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Generate impression based on findings. | Reason: PE, dissection History: CP PULMONARY ARTERIES: Technically adequate. No acute pulmonary embolus.LUNGS AND PLEURA: No suspicious pulmonary nodules or masses. Bibasilar dependent atelectasis. No focal consolidation, pleural effusion, or pneumothorax.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. H... | No acute pulmonary embolus or specific finding to explain 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. | History of large right MCA infarct, on anticoagulation Again seen is subacute infarct involving the right middle cerebral artery territory including the right frontal lobe, anterior parietal lobe, and the insular cortex. Again seen is local mass effect including sulcal effacement which is mildly decreased since 4/22/20... | Evolution of subacute right middle cerebral artery territory infarct without hemorrhagic transformation. There is mild decrease in local mass effect compared to 4/22/2015. |
Generate impression based on findings. | 61-year-old female with altered mental status in the setting of multiple myeloma, evaluate for intracranial pathology/hemorrhage. There is no evidence of acute intracranial hemorrhage or mass effect. The ventricles and basal cisterns are unchanged in size and configuration. There is no midline shift or herniation. Ther... | No evidence of acute intracranial hemorrhage or mass effect. Please note that CT is insensitive for the detection of acute nonhemorrhagic ischemic event. If there is continued clinical concern, MRI of the brain is recommended. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in maternal aunt diagnosed in her 50s. Two standard digital views of both breasts, additional bilateral MLO views were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibrogl... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Reason: interval follow up of intracranial bleed History: trauma CT head:The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a 10-mm hyperdense focus present in the left inferior frontal gyrus which is unchanged since the prior exam. There is a 8 x 6 mm axial dimension hyperdense... | 1.There is redemonstration of a small left temporal lobe hemorrhage and a small left frontal lobe hemorrhage both of which are stable when compared to the prior exam. There are scalp hematomas present adjacent to the following bones and the right parietal and occipital bones .2.There is no evidence for temporal bone fr... |
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, unchanged in pattern and distribution. Again seen are parti... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Female 12 years old Reason: fracture History: Left third finger injuryVIEWS: Left third finger AP and lateral 4/27/15 (two views) There is no evidence of acute or healing fracture, no joint effusion, soft tissue swelling or malalignment. | Normal examination. |
Generate impression based on findings. | 73 year old female status post right mastectomy in 2002 for DCIS, presents today for routine follow up. Patient received radiation therapy and tamoxifen. History benign left breast biopsy. No current breast complaints. No family history of breast cancer. Three standard views of the left breast were performed digitally ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left 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. | Reason: obstruction History: emesis, abd painVIEWS: Chest PA and abdomen AP, abdomen erect (3 views) 4/27/15 3:08 Cardiothymic silhouette is normal. No focal pulmonary acute, pleural effusions, or pneumothorax is seen.Paucity of bowel gas without definite evidence of obstruction. No evidence of pneumoperitoneum. | Paucity of bowel gas without definite evidence of bowel obstruction. |
Generate impression based on findings. | Female 30 years old. Reason: eval for osteo/retained fob. History: laceration closed 4/9 with continued pain/swelling/impaired sensation with subjective fever/chills Three views of the right hand demonstrate soft tissue swelling of the index finger distally. There is a defect along the soft tissue volar to the distal p... | 1.No radiographic evidence of osteomyelitis or retained foreign body.2.Findings compatible with prior laceration and possible distal phalanx fracture as described above. |
Generate impression based on findings. | 47 year old female status post left mastectomy in 2010 for invasive ductal carcinoma, presents today for routine follow up. Patient received radiation, chemotherapy, and hormonal therapy. No current breast complaints. Family history of breast carcinoma in her mother at age 65, sister at age 30, and maternal grandmother... | 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. | Female 2 months old Reason: assess for abn bowel patterns History: emesis and feeding toleranceVIEW: Abdomen AP (one view) 4/27/15 at 851 hours Disorganized, moderately distended and nonspecific abdominal gas pattern. No evidence of obstruction, free air, pneumatosis intestinalis or portal venous gas. | Disorganized, moderately distended and nonspecific abdominal gas pattern. |
Generate impression based on findings. | Clinical question: This increased ICP? Signs and symptoms: Headaches, bradycardia normal new leptomeningeal disease. Nonenhanced head CT:There is no detectable acute intracranial hemorrhage, edema, mass, mass effect, midline shift or hydrocephalus.There is subtle periventricular low attenuation of white matter in bilat... | No acute intracranial process or any convincing evidence of interval change when compared with prior brain MRI from 2013. |
Generate impression based on findings. | History of left lumpectomy in 2010 for IDC. Patient received radiation and chemotherapy. History of right breast reduction in 2012. 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 p... | 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. | Female 68 years old. Reason: worsening right sciatica -- comp fx? History: as above Five views of the lumbar spine are provided. Overall, the bones appear demineralized. There is severe degenerative disk disease at L4/5 which appears similar to the prior study. There is mild degenerative disk disease at L3/4. Moderate ... | Degenerative arthritic changes appearing similar to prior study. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and bilateral CC views 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. Benign appearing circums... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 33 year old female with tongue cancer. Explanation for the patient's sudden abdominal pain circumferentially around site of G. -- J-tube. ABDOMEN:LUNG BASES: Marked new airspace consolidation with air bronchograms in the right lower lung with pleural effusion -- most likely considerations are pneumonia or possible aspi... | 1. No abnormality seen affecting the percutaneous jejunostomy tube with percutaneous gastrostomy. 2. New marked right lower lobe air space disease with consolidation and air bronchograms worrisome for pneumonia. 3. Persisting left basilar nodular densities consistent with metastatic disease. 4. New small left pleural e... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of benign left breast biopsy in 2006. 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. S... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Male 57 years old. Reason: monoarticular arthritis. History: monoarticular arthritis (4th finger) Three views of the left hand demonstrate soft tissue swelling about the proximal interphalangeal joint of the fourth finger. There is a small defect along the radial aspect of the proximal phalanx of the fourth finger whic... | Arthritic changes with osteoarthritis of the IP joints but also erosions of the second MCP and probably the fourth PIP joints in addition to soft tissue swelling/mass volar to the interphalangeal joint of the thumb. Although an inflammatory arthritis is considered, the possibility of gout is also entertained. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of right breast aspiration in 2005. 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. Sta... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and additional left MLO and bilateral CC views were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. No suspicious masses, microcalcificatio... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually. Mammography is optimally performed when prior studies are available to detect changes. If the patient's prior mammograms can be submitted, then an addendum to this r... |
Generate impression based on findings. | Female 30 years old Reason: Evaluate for fracture. History: pain Again seen is a comminuted intra-articular fracture of the distal radius in near-anatomic alignment. There has been interval callus formation and the fracture line is less visible suggesting healing. | Healing distal radial fracture as described above. |
Generate impression based on findings. | Reason: 64 yo F with h/o micronodules on CT, now with fever, night sweats, weight loss, concerning for malignancy. Eval for possible lung CA and LAD. History: fevers, night sweats, weight loss LUNGS AND PLEURA: Severe emphysema appear similar to prior study. Interval increase in left lower lobe atelectasis, now complet... | Interval increase in left lower lobe atelectasis, now complete. A central obstructing mass/malignancy cannot be excluded. |
Generate impression based on findings. | 65-year-old female with expressive aphasia. Evaluate for ischemia. The exam is mildly degraded by motion artifact.No evidence of diffusion restriction to suggest acute ischemia. A punctate focus of hyperintensity on diffusion weighted images in the right frontal operculum may represent a small focus of subacute ischemi... | 1.No evidence of acute ischemia.2.Punctate hyperintensity on diffusion-weighted images in the right frontal operculum may represent a tiny focus of subacute infarct.3.Moderate to severe white matter T2/FLAIR hyperintensity, nonspecific though compatible with chronic small vessel ischemic disease.4.Chronic punctate left... |
Generate impression based on findings. | 33 years, Female. Reason: cause of sudden pain around G-J tube site after pt walked to bathroom. 33F tongue ca s/p recent extension of G-J tube. History: sudden and persistent abdominal pain around site of G-J tube Percutaneous gastrojejunostomy tube in place. Small amount of residual contrast in the nondilated colon. ... | Nonobstructive bowel gas pattern. GJ tube in expected position. |
Generate impression based on findings. | Asymptomatic female. Family history of breast cancer in paternal grandmother. Two standard digital views of both breasts, additional right CC view, and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is extremely dense, which lowers the sensitivity of mammography, unchanged i... | 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: NSD - Screening Mammogram. |
Generate impression based on findings. | 65 years, Female. Reason: 65F acute pancreatitis, now with LUQ/LLQ abd pain, constipation. fecal impaction/ileus/obstruction? History: abdominal pain No evidence of obstruction, intramural air or free air. Greater than average stool burden. Faint contrast in colon probably from oral contrast administered for CT scan. S... | Nonobstructive bowel gas pattern. Moderate stool burden. |
Generate impression based on findings. | Reason: mandibular fracture History: TTP jaw s/p baseball bat to face assault CT head:The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a 10-mm hyperdense focus present in the left inferior frontal gyrus. There is a 8 x 6 mm axial dimension hyperdense focus along the anterior a... | 1.Small focal hemorrhages are present in the left frontal lobe and left temporal lobe. There are associated scalp hematomas adjacent to the right parietal bone the right occipital bone and the left frontal bone.2.No evidence for cervical spine fracture3.CT of the maxillofacial bones is within normal limits. |
Generate impression based on findings. | Female 66 years old Reason: eval fracture healing History: s/p ORIF Plate and screw device affixing a fracture through the base of the proximal phalanx of the fourth finger in near anatomic alignment. K wires affixing a fracture of the base of the proximal phalanx of the fifth/little finger, also in near-anatomic align... | Orthopedic fixation of the proximal phalanx of the fourth and fifth fingers as described. |
Generate impression based on findings. | Female, 56 years old.Order Specific Questions RFO trigger:Organ TransplantSuspected RFO location:abdomenName of suspected RFO:none No evidence of unexpected radiopaque foreign object. Expected skin staples, towel clips, nephroureteral stent, and coils.Findings discussed with Dr. Becker as documented in Stat Consult For... | No evidence of unexpected radiopaque foreign body. |
Generate impression based on findings. | 68 years, Male. Reason: CHF, AKI, and fluid overload, r/o obstructive causes of abdominal pain History: abdominal pain Nonobstructive bowel gas pattern with some mildly prominent loops of jejunum representing minimal ileus. Moderate stool burden. Faint punctate calcifications consistent pancreatic calcifications demons... | No evidence of obstruction. Minimal ileus. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of bilateral breast reductions. 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. Benign ... | Stable right breast mass. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | 80 years, Female. Reason: NGT placement, resolution of ileus History: above NG tube tip in proximal gastric body. Sidehole in the distribution of cardia should probably be advanced somewhat.Persistent dilated loops of jejunum up to 5.2-cm in the left abdomen. Relatively collapsed colon with faint contrast from the CT s... | NG tube sidehole probably around the junction should be advanced somewhat. Persistent jejunal dilatation. |
Generate impression based on findings. | Male 66 years old. Reason: bone mets, with salivary cancer, pls f/u for prog. History: pain SKULL: No discrete lesion is seen.CERVICAL SPINE: Moderate degenerative disk disease affects C3/4 and C5/6. Small sclerotic foci within the vertebral bodies are better seen on recent CT.THORACIC SPINE: Mixed lucent and sclerotic... | Widespread metastatic disease predominantly affecting the axial skeleton and better seen on recent CT studies. |
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. A few benign calcifications are present. Probab... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 2 - Benign finding.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 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. Skin moles. Two standard digital views of both breasts, additional bilateral MLO views and cleavage view were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density. No suspicious masses, mi... | 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 20 years old. Reason: fx History: mvc, c7 tender Eight views of the cervical spine are provided. We see no fracture. The cervical spine is slightly kyphotic but we see no spondylolisthesis. The neural foramina appear patent. | Cervical kyphosis without evidence of fracture. If further imaging evaluation is clinically warranted, CT may be considered. |
Generate impression based on findings. | Reason: thoracic aortic aneurysm History: thoracic aortic aneurysm LUNGS AND PLEURA: Stable scattered is calcified and noncalcified micronodules compatible with a prior granulomatous disease.No suspicious pulmonary nodules or masses.No pleural effusions.MEDIASTINUM AND HILA: Stable ectasia of the ascending aorta measur... | Stable aneurysmal dilatation of the ascending aorta currently measuring 4.7 cm. |
Generate impression based on findings. | Female 53 years old. Reason: eval RT wrist out of cast. History: pain Three views of the right wrist demonstrate two side plate and screw devices affixing a distal radius fracture in near-anatomic alignment without evidence of hardware complication. The fracture line remains visible at this time. There is also a fractu... | Orthopedic fixation of the healing distal radius fracture. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and tomosynthesis were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microca... | 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. | Female 9 months old Reason: 9 mo F short gut syndrome with status epilepticus s/p intubation with diminished breath sounds at L>R base and LIJ CVC placement. Evaluate ETT position and line placement. History: SeizuresVIEW: Chest AP (one view) 4/27/15 at 916 hours. ET tube terminates below thoracic inlet. Left subclavia... | Interval improvement in right upper lobe atelectasis. |
Generate impression based on findings. | Male 6 years old Reason: injury VIEWS: Right hand AP, lateral and oblique 4/37/15 (3 views) There is a fracture of the base of the knee may carpal. Alignment is anatomic. | Right third metacarpal base fracture as described. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history of breast cancer in maternal aunt. 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 patte... | 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. | Status post fracture.VIEWS: Left ankle AP, lateral and oblique 4/27/15 (4/6/15 views) Healed fracture are in anatomic alignment. | Healed bimalleolar fractures in anatomic alignment. |
Generate impression based on findings. | Stage II colon cancer with lower left lung nodule seen on outside CT in July. Evaluate for lung lesions. LUNGS AND PLEURA: Left lower lobe 5-mm pulmonary nodule (series 5 image 223). Nonspecific right upper lobe focus of ground glass (series 4 image 36). Mild diffuse bronchial wall thickening. No pleural effusions.MEDI... | 1.Nonspecific 5-mm left lower lobe nodule. The size and appearance are highly suggestive of a post inflammatory nodule, though malignancy cannot be excluded. Given the history, direct comparison with outside exam for stability is recommended. If this is not possible, a repeat CT in 6-12 months is recommended. |
Generate impression based on findings. | Female 12 years old Reason: fracture VIEWS: Right foot AP and lateral 4/27/15 (two views) Interval cast removal. Healing fractures of the first and second metatarsal are in anatomic alignment. | Healing fractures, in anatomic alignment after cast removal. |
Generate impression based on findings. | 72 year old female with history of renal cell carcinoma. Evaluate for recurrence. ABDOMEN:LUNG BASES: Bibasilar, right greater than left tree in bud opacities, and mild bronchiectasis are again seen. 7 mm left lower lung posterior pleural based nodule (3/5), nonspecific and may be followed on subsequent imaging.LIVER, ... | 1.Postoperative findings of partial left nephrectomy without evidence of local recurrence.2.Complex right renal cysts is unchanged.3.Nonspecific left lower lung posterior pleural based nodule, may be postinflammatory in nature but should be followed for stability/resolution on subsequent exams. |
Generate impression based on findings. | Reason: 45yoF scleroderma, raynaud's, ILD with fevers, cough, bloody sputum. ILD protocol. History: ILD, fever, cough LUNGS AND PLEURA: Severe background pulmonary fibrosis with honeycombing, traction bronchiectasis, and interstitial disease consistent with known scleroderma lung disease. Subpleural multifocal areas of... | New right lower lobe thick walled cavitary lesion highly suggestive of a necrotizing infection. This should be followed to resolution to exclude malignancy, though this developed relatively rapidly and this is considered less likely.Findings communicated to Dr. Jun at the time of report. |
Generate impression based on findings. | MRI: No significant diffusion-weighted abnormalities are present. The ventricles and sulci are normal in size. The cerebellar tonsils are in normal position. There are no masses, mass effect or midline shift. There is mild T2 and flair signal hyperintensity present along the right periventricular white matter appearin... | 1.Unchanged 6 mm saccular basilar tip aneurysm with a 3 mm neck. No other aneurysm is identified.2.Unchanged focal stenoses of the right and left posterior cerebral arteries. 3.Stable moderate stenoses of the cavernous portion of the left internal carotid as well as the ophthalmic portion of the internal carotids bilat... |
Generate impression based on findings. | Reason: evaluate ILD History: cough SOB fibrosis LUNGS AND PLEURA: Stable mild basilar predominant subpleural reticulation with traction bronchiectasis and minimal honeycombing.No evidence of air trapping on the expiratory images.No focal areas of consolidation.No suspicious pulmonary nodules or masses.No pleural effus... | Stable mild basilar predominant interstitial fibrosis most likely representing UIP. |
Generate impression based on findings. | Left wrist injury.VIEWS: Left wrist AP and lateral 4/27/15 (two views) Healing fracture of the ulnar styloid process is anatomic alignment. | Healing fracture, in anatomic alignment. |
Generate impression based on findings. | Clinical question: New seizure, GBM status post resection, persistent encephalopathy. Signs and symptoms: As above. Unenhanced head CT:There is no evidence of acute new intracranial finding since prior exam. CT however is insensitive for early detection of acute ischemic strokes.Extensive postoperative changes right an... | 1.Minimal interval increased size of lateral ventricles since prior exam.2.No evidence of acute intracranial hemorrhage or new mass effect. 3.Stable extensive postoperative changes of right anterior temporal lobectomy, residual right hemispheric vasogenic edema, epidural postoperative CSF density collection under a lar... |
Generate impression based on findings. | 49-year-old female with history of ampullary cancer status post resection with small liver recurrence. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: Central venous catheter tip in the right atrium. The heart size is normal without pericardial effusion. Calcified right hilar lym... | 1. Increase in size and number of retroperitoneal lymph nodes as above concerning for disease progression. Close follow-up of these nodes is recommended on subsequent exams. No suspicious hepatic lesions.2. New right adnexal cyst is likely physiologic, however follow-up with ultrasound in two menstrual cycles is recomm... |
Generate impression based on findings. | 73 year-old female with metastatic appendiceal carcinoma. CHEST:LUNGS AND PLEURA: No significant change in the left upper lobe linear subpleural opacity with maximal dimension of approximately 5 mm (series 5, image 36) most likely scarring. No other abnormality seen elsewhere in the lung parenchyma to suggest significa... | Stable examination without significant change in size of reference lesions. 2. No change in the ill-defined soft tissue densities abutting duodenum and inferior aspect of gastric antrum/pylorus. |
Generate impression based on findings. | Left femur fracture.VIEWS: Left femur AP and lateral 4/27/15 (two views) Intramedullary rod and screws are affixing a left diaphyseal transverse healing fracture with periosteal reaction and callus formation of the left femur in anatomic alignment. | Healing fracture, in anatomic alignment with no evidence of hardware complications. |
Generate impression based on findings. | Male 2 months old Reason: assess for abn gas patterns History: emesis and feeding intoleranceVIEWS: Abdomen AP supine and left lateral decubitus 4/27/15 at 900 hours. (two views) NG tube terminates in the stomach. Bibasilar lung haziness noted. Normal abdominal gas pattern. No evidence of obstruction, free air, pneumat... | Normal abdominal gas pattern. |
Generate impression based on findings. | Reason: concern for ILD exacerbation v viral infection (ILD protocol please!) History: dyspnea, ILD, LUNGS AND PLEURA: Left pleural effusion has decreased. Persistent diffuse patchy predominately central groundglass opacities, though slightly decreased from prior. Associated mild bronchiectasis. Stable calcified nodes.... | Persistent diffuse patchy predominately central groundglass opacities, though slightly decreased from prior. Some of the change may be due to improved pulmonary edema. Associated mild bronchiectasis. The findings are nonspecific but are more likely due to ILD such as NSIP than infection. |
Generate impression based on findings. | Reason: h/o laryngeal ca and chemoRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Interval resolution of right upper lobe patchy ground glass nodular opacity, likely related to aspiration. Scattered bilateral calcified and noncalcified micronodules are unchanged, and likely post infectio... | 1.Interval resolution of right upper lobe ground glass opacity, likely related to aspiration.2.No evidence of metastases. |
Generate impression based on findings. | Reason: h/o HNC ca and CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Mild upper lobe predominant centrilobular emphysema. Debris seen within the right mainstem bronchus.New right middle lobe atelectasis, likely related to aspiration.No new or suspicious pulmonary nodule or mass. No pl... | New right middle lobe segmental atelectasis. Given associated debris in central airways this is likely due to aspiration though continued follow up is recommended. No evidence of metastases. |
Generate impression based on findings. | Male 51 years old Reason: Gout- eval for tophi/erosions History: gout Right hand: Mild radiocarpal joint narrowing. Small osteophytes at the distal interphalangeal joints indicating mild osteoarthritis. No specific radiographic evidence of gout.Left hand: Mild radiocarpal joint narrowing. Small osteophytes at the dista... | 1. Changes within the right foot which would be consistent with long-standing/burned out gout. 2. Mild osteoarthritis affects the hands and feet.3. Thickening, striation and elevation of the nails of the great toes raising the possibility of fungal infection. |
Generate impression based on findings. | CHEST:LUNGS AND PLEURA: Upper lobe predominant centrilobular and paraseptal emphysema. Right apical scarring. Wedge like opacity in the left upper lobe measuring 15 x 17 mm (image 36 series 80441), may represent scarring from prior infarct.MEDIASTINUM AND HILA: No significant abnormality noted in the extracardiovascul... | Wedge like opacity in the left upper lobe which could be due to old infarct. Recommend 1 year follow up to document stability. |
Generate impression based on findings. | 56-year-old male with colon cancer and chemotherapy -- evaluate for interval change. CHEST:LUNGS AND PLEURA: The right upper lobe nodule reported as new on 1/26/15 CT examination is not visualized on today's examination.The nonspecific subpleural groundglass nodule seen in the lingula (series 5, image 51) is unchanged.... | 1. Interval embolization with thrombosis of the right portal vein. 2. Nodule suggested as new on 1/26I16 CT examination in right upper lobe no longer seen. 3. Stable appearance to left lingular ground glass 5-mm nodule of uncertain significance. 4. Measurement of reference lesions in the liver appear larger when compar... |
Generate impression based on findings. | 74 year old female status post left lumpectomy in 2001 for IDC, presents today for routine follow up. Patient received radiation therapy and tamoxifen. No current breast complaints. Family history of breast carcinoma in her maternal great aunt. Three standard views of both breasts were performed digitally and reviewed ... | Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Male 9 years old Reason: pain History: pain Age-appropriate appearance to the growth plates. No fracture or malalignment. No specific findings to account for patient's symptoms. A specific site of clinical concern would increase specificity. | No fracture or malalignment. No specific findings to account for patient's symptoms. |
Generate impression based on findings. | CHEST:LUNGS AND PLEURA: Centrilobular emphysema. No pleural effusion or pneumothorax. No suspicious pulmonary nodules or masses. Calcified left upper lobe nodule likely due to prior granulomatous disease. Left lower lobe atelectasis. MEDIASTINUM AND HILA: No significant abnormality noted in the extracardiovascular por... | No significant abnormality noted in the extra cardiovascular portions of the examination. |
Generate impression based on findings. | Reason: restaging of lymphoma History: restaging LUNGS AND PLEURA: Extensive right upper lobe, and to lesser degree superior segment of right lower lobe ground glass and nodular opacity highly suggestive of infection. No significant pleural effusion. Minimal patchy ground glass and centrilobular nodular opacities noted... | 1. Extensive right upper lobe, and to lesser degree superior segment of right lower lobe ground glass and nodular opacity highly suggestive of infection. While the appearance is not typical of lymphoma, similar findings were seen on prior PET/CTs2. Partially calcified 18 mm right hilar lymph node is not significantly c... |
Generate impression based on findings. | Reason: r/o SAH History: headache, history of prior SAH The patient is status post embolic coil occlusion of the right vertebral artery.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portions of the par... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.Some mild mucosal thickening in the sphenoid sinuses is new since the prior exams and is most likely inflammatory in nature. It could provide an explanation for the patient's headache, however. Please correlate with patient's clinical symptoms and h... |
Generate impression based on findings. | Reason: LLL lung nodule, PET-avid, eval for mediastinal lymphadenopathy History: as above LUNGS AND PLEURA: 14-mm lobulated pulmonary nodule in the left lower lobe correlates with hypermetabolic nodule seen on PET/CT and is consistent with malignancy. Additional scattered calcified and noncalcified pulmonary micronodul... | 1.14-mm lobulated pulmonary nodule in the left lower lobe correlates with hypermetabolic nodule seen on PET/CT and is consistent with malignancy. 2. Borderline left hilar 9 mm node (image 48/112) was positive on recent PET. There are multiple 5mm and smaller scattered mediastinal nodes which are not pathologic by size ... |
Generate impression based on findings. | 52-year-old male with history of rectal cancer. Evaluate for chemotherapy response. CHEST:LUNGS AND PLEURA: Right upper lobe reference nodule (4/40) has decreased in size over the interval, currently measuring 6 x 4 mm, previously 10 x 8 mm. Additional non-reference pulmonary nodules have decreased in size over the int... | Dramatic interval decrease in size of reference pulmonary nodules. |
Generate impression based on findings. | Reason: evaluate for acute abnormality History: altered mental status, occipital neuralgia s/p stimulator A metallic stimulator is present along the right occipital scalp.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intrac... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.Status post occipital scalp stimulator placement. |
Generate impression based on findings. | 69-year-old male with history of metastatic rectal cancer in need of restaging prior to surgical resection of liver mets. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: Heart size is normal without pericardial effusion.Left chest wall Port-A-Cath with tip in the SVC.CORONARY ART... | 1. Postsurgical changes of partial hepatectomy with decreasing fluid noted along the cut edge of the liver. Stable small segment 4 hypoattenuating lesions.2. Stable asymmetric rectal wall thickening compatible with patient's known rectal cancer. Interval decrease in size of metastatic lesions with measurements as above... |
Generate impression based on findings. | 79 years, Male. Reason: DHT tube placement confirmation #2; re-positioned History: see above Dobbhoff tube and right lower lobe bronchus. Follow-up films over the been obtained at the time of this dictation showings removal.Persistent ileus pattern, surgical clips, bilateral pleural effusions and pigtail catheter over ... | Dobbhoff tube in right lower lobe bronchus.Follow up films have already been obtained by the time of this dictation showings its removal. Other findings as above. |
Generate impression based on findings. | Female 48 years old Reason: Evaluate for old fracture 1st \T\ 2nd MTPJ's right foot History: Fell and twisted her foot doing a cartwheel one year ago. Hallux valgus with pes planus deformity. No fracture or malalignment. No specific findings to for patient's symptoms. | Hallux valgus with pes planus deformity. No fracture or malalignment. No specific findings to for patient's symptoms. |
Generate impression based on findings. | CHEST:LUNGS AND PLEURA: Numerous calcified and non-calcified pulmonary nodules, likely due to prior granulomatous disease. Centrilobular emphysema. Trace left pleural effusion.MEDIASTINUM AND HILA: Multiple bilateral calcified mediastinal lymph nodes.CHEST WALL: Median sternotomy hardware.UPPER ABDOMEN: Numerous splen... | Numerous pulmonary nodules, some of which are calcified as well as calcified lymph nodes, likely due to prior granulomatous disease. |
Generate impression based on findings. | Clinical question: History of laryngeal cancer and chemo/RT compared to prior measurements please. Signs and symptoms: None. Enhanced CT of the soft tissues of the neck:Unremarkable images through the skull base and cavernous sinuses.Paranasal sinuses and bilateral mastoid air cells remain well pneumatized and unremark... | No evidence of mass or pathologic adenopathy. |
Generate impression based on findings. | 79 years, Male. Reason: DHT placed today; confirm placement History: see above Dobbhoff tube seen right lower lobe bronchus. Follow-up films already been obtained by the time of this dictation showing its removal.Other findings are unchanged including air space cystic disease in the right lower lobe, bilateral pleural ... | Dobbhoff tube seen right lower lobe bronchus. Follow-up films already been obtained by the time of this dictation showing its removal. |
Generate impression based on findings. | Female, 88 years old. Reason: Patient has CKD request ultrasound History: CKD RIGHT KIDNEY: The right kidney measures 10.7 cm, with increased cortical echogenicity. A right upper pole simple cyst measures 1.9 x 1.5 x 1.9 cm. No shadowing calculi or hydronephrosis.LEFT KIDNEY: The left kidney measures 10.3 cm in length,... | 1. A 4-cm solid exophytic structure of the left mid to lower pole was not clearly seen on prior CT imaging dated 1/11/2011 areas recommend CT follow up for further evaluation.2. Increased cortical echogenicity compatible with medical renal disease or parenchymal distortion. |
Generate impression based on findings. | 71 years, Male. Reason: vomiting History: vomiting A few mildly dilated loops of jejunum. Pattern most consistent with ileus. Some air is seen in the hepatic flexure but with no evidence of colonic obstruction. Given limitation supine view, no obvious intramural or free air.Multi-sidehole catheter overlies left abdomen... | Left upper quadrant ileus. |
Generate impression based on findings. | 77 years, Female. Reason: s/p Dobbhoff placement History: s/p Dobbhoff placement Dobbhoff tube distribution the pylorus. Paucity bowel gas.Vascular calcification and metallic object right abdomen, unchanged. | Dobbhoff tube projects over the pyloric area. |
Generate impression based on findings. | Clinical question: History of ESS , residual left sinus inflammation. Signs and symptoms: Cough and drainage. Nonenhanced Medtronic sinus CT:Frontal sinuses are well pneumatized and without evidence of disease or interval change.Ethmoid sinuses are unremarkable and stable since prior exam.Sphenoid sinus is well pneumat... | 1.Minute mucosal thickening in dependent right max sinus stable since prior.2.Minute mucosal thickening in dependent left max sinus is new since prior exa.3.Unremarkable stable other paranasal sinuses and post ESS surgical changes. |
Generate impression based on findings. | 60 years, Female. Reason: Constipation. Sitz marker study; Assess sitz marker distribution on day 5 History: constipation Sitz markers are distributed throughout the right colon with some in the distribution of the transverse and rectosigmoid.Total Sitz markers 12. Other metallic objects and surgical clips. | 12 Sitz markers |
Generate impression based on findings. | Reason: fracture VIEWS: right ankle AP oblique lateral (3 views) 4/27/15 10:12 Alignment is anatomic. No soft tissue swelling or joint effusion. 4-mm curvilinear ossification adjacent to the distal tip of the fibula is again seen, which may represent normal variant. No definite fracture or dislocation. | No definite fracture or dislocation. Alignment is anatomic. |
Generate impression based on findings. | History of fractureVIEWS: Left tibia/fibula AP lateral (2 views) 4/27/15 10:39 Overlying cast limits evaluation of fine bone details. Distal tibial fracture is again seen with minimal posterior displacement of the distal fracture fragment. | Fracture of the distal tibia not significantly changed. |
Generate impression based on findings. | 60 year old female status post right lumpectomy in 2010 for IDC, presents today for routine follow up. Patient received radiation and chemotherapy. No current breast complaints. Family history of breast carcinoma in 2 of her maternal aunts. Three standard views of both breasts were performed digitally and reviewed with... | 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. | 62-year-old male with HCC and therapy, evaluate for disease. CHEST:LUNGS AND PLEURA: No change since most recent prior examination. The 3-mm left upper lobe nodule (series 11, image 127) is unchanged. No new nodules or evidence of airspace disease is seen. No pleural disease.MEDIASTINUM AND HILA: No significant abnorma... | 1. Stable post ablative changes in segment 8 with less prominent perilesional arterial phase enhancement. No washout in the peri-lesional enhancement is seen to meet criteria for HCC. 2. Stable post ablative changes in segment 5. 3. Increasing size of arterial enhancing lesion in segment two which although does not mee... |
Generate impression based on findings. | 87 year-old with history of left breast cancer status post mastectomy. History of right breast calcifications. Three standard views of the right 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 distri... | 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: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 78-year-old male with history of rectal cancer on chemotherapy. CHEST:LUNGS AND PLEURA: Focal subpleural opacity in the right lower lobe measures 2.9 x 1.0 cm (image 78 of series 5).MEDIASTINUM AND HILA: Heart size normal without pericardial effusion. Large goiter extending into the superior mediastinum. Scattered smal... | 1. Interval decrease in size of patient's primary rectal carcinoma and metastatic lesions with reference measurements as above.2. Resolution of small bowel obstruction. |
Generate impression based on findings. | Reason: GIST History: GIST CHEST:LUNGS AND PLEURA: Biapical pleural parenchymal scarring. Bibasilar dependent atelectasis. Scattered pulmonary micronodules, unchanged. No new or suspicious pulmonary nodule or mass.No pleural effusions.MEDIASTINUM AND HILA: Punctate hypoattenuating lesion within the right lobe of the th... | Stable exam with prominent mediastinal lymph nodes and hepatic metastases. Known right lower quadrant mass is outside the field of view. |
Generate impression based on findings. | ORIF follow-up Dorsal fixation appears unchanged that evidence of hardware complication. Fracture planes are indistinct compatible with a healed distal radial comminuted fracture. Persistent mild soft tissue swelling | Healed distal radial fracture and uncomplicated/unchanged underlying hardware |
Generate impression based on findings. | Clinical question: Pseudotumor. Signs and symptoms:Pseudotumor Nonenhanced head CT:Examination demonstrates no detectable acute intracranial process. CT however is insensitive for early detection acute nonhemorrhagic ischemic strokes.The cerebral cortex and cortical sulci as well as ventricular system, CSF spaces and g... | Unremarkable nonenhanced head CT for age. |
Generate impression based on findings. | Male 19 years old. Reason: Hx Tib Fx s/p GSW and IMN - Eval Hardware. History: same Two views of the left tibia/fibula demonstrate an intramedullary rod and screw device affixing a healing/healed fracture of the mid-tibial diaphysis in near anatomic alignment. There is no evidence of hardware complication. Numerous bul... | Orthopedic fixation of healing/healed tibial fracture. |
Generate impression based on findings. | Clinical question: New weakness, persistent confusion in setting of TMA, bacteremia. A stem cell transplant 2 -- 3 -- 15. Signs and symptoms: Weakness and confusion. Nonenhanced head CT:There is no acute intracranial process or new finding since prior exam. CT however is insensitive for the early detection of acute non... | Negative nonenhanced head CT and stable since prior exam. |
Generate impression based on findings. | Female 27 days old Reason: respiratory distress, required intubation, need to assess tube, persistent pulmonary hypertension.VIEW: Chest AP (one view) 4/27/15 at 10 34 hours. ET tube tip is at the thoracic inlet. NG tube has been removed. Right upper extremity central line terminates at the SVC.Cardiac silhouette size ... | Persistent pleural effusions and right upper lobe atelectasis. |
Generate impression based on findings. | Treatment related findings are seen including infiltration of the fascial planes and scarring in the right neck. Findings are unchanged. No mass or pathologic adenopathy is detected. Mild edematous appearance of the supraglottic larynx again seen. Salivary glands and the thyroid are free of focal lesions. The cervical... | Post treatment changes in the neck without evidence of tumor recurrence or cervical lymphadenopathy. |
Generate impression based on findings. | 60 year-old male with history of rectal cancer. Evaluate for any fluid collections. Lack of intravenous contrast enhancement limits the evaluation of solid organ parenchyma and vascular structures. Given these limitations, the following observations can be made:CHEST:LUNGS AND PLEURA: Interval placement of right-sided ... | 1. Interval placement of right chest tube with residual mixed density pleural effusion. Left pleural effusion has increased in size.2. Stable abdominal drains with increase in size of anterior hepatic fluid collection and decrease in size of right perihepatic fluid collection.3. Moderate volume ascites with small scatt... |
Generate impression based on findings. | Female 8 months old Reason: r/o abuse History: burnEXAMINATION: 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 oblique, pelvis AP, right femur AP, left femur... | No evidence of nonaccidental trauma. |
Generate impression based on findings. | 19 year-old male. Tender to palpation over the lateral malleolus after rolling ankle. Evaluate for fibular avulsion fracture. No fracture or dislocation. Ankle mortise is intact. | No evidence of a fracture. |
Generate impression based on findings. | 77-year-old female. Pain. Right hip: Severe osteoarthritis affects the right hip with bone-on-bone apposition and extensive subchondral sclerosis and cyst formation. There is flattening of the subchondral femoral head.Pelvis: Aforementioned severe right hip severe osteoarthritis. Mild to moderate osteoarthritis affects... | Severe right hip osteoarthritis. |
Generate impression based on findings. | Clinical question: is there a bleed. Signs and Symptoms: fall and hit head on curb, +lac to right parietal area. Nonenhanced head CT:There is no detectable acute posttraumatic intracranial or calvarial findings. A small focus of subgaleal and scalp hemorrhage/edema in right posterior parietal is noted. Unremarkable cer... | 1.Small right parietal scalp and subgaleal hemorrhage. 2.Unremarkable nonenhanced head CT otherwise. |
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