intracranial tumor biopsy. There are interval postoperative findings related to left transfrontal biopsy of a partially calcified parafalcine mass that measures up to 25 mm. There is unchanged mass effect and edema in the adjacent left paracentral lobule region, as well as partial effacement of the left lat... | Interval postoperative findings related to left transfrontal biopsy of a partially calcified parafalcine mass that measures up to 25 mm with unchanged mass effect and edema in the adjacent left paracentral lobule region, but no evidence of acute intracranial hemorrhage. |
Generate impression based on findings. | Intraoperative guidance CT. There is a a stereotactic head frame in position. There is a partially calcified parafalcine mass that measures up to 25 mm. There is mass effect and edema in the adjacent left paracentral lobule region, as well as partial effacement of the left lateral ventricle. Further characterization of... | 1. Images for intraoperative guidance show a stereotactic head frame in position without apparent complications. 2. Partially calcified parafalcine mass that measures up to 25 mm with unchanged mass effect and edema in the adjacent left paracentral lobule region. |
Generate impression based on findings. | 80 year old female with history of nausea and vomiting. Evaluate for structure. ABDOMEN:LUNG BASES: Mild basilar scarring.LIVER, BILIARY TRACT: No biliary dilatation or other significant abnormality.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: Small right adrenal gla... | Small bowel obstruction with transition point as above. The dilated bowel has the appearance of pneumatosis, suggestive of bowel injury.Discussed with surgery resident Dr Schneider at time of dictation. |
Generate impression based on findings. | 32 year old female with history of right upper quadrant and right flank pain. Evaluate for stone. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abn... | No findings to account for the patient's pain. |
Generate impression based on findings. | Infantile GBS meningitis with resulting hydrocephalus, has a VPS, hearing loss, and focal epilepsy. Recent left cochlear implant failure. Right: There is a tympanostomy tube that is laterally displaced in the external auditory canal. There is opacification of Prussak's space and blunting of the scutum. The mastoid air ... | 1. The left cochlear implant electrode array appears to be intact.2. Bilateral tympanostomy tubes, with extrusion of the tube on the right side.3. Opacification of the right Prussak's space and blunting of the scutum may represent a cholesteatoma or an effusion. 4. Partially imaged marked ventriculomegaly with ventricu... |
Generate impression based on findings. | Female 16 years old Reason: eval for bony deformity History: wrist injuryVIEWS: Right wrist AP, lateral and oblique 4/24/15 (3 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Reason: evaluation of full lung fields for extent of nodularity History: persistent cough, nodules on lower lobes on abd CT; CVID and kabuki syndrome LUNGS AND PLEURA: Numerous pulmonary nodules bilaterally measuring up to 1.2 cm. Several of these nodules are cavitary. No pleural effusions or pneumothorax.MEDIASTINUM A... | 1.Numerous bilateral non-cavitary and cavitary pulmonary nodules. Differentials include TB, aspergillosis or other fungal infections, or granulomatous disease. 2.Splenomegaly again seen. |
Generate impression based on findings. | Reason: SDH History: SDH There is redemonstration of a burr hole placement along the right parietal bone for right subdural collection evacuation. There is no redemonstration of subdural air and air-fluid level in at the level of the burr hole the thickness of the subdural is approximately 27 mm current exam and was ap... | 1.Since the previous exam the patient's right-sided subdural collection and midline shift have mildly decreased in size. There is subfalcine herniation present. |
Generate impression based on findings. | 72 year old female with rectal pressure, incomplete defecation, s/p fall onto coccyx, 2 months ago. There is prompt opacification of the rectum, sigmoid, and descending colon of normal static morphology.Trial straining showed appropriate descent of the perineal floor; voluntary anal sphincter contraction demonstrated d... | 1. Small anterior rectocele and broad based posterior rectocele, with reference measurements provided above. 2. Less than expected perineal elevation with voluntary anal sphincter contraction. Correlation with the patient's history for prior incontinence is recommended. |
Generate impression based on findings. | 50 years, Male. Reason: Rule out intestinal obstruction History: Nausea \T\ vomiting Nonobstructive bowel gas pattern. Residual contrast is seen within the distal colon. Gastrostomy tube projects in expected location. Multiple surgical clips, suture material, and surgical coils project throughout the abdomen. Extensive... | No evidence of bowel obstruction. |
Generate impression based on findings. | Male 55 years old Reason: pubic rami fx History: groin pain, trauma No fracture or malalignment. Minimal osteoarthritis affects both hips. | No fracture or malalignment. |
Generate impression based on findings. | 57-year-old female. Sacroiliac pain. Mild osteoarthritis of the sacroiliac joints with mild subchondral sclerosis of the ilium and tiny foci of nitrogen gas. No fracture is identified. No fusion of the sacroiliac joints. There is transitional lumbosacral anatomy with partial sacralization of the L5 vertebra. There is a... | 1. Mild osteoarthritis of the sacroiliac joints.2. Lumbosacral transitional anatomy, as described above. |
Generate impression based on findings. | Reason: Concern for fracture distal right tib fib History: lateral / medial malleolar tendernessVIEWS: Right ankle AP oblique lateral (3 views) 4/24/15 9:35 Non displaced fracture of the medial malleolar epiphysis that extends to the intraarticular surface. Small joint effusion and soft tissue swelling. | Non displaced fracture of the medial malleolar epiphysis that extends to the intraarticular surface. |
Generate impression based on findings. | 82-year-old female status post nephroureterectomy with urine leak on recent CT examination. Evaluate for continued leak. Scout images of the pelvis demonstrate a Foley catheter in place. Surgical clips and staples project over the pelvis. Note is made of left-sided vesicoureteral reflux to the level of the proximal lef... | Contrast extravasation from the anterior wall of the urinary bladder consistent with a continued urinary leak. Findings were discussed with Dr. Steinberg, at 11:00 a.m. on 4/24/15 by phone. |
Generate impression based on findings. | Age: 36 years. Sex : Female. Reason for study: Reason: r/o 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. The exam w... | The exam was positive for penetration and positive for aspiration. Please refer to concomitant speech pathology report for further details and feeding recommendations. |
Generate impression based on findings. | There is no abnormal enhancement, mass, or mass-effect. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. There is opacification of a single right ethmoid air cell. The skull and extracranial soft tissues are unremarkable. | No intracranial metastatic disease, although MRI would be more sensitive for detection of small lesions. |
Generate impression based on findings. | 61-year-old male history of rectal cancer resected in 2011 with positive margins. CHEST:LUNGS AND PLEURA: No suspicious pulmonary lesions.MEDIASTINUM AND HILA: The heart size is normal without pericardial effusion. Calcified mediastinal lymph nodes.CORONARY ARTERY CALCIFICATION: Mild.CHEST WALL: No axillary, subpectora... | Stable exam without evidence of metastatic disease. |
Generate impression based on findings. | Male 9 years old Reason: r/o fx History: fall off swing, pain superior/anterior medial malleolus w/swelling; unable to bear weight; injury last nightVIEWS: Left ankle AP lateral oblique 4/34/16 (3 views) Soft tissue swelling with no joint effusion, fracture or malalignment. | Soft tissue swelling with no fracture. |
Generate impression based on findings. | Female 12 years old Reason: r/o fx History: jumping and rolling L ankle w/snap Wed; unable to bear weight sinceVIEWS: Left ankle left port AP collateral oblique 4/34/15 (6 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | 59-year-old female patient with suspicious left breast mass on mammography and ultrasound. Targeted left breast ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a hypoechoic mass measuring 5 x 5 x 4 mm at the 1 o’clock position with mild peripheral vascularity, 7 cm from the nipple. T... | Successful ultrasound-guided core biopsy of the left breast lesion and clip placement. Pathology is pending at this time.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Status post fracture.VIEWS: Left forearm AP and lateral 4/24/15 (two views) Compression plate and screws affixing a healing fracture of the proximal diaphyses of the left ulna is again noted. Healing fracture is in anatomic alignment. Material obscures fine bone detail. | Healing fracture, in anatomic alignment with no evidence of hardware complications. |
Generate impression based on findings. | Reason: likely PE, tachycardiac, SOB History: tachycardia, SOB, respir depr PULMONARY ARTERIES: Technically adequate. No acute pulmonary embolus.LUNGS AND PLEURA: Extensive bilateral multifocal ground glass and airspace opacities in the upper lobes with dense consolidation in the bilateral lower lobes.Bilateral pleural... | 1.No acute pulmonary embolus.2.Extensive bilateral multifocal ground glass opacities and airspace opacities in the upper lobes with dense consolidation in the bilateral lower lobes. Findings may represent multifocal infection or extensive hemorrhage, but would be atypical for edema. In addition, concomitant aspiration ... |
Generate impression based on findings. | 54 year old female. Pain. Surgery follow-up. Again seen is an intramedullary rod and screw device affixing the tibiotalar and subtalar joints in near anatomic alignment. There has been interval retraction of the middle inferior screw. A plate and screw device affixes the distal fibula in near-anatomic alignment. Extens... | Interval retraction of one of the inferior screws in the hardware affixing the tibiotalar and subtalar joints. |
Generate impression based on findings. | History of benign bilateral breast biopsies, including a right breast biopsy performed 4/2012 revealing an intramammary lymph node with reactive lymphoid hyperplasia and plasmacytosis. No new breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The br... | Stable benign bilateral masses. 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. | 51-year-old female. Pain. Evaluate left knee. Moderate osteoarthritis affects the left knee with medial tibiofemoral compartment joint space narrowing and tricompartmental osteophytes. | Moderate osteoarthritis. |
Generate impression based on findings. | Reason: ?pleural mass on CXR History: cough, f/c LUNGS AND PLEURA: Biapical pleural /parenchymal scarring. Right middle, left lingular, and bilateral lower lobe patchy air space opacities, bronchial wall thickening, and atelectasis. Small right pleural effusion/thickening.MEDIASTINUM AND HILA: Small mediastinal and hil... | 1.Multifocal areas of atelectasis, possibly related to aspiration no specific evidence of infection.2.Extensive bilateral supraclavicular, subpectoral and axillary lymphadenopathy. |
Generate impression based on findings. | The scout film shows multiple dilated loops of small bowel, which is likely related to known resolving small bowel obstruction.Water-soluble contrast was administered via a Foley catheter inserted transrectally. Contrast freely opacified the rectum and distal colon to the level of the anastomosis. The distal anastomos... | 1. No evidence of leak at the proximal or distal anastomoses. 2. Persistently dilated small bowel, suggestive of continued small bowel obstruction. |
Generate impression based on findings. | 60 year-old male with history of left lower quadrant pain. ABDOMEN:LUNG BASES: Scattered calcified pulmonary micronodules.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETE... | Above average fecal burden especially in the right colon, but otherwise unremarkable exam. |
Generate impression based on findings. | Reason: dysphagia, SOB after endoscopy, r/o perforation History: see above LUNGS AND PLEURA: Tracheomegaly, unchangedPostsurgical changes of a partial left upper lobectomy. Multiple bilateral pulmonary nodules again noted with new nodules in the bilateral lower lobes (series 5 image 50, 63). Reference left apical nodul... | 1.Several new pulmonary nodules suspicious for metastases. Additional nodules are stable in size.2.No pneumomediastinum to suggest esophageal perforation. |
Generate impression based on findings. | 42-year-old male with history of esophageal/ gastric cancer. CHEST:LUNGS AND PLEURA: Minimal groundglass/tree in bud opacities in the left lower lobe, with small left pleural effusion and superimposed atelectasis/consolidation. Favor infectious/inflammatory etiologies.MEDIASTINUM AND HILA: No significant abnormality no... | 1.Interval increased size of multiple hepatic hypoattenuating metastases, and increased abdominal/pelvic ascites.2.No change in reference para-aortic lymph node.3.Small left pleural effusion, slightly increased in size, with superimposed patchy opacities in the left lower lung that are nonspecific but may be postinflam... |
Generate impression based on findings. | Female; 84 years old. Reason: evaluate for umbilical hernia History: abdominal pain ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Cholelithiasis.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS:... | Interval colectomy with new large ventral hernia without evidence of acute complication. A few of the left-sided small bowel loops within the hernia sac are prominent, which may be due to adhesive disease. |
Generate impression based on findings. | Reason: OG placement History: s/p OG Enteric tube tip terminates in the distribution of the gastric body. Gaseous distention multiple loops of bowel can be seen in the setting of a dynamic ileus. Degenerative disease affects the lumbar spine and bilateral hips. Suture material projects over the midline abdomen. Please ... | Enteric tube tip overlies the gastric body. Bowel gas pattern is suggestive of adynamic ileus. |
Generate impression based on findings. | Reason: Crohn's disease s/p isoperistaltic side-to-side stricturoplasty and multiple Heineke-Mikulitz stricturoplasties and ileocecectomy with abdominal pain and periodic vomiting. Evaluate for active Crohn's, SBO History: abdominal pain and periodic vomiting The scout film demonstrates numerous air-fluid levels with a... | Mild dilatation of a loop of small bowel in the lower abdomen, as well as an area of narrowing in the right lower quadrant, appear somewhat similar to remote study in 2009. Contrast flows freely and quickly through the bowel without evidence of obstruction. Patient states her symptoms can occur up to several hours afte... |
Generate impression based on findings. | 63 years, Male, Reason: carcinoid tumor compare to last Ct \T\ measure 1) aortopulmonary node, 2) hepatic dome lesion, 3) right inguinal node and 4) L2 vertebral body lesion History: post 2 cycles of chemo. CHEST:LUNGS AND PLEURA: Nonspecific right apical ground glass opacity is unchanged measuring 8 mm (image 21; seri... | With the exception of an equivocally enlarging bony metastasis, stable examination with reference measurements given above. |
Generate impression based on findings. | 49-year-old female with a right breast lump for 6 months present for bilateral diagnostic mammogram. Family history of breast cancer in maternal aunt. History of benign right breast biopsy. Mammogram: Three standard views of both breasts, spot compression views of right breast and exaggerated CC lateral view were perfo... | Palpable pea-sized mass right breast 9 o'clock position for past 6 months without mammographic correlate, corresponds to a subtle hypoechoic area on ultrasound. This is very low suspicion, however, given the palpable abnormality surgical consultation with FNA is recommended.BIRADS: 4 - Suspicious Abnormality.RECOMMENDA... |
Generate impression based on findings. | Reason: lung cancer compare to last CT \T\ measure all previously measured lesions History: post 2 cycles of chemo CHEST:LUNGS AND PLEURA: Reference right lower lobe nodule with associated atelectasis measures approximately 22 x 20 mm (series 3 image 53), previously 21 x 16 mm.Reference left upper lobe 4-mm micronodule... | 1.Interval increase in size and number of bilateral pulmonary nodules.2.Interval increase in size and number of hepatic lesions compatible with metastases. |
Generate impression based on findings. | Colon is extremely redundant. The sigmoid colon is seen taking a course to abut the left leaf of the diaphragm and then descending again into the pelvis. This would explain the difficulty completing prior examinations.The colon is well distended and adequately cleansed. There is a small amount of residual fecal matter... | Normal examination. Redundant colon.*OPTIONAL C-RADS CLASSIFICATION:C-1 E-1*(see full definitions in: Zalis et al. CT Colonography reporting and data system: a consensus proposal. Radiology 2005;236:3-9)C1: Normal or benign lesions (no polyps > 6mm). Continue routine screening.C2: Intermediate polyp (less than three 6-... |
Generate impression based on findings. | History of right lumpectomy in 2008 for poorly differentiated carcinoma with squamous features. Patient received chemotherapy and radiation therapy. No new breast complaints. Three standard views of both breasts and two spot magnification views of right breast were performed digitally and reviewed with the aid of R2 CA... | 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. | Male 51 years old; Reason: Evaluate for progression of metastatic disease; compare to previous scan History: Ampulla of Vater cancer. Chemotherapy CHEST:LUNGS AND PLEURA: Basilar pleural-based masses containing calcifications again visualized. Stable reference right basilar pleural-based mass measuring 4.3 x 1.5 cm, (i... | Stable exam with reference measurements given above. |
Generate impression based on findings. | Female 65 years old Reason: right hip pain, previous hemi Two views of the right hip reveal a dislocated bipolar hemiarthroplasty. The previously described bone fragment superior to the head of the prosthesis is more conspicuous on today's study and is suggestive of pseudoacetabulum formation. There is increasing lucen... | 1. Dislocated bipolar hemiarthroplasty with pseudoacetabulum formation.2. Increasing lucency about the cement bone interface suspicious for loosening. |
Generate impression based on findings. | Reason: pt has h/o lung cancer, f/u cancer History: h/o lung cancer CHEST:LUNGS AND PLEURA: Postsurgical changes of a right upper lobectomy. Right paramediastinal radiation fibrosis, unchanged. Mild predominant centrilobular emphysema. Focal areas of subpleural reticulation, unchanged. No new or suspicious pulmonary no... | Stable exam without evidence of recurrence or metastases. |
Generate impression based on findings. | 63-year-old male. Severe neck pain and back pain. Cervical spine: Bulky anterior streaming osteophytes from C4 to C6 consistent with DISH. Mild degenerative arthritic changes of the cervical spine with neural foraminal narrowing bilaterally, most pronounced at the right C3-4 and C6-7 and left C5-6 and C6-7 levels. Vert... | DISH and degenerative disk disease, as above. |
Generate impression based on findings. | Status post fracture.VIEWS: Right elbow AP and lateral 4/24/15 (two views) Three K wire are affixing a healing supracondylar fracture with periosteal reaction transformation in anatomic alignment. Interval cast removal. | Interval cast removal. Healing fracture unchanged in alignment with no evidence of hardware complications. |
Generate impression based on findings. | Say 5-year-old woman with appendiceal adenocarcinoma status post chemotherapy and tumor debulking surgery. Evaluate extent of disease ABDOMEN:LUNG BASES: Minimal dependent atelectasis or scarring which appears similar priorLIVER, BILIARY TRACT: No significant abnormality noted. Probable cysts in the subcapsular region ... | Decreased ascites with no definite measurable peritoneal implants. Slight interval enlargement of pericardiophrenic lymph nodes. Right adrenal nodule, stable. Status post splenectomy. |
Generate impression based on findings. | 20 year-old female with a history of ulcerative colitis, however, concern for Crohn's disease. Presents with abdominal pain and diarrhea. Scout radiograph showed a nonobstructive bowel gas pattern. Transit time to the colon was approximately 1 hour. Fluoroscopic evaluation showed normal mucosa throughout the small bowe... | No evidence to suggest Crohn's disease, as clinically questioned. Otherwise unremarkable examination of the small bowel. |
Generate impression based on findings. | Male; 52 years old. Reason: 52 w/ h/o crohn's disease s/p TAC. no has abdominal pain with eating. please eval. History: abdominal pain ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Cholelithiasis without CT evidence of acute cholecystitis. No biliary ductal dilation.SPLEEN: No significant ab... | No acute abdominopelvic abnormality. |
Generate impression based on findings. | Assess for progression of uterine cancer, history of massive acute DVT in right leg CHEST:LUNGS AND PLEURA: The descending right pulmonary artery is expanded with central hypoattenuation consistent with an acute pulmonary embolus (series 3, image 55).Scattered pulmonary micronodules without suspicious nodules or masses... | 1.Acute pulmonary embolus in the right descending pulmonary artery.2.Deep venous thrombosis of the right external iliac and common femoral veins.3.Retroperitoneal and pelvis lymphadenopathy, increased from the 2013 exam.Findings discussed with Dr. Levy by telephone at time of dictation. |
Generate impression based on findings. | 35-year-old male. Close fracture of the lateral malleolus. Overlying cast obscures fine bone detail. A side plate and screws affix a distal fibular fracture in gross anatomic alignment. No radiographic evidence of hardware complication. | Orthopedic fixation of a distal fibular fracture. |
Generate impression based on findings. | Female 48 days old Reason: eval for signs of pneumatosis and persistent dilated loops History: inc desats and previous Xray concerning for dilated loopsVIEW: Abdomen and chest AP (two views) 4/24/15 at 1051 hrs. Proximal side-port of NG tube is above GE junction. Right lower extremity venous axis unchanged. Cardiac sil... | Interval retraction of NG tube as described.Interval slight improvement in abdominal gas pattern. |
Generate impression based on findings. | History of left mastectomy for IDC with TRAM reconstruction and right breast reduction in 2009. Personal history of colon cancer. History of breast carcinoma in sister diagnosed at the age of 48. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenc... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Male 15 years old Reason: eval fracture healing History: hand fractureVIEWS: Right hand AP, lateral and oblique 4/24/15 (3 views) Interval cast removal. Healing boxer's fracture with periosteal reaction and callus formation of the right fifth metacarpal is in anatomic alignment. | Healing fracture, in anatomic alignment after cast removal. |
Generate impression based on findings. | 76-year-old male history of recurrent esophageal cancer status post esophagectomy. CHEST:LUNGS AND PLEURA: Nonspecific right middle lobe nodule appears similar to the prior exam. Left upper lobe pleural-based linear opacity likely representing focal scarring and bronchiectasis. Scattered micronodules.MEDIASTINUM AND HI... | 1. Postsurgical changes from esophagectomy with no evidence of complication.2. Stable mediastinal lymph nodes.3. Pulmonary lesions do not have the appearance of metastases, although close followup recommended.4. Unchanged adrenal lesions, likely representing adenomas. |
Generate impression based on findings. | Right elbow painVIEWS: Right elbow AP, lateral and oblique 4/24/15 (3 views) Minimal punctate ossific foci is visualized laterally, in the humeral/radial space. No soft tissue swelling, effusions or malalignment. | Punctate ossific density as described, otherwise normal examination. |
Generate impression based on findings. | Age: 63 years. Sex : Male. Reason for study: Reason: evaluate for aspiration History: head and neck cancer, cough with eating, evidence of aspiration on chest CT. Fluoroscopic guidance was provided for an oropharyngeal motility study performed by the Speech Pathology section of the ENT service. The examination was reco... | The exam was negative for penetration and negative for aspiration. Please refer to concomitant speech pathology report for further details and feeding recommendations. |
Generate impression based on findings. | Reason: 3 small aneurysms (dist. rt. post. inferior cerebellar artery, distal basilar-rt pca origin rt ica terminus) History: dizziness (has endolymphatic hydrops) Brain CTA: There is a 3-mm aneurysm present at the right carotid terminus which is directed anteriorly and slightly towards the right. It has a relatively s... | 1.There are tiny aneurysms present along the carotid terminus, right basilar tip/proximalP1 segment, distal vermian artery of the right PICA and the right vertebral artery after it pierces the dura.2.No evidence for cerebral vascular occlusive disease |
Generate impression based on findings. | 58-year-old female patient with two focal asymmetries in the right upper outer breast at mid and posterior depth presents for diagnostic mammogram/ultrasound. RIGHT BREAST DIAGNOSTIC MAMMOGRAM: Three standard views of the right breast and two spot compression views were performed digitally and reviewed with the aid of ... | Two right breast cysts. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Unable to walkVIEWS: Right tibia/fibula AP lateral (2 views), right ankle AP lateral oblique (3 views), right foot AP oblique lateral (3 views) 4/24/15 10:16 Right tibia/fibula: Toddler's fracture in the mid diaphysis of the right tibia.Right ankle: No fracture or dislocation. Right foot: No fracture or dislocation. | Toddler's fracture in the mid diaphysis of the right tibia. |
Generate impression based on findings. | 75-year-old male with history of metastatic lung cancer with lower extremity stiffness. CHEST:LUNGS AND PLEURA: Large bilateral pleural effusions have increased in size with associated compressive atelectasis.Multiple metastatic pulmonary nodules with reference measurements as follows:*Right upper lobe solid/cavitary n... | 1. Interval progression of metastatic disease within reference measurements as above. More specifically, bilateral psoas muscle metastatic involvement has significantly increased in size and number which may be related to the patient's lower extremity weakness given proximity to the femoral nerves. An MRI of the lumbar... |
Generate impression based on findings. | 66 year old female with history of left buttock abscess incision and debridement, now with cellulitis. Evaluate for drainable fluid collection. PELVIS:UTERUS, ADNEXA: Heterogeneous uterus, correlate with gynecologic exam.BLADDER: No significant abnormality notedLYMPH NODES: Mildly enlarged retroperitoneal lymph node (3... | 1.Findings of cellulitis, without drainable abscess.2.Heterogeneous uterus, correlate with gynecologic exam. |
Generate impression based on findings. | Reason: 22 month old with LCH, h/o left temporal bone mass and partial loss of the T7; end of therapy eval History: 22 month old with LCH, h/o left temporal bone mass and partial loss of the T7; end of therapy evalEXAMINATION: Skull AP/lateral, cervical spine AP/lateral, thoracolumbar spine AP/lateral, right humerus AP... | Redemonstration of loss of the T7 vertebral body height. No new suspicious lesion identified. |
Generate impression based on findings. | History of head and neck carcinoma and chemoradiation therapy. Compare to previous measurements. There are post-treatment findings related to pharyngolaryngectomy with tracheostomy, voice prosthesis insertion, and neck dissection. There is no evidence of measurable tumor in the surgical bed. There is slight interval in... | 1. Extensive post-treatment findings in the neck, without convincing evidence of measurable tumor recurrence.2. Although not significantly enlarged by size criteria, there has been slight interval increase in size of several cervical, paratracheal, and superior mediastinal lymph nodes. 3. Slight interval increase in si... |
Generate impression based on findings. | 58-year-old female presents for follow up of left breast calcifications Three standard views of both breasts and two spot magnification views of left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and d... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | pT3N0 mammary analogue secretory carcinoma of the left parotid gland and pleomorphic adenoma of the left submandibular gland status post recent surgery. There are recent postoperative findings in the left parotid and submandibular regions with foci of gas and fluid in the treatment bed, but no evidence of measurable ma... | 1. Recent postoperative findings in the left parotid and submandibular regions without evidence of gross residual mass lesions in the treatment bed and no evidence of significant cervical lymphadenopathy, within the limitations of postoperative alterations. The fluid and emphysema in the treatment bed is likely within ... |
Generate impression based on findings. | 70 year-old female with history of bladder cancer post cystectomy and ileal conduit. Evaluate for metastatic disease or new primary. CT urogram requested. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Multiple low attenuation lesions throughout the liver are unchanged. The largest lesions cl... | Stable examination without evidence for metastatic disease or new uroepithelial abnormality.Decrease in size of aortic aneurysm with stent graft. |
Generate impression based on findings. | Female, 76 years old, with frequent falls on aspirin. Assess for chronic subdurals. No evidence of intracranial hemorrhage or any abnormal extra-axial fluid collection is seen. No significant parenchymal edema or mass effect is detected. No loss of gray-white distinction is suspected. Ventricles are normal in size and ... | 1.No evidence of any acute or chronic intracranial hemorrhage.2.No significant findings. |
Generate impression based on findings. | TXN2CM0 squamous cell carcinoma, status post chemoradiation. There are post-treatment findings in the neck, including diffuse pharyngeal edema. There is interval decrease in size of the previously necrotic appearing left level 2A lymph node, which now measures 3 mm in short axis, previously 5 mm. Another left level 2A ... | Post-treatment findings in the neck with continued interval decrease in size of the cervical lymphadenopathy.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 40 year-old female presents for 6 month follow up right breast hamartoma. Patient intends to get pregnant.Family history of breast carcinoma in maternal grandmother and paternal aunt. Mammogram: Two standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchym... | Stable benign hamartoma right breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mam... |
Generate impression based on findings. | Female 39 years old Reason: H/O Hodgkins Lymphoma s/p 6 cycles of AVD in need of end of treatment reimaging. Please compare History: Hodgking Lymphoma CHEST:LUNGS AND PLEURA: Bilateral patchy ground-glass opacities in both lungs described previously have regressed but are still present at the apices.MEDIASTINUM AND HIL... | Roughly stable examination with reference measurements given above. |
Generate impression based on findings. | Hodgkin lymphoma status post 6 cycles of AVD in need of end of treatment reimaging. There is no evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. However, there is partially-imaged superior mediastinal lymphadenopathy. The thyroid and major salivary glands are unremarka... | 1. No evidence of measurable mass lesions or significant lymphadenopathy in the neck, but superior mediastinal lymphadenopathy is partially-imaged. Please refer to the separate chest CT and PET reports for additional details.2. Persistent patchy ground glass opacities in the imaged portions of the lungs. Please refer t... |
Generate impression based on findings. | Metastatic squamous cell carcinoma of the right tonsil status post treatment. There are post-treatment findings in the neck, including a tracheostomy with intubation. There is diffuse edema in the treatment field. The infiltrative mass that centered in the right tonsillar region has decreased in size, now measuring app... | 1. Interval decrease in size of the infiltrative right tonsillar squamous cell carcinoma and cervical lymphadenopathy, indicating treatment response.2. Findings suggestive of chronic right internal jugular and sigmoid sinus thrombosis versus impaired flow due to mass effect.3. Right apical lung nodules. Please refer to... |
Generate impression based on findings. | Reason: h/o HNC, for CRT, need baseline scan History: none CHEST:LUNGS AND PLEURA: No sign metastases.Previously described mild mosaic attenuation is stable, likely insignificant.MEDIASTINUM AND HILA: Previously measured mediastinal and hilar lymph nodes are unchanged and within normal size limits and will not be measu... | No sign of metastases, or other significant abnormality. Benign-appearing left adrenal nodule. |
Generate impression based on findings. | Female 41 years old Reason: Pt is a 41 y/o female with h/o RCC, evaluate for recurrence History: RCC CHEST:LUNGS AND PLEURA: No focal consolidation, pleural effusions, or pneumothorax. No suspicious pulmonary masses or nodules. Nonspecific right sided pleural plaque. MEDIASTINUM AND HILA: No mediastinal or hilar lympha... | Status post right nephrectomy with no definite evidence of recurrent or residual disease. |
Generate impression based on findings. | Reason: GSW infradiaphragmatic 2001, need CT to localize location History: pt with chronic, worsening pain to chest pain Current examination incomplete in scan length, superseded by the examination 3 days ago which showed the location of the bullet. There has been no change since that study and reference made to that r... | Reference should be made to the CT report 3 days ago which described the location of the bullet. The patient will be credited for the charges for this examination. |
Generate impression based on findings. | Clinical question: Evaluate neuro status while intubated unable to wean sedation. Sinusitis symptoms: Unable to evaluate mental status, agitated off medication. Nonenhanced head CT:Examination demonstrate a focus of low attenuation involving the cortex and subcortical white matter right anterior frontal lobe and with e... | 1.Acute to early subacute hemorrhagic right anterior frontal and basal ganglia ischemic and stroke.2.Unremarkable intracranial contents otherwise.3.Extensive opacification of left mastoid air cells and left middle ear cavity. |
Generate impression based on findings. | Dizziness and giddiness, vertigo, ataxia. Evaluate for Meniere changes. RIGHT TEMPORAL BONE: The external auditory canal is patent. The middle ear and mastoid air cells are well-pneumatized and clear. The tegmen is intact. The ossicular chain is intact. The inner ear structures are unremarkable. In particular, the vest... | 1. No findings specific for Meniere disease, within the limits of CT.2. No evidence of semicircular canal dehiscence. |
Generate impression based on findings. | Male 89 years old Reason: left hip pain History: left hip pain Pelvis: Degenerative disk disease affects the lower lumber spine as seen on the AP view. Vascular calcification is noted. Surgical suture material projects over the right lower quadrant. Right hip: Moderate osteoarthritis affects the right hip. No fracture.... | Osteoarthritis of the hips and lower lumbar spine. |
Generate impression based on findings. | 60 years old male with a history of head and neck cancer, status post surgery. Reason: baseline scans needed. The study was performed for restaging.RADIOPHARMACEUTICAL: 14.9 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 120 mg/dL. Today's CT portion of the neck demonstrates post surgical changes in the lef... | 1.Hypermetabolic lesion in the left maxillary bone and posterior and inferior aspect of the left maximal sinus, which can be due to tumor or infection.2.Diffuse FDG uptake in the left parotid gland and left neck is most likely due to post surgical change. However, focal areas of increased activity in the left submandib... |
Generate impression based on findings. | Male 8 months old Reason: HISTORY OF CONSTIPATION History: CONSTIPATIONVIEW: Abdomen and chest AP (two views) 4/24/15 at 1209 hrs. Interval removal of central line and epicardial pacer leads. Mediastinal clips again noted. Stable cardiomegaly. No focal opacities, effusions or pneumothorax. No vascular engorgement.Disor... | Interval removal of central line and epicardial pacer leads.Resolution of lung vascular engorgement with persistent cardiomegaly.Disorganized, distended and nonspecific abdominal gas pattern. |
Generate impression based on findings. | Female 86 years old Reason: bilateral knee pain Right knee: Severe osteoarthritis affects the right knee with severe joint space narrowing particularly in the medial joint compartment and at the patellofemoral joint. Left knee: Severe osteoarthritis affects the left knee, particularly in the medial joint compartment an... | Severe bilateral osteoarthritis with synovial osteochondromatosis and a joint effusion on the left side. |
Generate impression based on findings. | Female 16 years old Reason: possible rib injury due to rowingVIEWS: Chest AP and both obliques 4/24/15 at 1231 hours (3 views) The aortic arch, cardiac apex and stomach are left-sided.Cardiac silhouette is normal in size and shape. Right lung base small nodule with suggestion of calcification may represent, among other... | Right lung base nodule as described |
Generate impression based on findings. | Female 71 years old Reason: assess for bony abnormality History: tender at posterior calcaneus, effusion, erythema, possible gout. Denies trauma. No fracture or malalignment. Plantar calcaneal spur is noted and there is an enthesophyte on the posterior calcaneus. There is thickening of the distal Achilles' tendon at it... | Thickening of the distal Achilles' tendon with loss of the normal retrocalcaneal fat. The appearance is suggestive of Achilles tendinopathy. |
Generate impression based on findings. | Male 74 years old Reason: eval for fracture History: right shoulder pain s/p injury No fracture or malalignment. Osteophytes at the acromioclavicular joint and inferior glenoid with subchondral cysts in the humeral head, compatible with mild osteoarthritis. No fracture or dislocation. | Mild osteoarthritis. No fracture or malalignment. |
Generate impression based on findings. | Female 12 years old Reason: strep pneumo sepsis, eval for abscess. Elevated CRP, spiking fevers CHEST:LUNGS AND PLEURA: No focal lung opacity or pneumothorax. Right sided pleural thickening/effusionMEDIASTINUM AND HILA: Right subclavian venous access terminates at the SVC. No mediastinal or hilar lymph nodes. No perica... | 1.Right-sided pleural thickening/effusion with no focal opacities.2.Right humeral head and vertebral bodies bone changes related to sickle cell disease.3.None complicated gallbladder stones.4.Small almost atrophic spleen. |
Generate impression based on findings. | Female 58 years old Reason: eval for RTC disease, OA History: pain Right shoulder: No significant osteoarthritis. The acromiohumeral distance is within normal limits.Left shoulder: No significant osteoarthritis. The acromiohumeral distance is within normal limits.Right knee: Moderate osteoarthritis affects the right kn... | 1. Osteoarthritis affects both knees. 2. The shoulders appear unremarkable. |
Generate impression based on findings. | Female, 82 years old, status post fall on Coumadin. No evidence of intracranial hemorrhage or any abnormal extra-axial fluid collection is seen.Chronic bilateral infarcts of the basal ganglia are demonstrated as well as a small cortical infarct of the left medial occipital lobe. Patchy periventricular hypoattenuation l... | 1.No definite evidence of acute intracranial abnormality including no evidence of intracranial hemorrhage.2.Numerous chronic ischemic lesions as well as age indeterminate microvascular ischemia are noted.3.Presumed endovascular coils are evident in the bilateral masticator spaces likely reflecting prior internal maxill... |
Generate impression based on findings. | Male 55 years old Reason: follow up study, compare w/ previous Again seen are findings consistent with an osteotomy of the third distal metatarsal. New bone formation at the osteotomy site appears well corticated without evidence of osteomyelitis. Again seen is deformity of the base of the proximal phalanx of the third... | Deformity of the third metatarsal and third proximal phalanx compatible with healed surgery/prior infection. No radiographic evidence of acute osteomyelitis. |
Generate impression based on findings. | 52-year-old male with history of rectal carcinoma with prior low anterior resection and ileostomy. Drainage of fluid collection follow-up. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormalit... | Almost complete resolution of pre-coccygeal fluid collection.No evidence for metastatic disease. |
Generate impression based on findings. | Female 62 years old Reason: s/p curettage/cementation of left proximal tibia GCT, evaluate for complications History: above Postsurgical changes of curettage and cementation of the left proximal tibia. No fracture or malalignment. | Postsurgical changes of curettage and cementation of the left proximal tibia without complication. |
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