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Generate impression based on findings. | s/p fall The cervical vertebral bodies are appropriate in overall alignment and height. No fractures are identified in the cervical spine.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or neural foramina. Small right-sided... | 1.No cervical spine fracture is appreciated.2.There are degenerative changes present in the cervical spine which appear to be worse at C6-7 where there is a mild to moderate degree of spinal stenosis suspected in some encroachment of the right-sided exiting nerve roots. |
Generate impression based on findings. | Female 2 months old Reason: assess for worsening aeration History: tachypnea, increased wobVIEW: Chest AP (one view) 5/5/2015 at 1459 hours Cardiac silhouette size is normal. Interval improvement in right upper lobe atelectasis with development of bibasilar opacities likely atelectasis as well. No effusions or pneumoth... | Interval slight improvement in right upper lobe atelectasis but development of bibasilar opacities as described. |
Generate impression based on findings. | Headache(784.0)Subarachnoid hemorrhage Cerebral aneurysm, nonrupturedClinical question: ON 3 T SCANNER- assess coiled and untreated aneurysm, sp craniotomy for right MCA clippingSigns and Symptoms: h/o SAH, untreated aneurysm, FU POST rt MCA clipping MRA brain:Antegrade flow is present in the distal internal carotid ar... | 1.The right middle cerebral artery is obscured by aneurysm clips.2.Patient is status post embolic coil occlusion of a basilar tip aneurysm. There is a 1.5 mm residual base present.3.There is a 2 mm left middle cerebral artery aneurysm present |
Generate impression based on findings. | Age: 59 years. Sex : Male. Reason for study: Reason: Eval for resolution of Dysphagia History: Previous abnormal OPM. 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. Static images were obtaine... | Positive for trace penetration and negative for aspiration.Please see the speech pathology report for additional details. |
Generate impression based on findings. | 9-year-old male with history of postoperative ankle.VIEWS: 3 views of the right ankle and 3 views of the left ankle, including AP, lateral and oblique of each on 5/5/2015 at 1403 The left ankle has overlying cast material which obstructs fine bone detail. No fracture or dislocation is seen.The right ankle is normal in ... | Left ankle cast material limits evaluation, however no significant abnormality is noted in either ankle. |
Generate impression based on findings. | 88 years old, Male, Reason: Hx of metastatic colon cancer; currently in watchful waiting; evaluate for cancer status History: See Above CHEST:LUNGS AND PLEURA: Stable changes of chronic lung disease. No suspicious pulmonary nodules or masses. Interval resolution of small right pleural effusion.MEDIASTINUM AND HILA: Car... | Mild decreased size in hepatic metastases and left lower quadrant peritoneal mass. No new sites of disease. |
Generate impression based on findings. | 54-year-old female patient with triple negative breast cancer presents with lymphadenopathy in the neck, chest, and abdomen. There are bilateral enlarged cervical lymph nodes, right greater than left, some of which demonstrate necrosis. There is a necrotic level right 2B lymph node that measures 9 x 9 mm (series 7 imag... | 1.Neck lymphadenopathy and lung nodules compatible with metastatic disease. Reference measurements provided.2.Small nonspecific sclerotic focus in the posterior superior aspect of the T1 vertebral body, otherwise, no definitive osseous metastatic lesions. |
Generate impression based on findings. | 73-year-old female fell on hip and back. 4 views of the lumbar spine reveal flowing ossification along the anterior aspect of the lower thoracic spine compatible with diffuse idiopathic skeletal hyperostosis (DISH). Anterior projections in the lower lumbar spine most likely represent early findings of DISH. Otherwise a... | Findings compatible with DISH of the lower thoracic spine and what most likely represent early findings of DISH in the lower lumbar spine. |
Generate impression based on findings. | Male 65 years old; Reason: Unilateral scrotal enlargment History: Unilateral scrotal enlargment RIGHT TESTIS: 4.2 x 3.2 x 2.7 cm. No intratesticular massLEFT TESTIS: 5.1 x 3.4 x 2.4 cm no intratesticular massRIGHT EPIDIDYMIS: No significant abnormalities noted.LEFT EPIDIDYMIS: No significant abnormalities noted.OTHER: ... | No intratesticular mass. Bilaterally symmetric Doppler flow characteristics. Bilateral large hydroceles. |
Generate impression based on findings. | 77-year-old female with decreased range of motion in the shoulders Right shoulder: Mild osteoarthritis affects the right shoulder. No acute fracture is evident. Alignment is anatomic.Left shoulder: Mild osteoarthritis affects the left shoulder. No acute fracture is evident. Alignment is anatomic. | Mild osteoarthritis affects bilateral shoulders. |
Generate impression based on findings. | 65 year female with lower back and bilateral hip pain, history of MS, DM2 on steroids 4 views of the lumbar spine reveal vacuum disc phenomenon of L5/S1 compatible with mild degenerative changes. Otherwise alignment is anatomic with preservation of the remaining disc spaces.3 views of the SI joints reveal no abnormalit... | Mild degenerative changes of the lumbar spine. Otherwise no abnormality is noted within the SI joints and hips. |
Generate impression based on findings. | Male 16 years old Reason: r/o fx History: painVIEWS: Left knee AP, lateral and oblique 5/5/2015 (3 views) Joint effusion with no fracture or malalignment. | Joint effusion with no fracture. |
Generate impression based on findings. | Male 27 years old; Reason: please evaluate for etiology of testicular swelling/pain, scrotal vein engorgement. Also evalaute for possible herina in inguinal canal. If not present in inguinal canal, please evaluate LLQ as well. History: (L) testicular pain/swelling, LLQ pain temporally asocaited with lifting heavy weigh... | No intratesticular mass. Bilaterally symmetric Doppler flow. Possible small left inguinal hernia. |
Generate impression based on findings. | Male 78 years old; Reason: History of metastatic prostate and renal cancer, on androgen ablation. Assess for response CHEST:LUNGS AND PLEURA: Bilateral metastatic pulmonary nodules, demonstrating mixed response. Reference left upper lobe lung nodule measures up to 0.2 mm, image 13 series 4, previously measured 0.6 x 0.... | 1. Multiple bilateral lung nodules, mixed treatment response suggested as above.2. Enlarging hepatic lesion, suspicious for metastatic focus. |
Generate impression based on findings. | 55-year-old female with low back pain There are five nonrib-bearing lumbar-type vertebra. Vertebral body heights, disc spaces, and alignment are preserved. No acute fracture is evident. Anterior osteophytes at multiple levels suggestive of mild degenerative disease. | Mild degenerative changes without acute fracture or malalignment. |
Generate impression based on findings. | 55-year-old female with left hand pain status post MVC 3 views of the left hand reveal no effusion, fracture or dislocation. Alignment within normal limits. | No fracture or dislocation. |
Generate impression based on findings. | 54-year-old male with neck and upper extremity pain The cervicothoracic junction is obscured by overlying anatomy. Anterior osteophytes and disc space narrowing affect C4-C5, C5-C6, and C6-C7. There is straightening of the usual cervical lordosis which may be secondary to positioning or muscle spasm. Extension and flex... | Degenerative disease without evidence of instability. |
Generate impression based on findings. | 27-year-old male with decrease rom, pain to bear weight. Patient was assaulted today, left knee swelling, unable to bend or bear weight. 4 nonweightbearing views of the left knee reveal a moderate anterior joint effusion with no evidence of fracture or dislocation. | Moderate joint effusion with no evidence of fracture or dislocation.Findings were discussed with Dr. Eric Toone by phone on 5/5/2015 at 3:25 PM. |
Generate impression based on findings. | Unspecified cerebral artery occlusion with cerebral infarctionDiagnosis Edits: Clinical question: Rule out hemorrhage given PTT now at 119 A hypodense focus is present in the right frontal lobe subcortical white matter involving predominantly the white matter of the right inferior and middle frontal vagina arising. Thi... | 1.There is a subacute infarction present in the right frontal lobe mainly involving white matter corresponding to the middle cerebral artery branch occlusion. There is no evidence for hemorrhagic conversion.2.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. At this age they are... |
Generate impression based on findings. | Papillary thyroid carcinoma; intraoperative evaluation of cervical lymph nodes Mildly enlarged but morphologically unremarkable left level 2 lymph nodes; favor benign reactive etiology. An isolated left level 5 lymph node measuring approximately 0.6 x 0.3 cm also demonstrates benign reactive morphology. | Mildly enlarged but morphologically unremarkable left level 2 and isolated left level 3 lymph nodes; favor benign reactive etiology. Accordingly, no lymph nodes were marked intraoperatively |
Generate impression based on findings. | 27-year-old male with pain. Evaluate for fracture. Patient was assaulted today, right wrist pain. 3 views of the right wrist reveal a comminuted intra-articular nondisplaced fracture of the ulnar styloid. No other fractures are identified. | Comminuted intra-articular nondisplaced fracture of the ulnar styloid.Findings were discussed with Dr. Eric Toone by phone on 5/5/2015 at 3:25 PM. |
Generate impression based on findings. | 34-year-old female with lifelong recurrent urinary tract infections. Evaluate for renal calculi or ureteral anomalies. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Mild diffuse hepatic steatosis.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS... | 1. Mild diffuse hepatic steatosis.2. Small focus of air within the bladder is nonspecific and may be related to recent instrumentation. |
Generate impression based on findings. | 50-year-old female with right neck pain Two views of the cervical spine show C1 through C6. The cervicothoracic junction is obscured by overlying anatomy. Anterior osteophytes at C3-C4, C4-C5, C5-C6, and C6-C7. Mild loss of disc space height at C5-C6. Straightening of the usual cervical lordosis may be secondary to pos... | Degenerative disease without evidence of acute fracture or subluxation. |
Generate impression based on findings. | Fracture.VIEWS: Left wrist PA/lateral (two views) 05/05/15 A splint obscures bone detail. The buckling fracture along the anterior surface of the distal radial diaphysis is again seen. | Buckling fracture of the anterior surface of distal radial diaphysis. |
Generate impression based on findings. | 16-year-old female with bilateral knee pain Right knee: No acute fracture or malalignment is evident. No joint effusion. The extensor mechanism appears intact.Left knee: No acute fracture or malalignment is evident. No joint effusion. The extensor mechanism appears intact. | Normal examination. |
Generate impression based on findings. | Male 37 years old Reason: worsening obstruction? History: CKD, h/o ureteral stenting and PCNs Both kidneys demonstrate diminished uptake and excretion bilaterally, with prolonged parenchymal activity. Spontaneous emptying into nondilated collecting systems is demonstrated bilaterally with rapid washout on both sides. R... | 1.No evidence of collecting system obstruction of either kidney.2.Bilateral nearly symmetric diminished parenchymal activity suggesting medical renal disease, left slightly worse than right. |
Generate impression based on findings. | 55-year-old male with joint pain Right hand: Triscaphe joint arthritis. Extensive arterial calcifications are again noted.Left hand: Triscaphe joint arthritis. Extensive arterial calcifications noted.Right foot: Again noted is amputation at the mid first metatarsal. Interval amputation at the proximal phalanx of the se... | Degenerative and postsurgical changes as described above. |
Generate impression based on findings. | 40-year-old male with poor/weak distal pulses. Evaluate vasculature to support kidney transplant. Lack of intravenous and oral contrast limits sensitivity for solid organ and bowel pathology respectively.ABDOMEN:LUNG BASES: Low density of the cardiac blood pool, suggestive of anemia. Small pericardial effusion. Trace r... | 1. Appearance of the kidneys typical for although somewhat dominant polycystic kidney disease.2. Minimal atherosclerotic calcifications of the abdominal aorta and its branches.3. Duplicated IVC. |
Generate impression based on findings. | 65-year-old female with history of abdominal aortic aneurysm. ANGIOGRAM: There is moderate to severe atherosclerotic calcifications of the abdominal aorta. There is saccular aneurysmal dilatation of the infrarenal abdominal aorta measuring up to 3.9 x 3.6 cm. There is eccentric mural thrombus contained within the aneur... | 1. Abdominal aortic aneurysm has increased in size with maximum diameter of 3.9 cm.2. Marked focal high grade atherosclerotic stenosis of the right common iliac artery just distal to the aortic bifurcation with heavy calcification.3. Mild short segment narrowing of the SFA at the adductor canal.I personally reviewed th... |
Generate impression based on findings. | Male 81 years old; Reason: 81M with metastatic colon cancer involving the lungs. Surveillance scans CHEST:LUNGS AND PLEURA: Upper lobe predominant emphysema. Stable peripheral lingular micronodule. There is a pleural-based right lower lobe mass demonstrating interval decrease in size, measuring 5.3 x 3.9 cm, image 52 s... | 1. Decreased size of right-sided lower lobe mass and hilar adenopathy. |
Generate impression based on findings. | 55-year-old female with low back pain status post MVC. 4 views of the lumbar spine reveal normal alignment with preservation of the disc spaces. No evidence of fracture. | Normal alignment with preservation of the disc spaces. No acute abnormality identified. |
Generate impression based on findings. | 58-year-old male patient with a right sided gingival/mouth cancer status post reconstruction and chemoradiotherapy. Recent right mandibular swelling. Evaluate for osteoradionecrosis of the mandible. There are postsurgical findings related to partial right hemimandibulectomy with sideplate and screw fixation and graft a... | 1. Extensive postsurgical findings in the neck without definite evidence of locoregional tumor recurrence or significant lymphadenopathy. Unchanged mandibular lytic changes in the right parasymphyseal region. No new mass, new destructive changes, or new fluid collections to suggest abscess are appreciated.2. Unchanged ... |
Generate impression based on findings. | 55-year-old female with left leg pain. 2 nonweightbearing views of the left femur reveal no effusion, fracture or dislocation. Alignment is normal. | No fracture or dislocation. |
Generate impression based on findings. | Reason: HCC treated with TACE/RFA assess for tx History: HCC and cirrhosis ABDOMEN:LIVER, BILIARY TRACT: Preoperative signal on in phase images suggesting iron deposition. Morphologic changes compatible with cirrhosis. Lacelike increased T2 signal compatible with fibrosis. Stable right hepatic cysts. Cholelithiasis.Seg... | 1.Interval ablation of segment 3 hepatic lesion. Anterior part of the lesion still demonstrates enhancement with washout, and is likely residual disease.2.Cirrhosis with portal hypertension. Minimal ascites.3.Small bilateral pleural effusions with adjacent compressive atelectasis. |
Generate impression based on findings. | Female 75 years old; Reason: Eval TEVAR History: s/p TEVAR CTA:Stable postoperative changes from endovascular stent placement within the descending thoracic aorta just distal to the takeoff of the left subclavian artery. The stent graft extends inferiorly to the mid descending thoracic aorta at the level of the coronar... | 1. Slightly increased mural thrombus in the excluded aneurysm at the mid descending thoracic aorta, but otherwise no significant interval change in the appearance of the thoracoabdominal aorta.2. Stable focal dissection immediately distal to the endovascular stent within the distal descending thoracic aorta. |
Generate impression based on findings. | Male 68 years old Reason: hx of prostate cancer, evaluate for disease, prostate biopsy to follow History: see above PELVIS:PROSTATE:Prostate Size: 5.5 x 3.2 x 4.3 cm.Peripheral Zone: Punctate hypointensity in the right mid peripheral zone on image #13, series #801 there present a small cancer focus.Central Gland: There... | 1.Large anterior tumor in the right apex and right mid prostate tumor arising from the transition zone. This lesion is amenable for MR guided biopsy. |
Generate impression based on findings. | 25-year-old male with history of hepatitis B. Screening for HCC. LIVER: Normal hepatic echotexture and size, measuring 14 cm in length. No focal hepatic lesion is detected.GALLBLADDER, BILIARY TRACT: No cholelithiasis, gallbladder wall thickening, or pericholecystic fluid. Negative sonographic Murphy sign. No intra or ... | No focal hepatic lesion identified. |
Generate impression based on findings. | Female 72 years old; Reason: endometrial cancer please measure the following lesion using recist criteria and immune response criteria 1) recurrent soft tissue mass at site of uterus History: post 2 cycles of chemo CHEST:LUNGS AND PLEURA: Visualized lung fields stable in appearance. Right upper lobe calcified granuloma... | 1. Interval increase in size of retroperitoneal and pelvic lymphadenopathy as above.2. Decreased size of presumed residual/recurrent neoplasm at level of uterine bed. |
Generate impression based on findings. | 53 -year-old female. Call back from screening for subtle distortion in the right retroareolar region. MAMMOGRAM: An ML view and three spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masse... | No mammographic or sonographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Disturbance of skin sensation. New onset R arm numbness The CSF spaces are appropriate for the patient's stated age with no midline shift. Periventricular and subcortical white matter hypodensities of a mild degree are present.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identi... | 1.No evidence for acute intracranial hemorrhage mass effect or edema. CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction. 2.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 3.Hyperdense opacificat... |
Generate impression based on findings. | 12-year-old female with left facial abscess. Evaluate left mandibular body status post curettage. Panorex view of the mandible reveal a focal radiolucency at the base of the left first mandibular molar tooth not as conspicuous as in the previous study but still apparent consistent with prior curettage. No fracture or m... | Findings compatible with prior curettage. No fracture or malalignment. |
Generate impression based on findings. | Reason: eval liver lesion. *FNH protocol" History: liver lesion ABDOMEN:LIVER, BILIARY TRACT: Unchanged right hepatic cyst and cholelithiasis. Redemonstrated 4.4 x 4.6 cm avidly arterially enhancing slightly T2 hyperintense which gradually becomes isointense to hepatic parenchyma and no demonstrable washout. This lesio... | 1.Redemonstrated 4.6cm mass compatible with focal nodular hyperplasia of the liver.2.Cholelithiasis. |
Generate impression based on findings. | Frontal sinus: The frontal sinus and frontoethmoidal recesses are clear.Anterior ethmoids: The anterior ethmoid air cells are clear.Maxillary sinuses: The maxillary sinuses are clear. The ostiomeatal units are clear.Posterior ethmoids: The posterior ethmoid air cells are clear.Sphenoid sinus: The sphenoid sinus and bi... | No paranasal sinus disease. |
Generate impression based on findings. | 38 year old man with history of tobacco use presents with 1 week of chest pain. He is referred to rule out severe coronary artery disease.CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of valsalva and trifurcates into the left anterior descending, left circumfle... | 1. There are no significant coronary artery stenoses present. 2. A small ramus intermedius branch has a 26-50% stenosis in the proximal portion of the vessel. 3. Mild burden of coronary atherosclerosis (non-calcified) is noted throughout the coronary tree. 4. Aneurysmal interatrial septum noted. This portion of the re... |
Generate impression based on findings. | DBS frame placement and surgical planning, Parkinson's Examination is obtained for operative planning and intraoperative guidance. Again seen is left transfrontal deep brain stimulator lead terminating near the left subthalamic nucleus. Interval placement of right transfrontal DBS lead is seen, also terminating near th... | Expected postsurgical changes of right transfrontal DBS lead placement. Bilateral DBS leads terminate near the level of the subthalamic nuclei. |
Generate impression based on findings. | 47-year-old female who was found to have a new probably benign asymmetry at the far posterior 5:00 position of the left breast on a prior mammogram performed at Mercy Hospital on January 3, 2014. Patient return for additional imaging on February 26, 2014. No correlate was found on ultrasound however the asymmetry persi... | Stable highly probable benign mammographic mass at the 5:00 position of the left breast. Continued six-month follow-up recommended. Therefore, the patient should return in 6 months for left breast diagnostic mammogram and possible ultrasound. The results and recommendations were discussed with the patient after complet... |
Generate impression based on findings. | Male, 79 years old. Reason: eval for dilated loops, free air History: abd pain and distension The lower pelvis is excluded from the field of view.Nonobstructive bowel gas pattern. No free air.TIPS in place. Status post median sternotomy. | Nonobstructive bowel gas pattern. No free air. |
Generate impression based on findings. | Male 17 years old Reason: pain, r/o carpal pain VIEWS: Left hand AP, lateral and oblique 5/5/2015 (3 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Status post fracture.VIEWS: Right forearm AP and lateral 5/5/2015 (2 views) Cast material obscures fine bone details. Healing fractures of the distal radius and overlying with periosteal reaction, callus formation and dorsal angulation are unchanged in alignment. | Healing fractures, unchanged in alignment after casting. |
Generate impression based on findings. | 52-year-old male patient with history of fall on Lovenox 4 days ago, struck right forehead. Patient is experiencing increasingly altered mental status. There is no evidence of intracranial hemorrhage. The ventricles and basal cisterns are normal in size and configuration. There is no mass effect or herniation. Minimal ... | No evidence of intracranial hemorrhage or mass effect. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 3-year-old male, evaluate hips for dislocation.EXAMINATION: Pelvis AP view (1 view) 5/5/2015 at 15:24 The femoral heads are directed towards the acetabula with no evidence of dislocation. There is bilateral coxa valga deformity. No acute fracture is identified. | Bilateral coxa valga deformity with no evidence of dislocation. |
Generate impression based on findings. | Ankle fracture post.VIEWS: Left ankle AP/lateral (two views) 05/05/15 Two screws remain in place in the fibula. The fractures of distal tibia and fibula have healed. Alignment is anatomic. There is demineralization. Soft tissue swelling is present medially. | Healed fractures of distal tibia and fibula. |
Generate impression based on findings. | PHARYNX/LARYNX: The nasopharynx, oropharynx, hypopharynx, and larynx are unremarkable. The upper trachea and esophagus are unremarkable. There is no abnormal soft tissue mass or pathological enhancement.GLANDS: The postcontrast appearance of the salivary glands is unremarkable. The thyroid gland is unremarkable. ORAL ... | 1. Slight increased size of extensive lymphadenopathy in the neck and partially imaged mediastinum.2. Progression of thrombosis of the right internal jugular vein just below the skull base. |
Generate impression based on findings. | Male 13 years old Reason: rule out obstruction History: abd pain, hx cecostomy, hx Hirschsprung'sVIEWS: Abdomen AP supine and upright on 5/5/2015 1552 hours. (Two views) Normal abdominal gas pattern. No evidence of obstruction or free air. | Normal examination. |
Generate impression based on findings. | Male 65 years old Reason: See CT neck 3/27 History: History of head and neck cancer and CRT. Neck CT 3/27/2015 demonstrated nonspecific asymmetric prominence of the soft tissues.RADIOPHARMACEUTICAL: 12.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 98 mg/dL. Today's CT portion grossly demonstrates posttre... | No current FDG avid tumor. Soft tissue asymmetry on neck CT most likely posttreatment in etiology. |
Generate impression based on findings. | 73 year old female fell on her back and hip 2 views of the left hip reveal enthesopathy at the greater trochanter consistent with findings of DISH. Alignment is within normal limits with no evidence of effusion or fracture. | Findings compatible with DISH of the left hip. |
Generate impression based on findings. | 53-year-old female with history of metastatic colon cancer, status post resection. CHEST:LUNGS AND PLEURA: Stable 4 mm right upper lobe micronodule. No new suspicious pulmonary nodules identified. No focal consolidation or pleural effusion is present.MEDIASTINUM AND HILA: There is increased superior mediastinal lymphad... | 1.Interval increase in superior mediastinal lymphadenopathy; nonspecific though metastatic progression not excluded.2.Stable retroperitoneal lymphadenopathy.3.Interval hysterectomy and bilateral salpingo-oophorectomy.4.Interval increase in prominence of few bilateral iliac chain lymph nodes; may be reactive given inter... |
Generate impression based on findings. | Solitary pulmonary nodule. History of urothelial cell cancer with lung metastasis status post chemotherapy and radiation.RADIOPHARMACEUTICAL: 14.4 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 117 mg/dL. Today's CT portion grossly demonstrates two adjacent large left upper lobe pulmonary parenchymal masses... | 1.Significant progression of markedly hypermetabolic left-sided pulmonary parenchymal masses in the left upper and lower lobes, consistent with progression of tumor, either metastatic disease or new primary lung cancer.2.New hypermetabolic left mediastinal lymph nodes indicate additional tumor progression.3.New hyperme... |
Generate impression based on findings. | Female 54 years old; Reason: progressive triple negative breast cancer with neck, chest and abdominal adenopathy, please measure using bidimensional measurements History: pre chemo CHEST:LUNGS AND PLEURA: Multiple ill-defined bilateral nodular pulmonary opacities seen, suspicious for metastatic disease. Submitted for r... | 1. Enlarged axillary, mediastinal and hilar lymphadenopathy. 2. Pulmonary nodularity, see discussion above.3. Left chest port with tip located in left innominate vein, repositioning should be considered.4. Please refer to concomitant CT soft tissues neck study from same day for findings. |
Generate impression based on findings. | Female 50 years old; Reason: metastatic breast cancer - evaluate response to treatment with bidimensional measurements per recist 1.1 History: axillary soft tissue masses. patient also getting ct of neck CHEST:LUNGS AND PLEURA: Scattered nonspecific micronodules, unchanged. Reference 4 mm left lower lobe nodule is stab... | 1.Worsening thoracic disease as above. |
Generate impression based on findings. | Female 59 years old Reason: evaluate for disease metastatic distribution History: new CT findings and history of uterine cancer to see extent of diseaseRADIOPHARMACEUTICAL: 10.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 94 mg/dL. Today's CT portion grossly demonstrates linear scarlike opacity noted in ... | Extensive hypermetabolic lymph node metastases extending inferiorly from the right common iliac chain, into the retroperitoneum and superiorly as high as the right retrocrural location. |
Generate impression based on findings. | 14-year-old female, evaluate for stoolEXAMINATION: Portable chest radiograph and AP view of the abdomen (2 views) 5/5/2015 at 15:49 Chest: Right chest port with tip at the SVC/RA junction, unchanged. The heart size is normal. Low lung volumes with unchanged right lower lobe opacity. There is a new opacity in the mid le... | 1.New left midlung opacity compatible with pneumonia.2.Unchanged right lower lobe opacity, this likely represents chronic atelectasis. 3.No evidence of bowel obstruction or fecal impaction.4.Subluxed right and dislocated left hip. |
Generate impression based on findings. | Esophageal carcinoma CHEST:LUNGS AND PLEURA: Interval appearance of several subcentimeter nodular opacities bilaterally. A representative focus within the right lower lobe as seen on image 75 series 5 measures 0.4 cm in diameter.MEDIASTINUM AND HILA: Slight interval increase in size of reference subcarinal lymph node b... | Interval appearance of several bilateral subcentimeter nodular opacities within the lung; while these may represent inflammatory findings, early metastatic lesions cannot be excluded. Would pay special attention to these nodular opacities on future surveillance scans.Slight interval increase in size of reference subcar... |
Generate impression based on findings. | Female 36 years old; Reason: pleural and peritoneal mesothelioma, s/p multiple surgeries, on observation, eval EOD, compare to previous History: SOB CHEST:LUNGS AND PLEURA: Status post right thoracotomy and healing right-sided rib fracture seen as well as parietal pleurectomy and right lower lobe wedge resection. Decre... | 1. Mild interval increase in amount of small perihepatic ascites. Diffuse hepatic steatosis, making evaluation for underlying lesion suboptimal. Too small to characterize hepatic segment 7 hypoattenuating foci stable, images 74 and 77 series 3. 2. Decreasing small right pleural effusion. |
Generate impression based on findings. | The extraocular muscles and optic nerves are normal in size and density. No mass is seen in the orbits within the limitations of this noncontrast exam. No bone destruction or fracture of the orbital walls is seen. There is no significant abnormal amount of orbital fat. | Unremarkable noncontrast CT of the orbits. |
Generate impression based on findings. | The ventricles and sulci are within normal limits. There is no midline shift or mass effect. There is no intracranial hemorrhage, within the limitations of only postcontrast imaging. There are no areas of abnormal attenuation or pathological enhancement. There is no extraaxial fluid collection. The visualized portions... | Post treatment changes within the neck. No evidence of neck mass or cervical lymphadenopathy. |
Generate impression based on findings. | 32-year-old male with fever and tachycardia. Evaluate for abscess. CHEST:LUNGS AND PLEURA: New large bilateral pleural effusions with moderate nonspecific bibasilar dependent atelectasis/consolidation, for which underlying infection cannot be excluded.MEDIASTINUM AND HILA: No significant abnormality notedCORONARY ARTER... | 1. Interval postsurgical changes from subtotal colectomy with right lower quadrant ileostomy. Findings suggestive of ileus, but obstruction at the level of the right lower quadrant ileostomy cannot be entirely excluded. Clinical correlation with physical exam and ostomy output is recommended.2. Large amount of abdomino... |
Generate impression based on findings. | Prerenal transplant evaluation; assess abdominal vessels ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Interval ... | Minimal atherosclerotic calcification involving the distal abdominal aorta and iliac bifurcation. No significant atherosclerotic calcification involving the external and internal iliac vessels bilaterally. |
Generate impression based on findings. | Male 62 years old Reason: presence of FDG avid nodules History: new lung nodule, patient with known renal cellRADIOPHARMACEUTICAL: 13.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 190 mg/dL. Today's CT portion grossly demonstrates right suprahilar lung mass measuring on the order of 3 cm, and additional ... | 1.Widespread markedly hypermetabolic tumor involving the chest and abdomen including lung, liver, multiple lymph nodes, and mesenteric deposits.2.Additional hypermetabolic focus of some suspicion in the sigmoid colon. Synchronous colon neoplasm is a consideration, and if no recent colonoscopy has been performed, recomm... |
Generate impression based on findings. | Restaging testicular cancer status post chemotherapy with autologous stem cell transplantation.RADIOPHARMACEUTICAL: 15.3 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 96 mg/dL. Today's CT portion grossly demonstrates multiple bilateral small and medium sized pulmonary nodules. For reference, the largest is... | No significantly FDG avid tumor currently. Minimal uptake involving a right pulmonary nodule and a right inguinal lymph node most likely inflammatory or minimal residual tumor activity. |
Generate impression based on findings. | 64-year-old female with pain and swelling, evaluate for RA Right foot: Status post bunion surgery with orthopedic screw traversing the distal first metatarsal. An additional screw is noted at the head of the second metatarsal. No acute fracture or malalignment is evident. No osseous erosions. Mild degenerative disease ... | No specific evidence of rheumatoid arthritis. Post surgical changes of bilateral bunion surgery as described above. |
Generate impression based on findings. | 16-year-old male status post biopsy of proximal humerus lesion and bone graftingVIEWS: 2 views of the right shoulder Packing of lytic bone lesion in the proximal humeral metaphysis and epiphysis with bone graft. Mild cortical irregularity along the humeral metaphysis likely represent a minimally displaced fracture. | Packing of proximal humeral lytic bone lesion with bone graft as described above. Minimally displaced pathologic fracture. |
Generate impression based on findings. | 42-year-old female with fall No acute fracture or malalignment is evident. No joint effusion. | No acute fracture or malalignment is evident. |
Generate impression based on findings. | 27-year-old male with laceration to the hand with glass, evaluate for foreign body or fracture Laceration is noted along the ulnar surface of the fifth PIP joint and at the third/fourth interdigital folds. No acute fracture or malalignment is evident. No radiopaque foreign body is seen. | No radiopaque foreign body, fracture, or malalignment is evident. |
Generate impression based on findings. | 43-year-old female with bilateral hip pain Severe osteoarthritis affects bilateral hips with femoral head deformities and large bulky osteophytes. No acute fracture or malalignment is evident.Right knee: Two nonweightbearing views demonstrate moderate tricompartmental osteoarthritis affects the right knee with joint sp... | Severe osteoarthritis as described above. |
Generate impression based on findings. | Metastatic breast cancer. There is overall stable to increased size of the extensive infiltrative and necrotic lymphadenopathy in the neck and partially-imaged mediastinum. For example, a right level 5 lymph node measures 39 x 31 mm, previously 36 x 30 mm and a left level 5 lymph node measures 34 x 28 mm, previously 34... | 1. Overall stable to slight increase in size of the extensive lymphadenopathy in the neck and partially-imaged mediastinum. 2. New thrombosis of the superior right internal jugular vein. |
Generate impression based on findings. | History of left upper tract urothelial carcinoma status post left nephrectomy with high-grade bladder cancer now with suspicious left upper quadrant nodule on CT.RADIOPHARMACEUTICAL: 12.0 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 87 mg/dL. Today's CT portion grossly demonstrates chronic appearing bilat... | 1.Subcentimeter hypermetabolic focus in the right prostate is nonspecific and can represent inflammatory or neoplastic etiologies. Correlate clinically as to the need for further evaluation such as with MRI.2.Otherwise no suspicious FDG avid lesion to indicate tumor activity currently in the neck, chest, abdomen or pel... |
Generate impression based on findings. | 76 year old man with mitral valve disease referred for evaluation of cardiovascular structures prior to possible robotic surgery.CPT: 75572 Aorta. There is a left sided aortic arch with a pseudo-bovine brachiocephalic branching pattern. No thoracic aortic dissection or aneurysm is noted. The thoracic aorta has no signi... | 1.Normal aortic anatomy with mild calcification. 2.Severe circumferential mitral annular calcification extending onto the anterior leaflet and aorto-mitral continuity. 3. Evidence of mitral valve leaflet thickening and systolic anterior motion of the leaflets resulting in a likely "fibrous" contact point in the LVOT. 4... |
Generate impression based on findings. | Female 40 years old; Reason: Crohn's complication? History: severe abd pain, diffuse tender, h/o Crohn's ABDOMEN:LUNG BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Cholelithiasis. SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormali... | 1.Inflammation of the distal ileum which would be compatible with enteritis secondary to provided history of Crohn's disease with suspicion for enteroenteric fistula. There is a partial small bowel obstruction. There is no drainable fluid collection.2.Cholelithiasis. |
Generate impression based on findings. | Clinical question: Rule out worsening intracranial hemorrhage. Signs and symptoms: Headache and recent brain surgery. Nonenhanced head CT:Examination demonstrates interval decreased pneumocephalus since prior exam. Residual epidural air and fluid confined under the craniotomy flap is noted. Small amount of residual air... | 1.Interval improvement of postoperative changes.2.No evidence of new hemorrhage or increased edema/mass effect. |
Generate impression based on findings. | Post right frontal craniotomy follow-up There is evidence of right frontal craniotomy weight right frontal edema on the site of prior surgery. However, there is no definitive mass lesion on this scan.There is no evidence of acute ischemic or hemorrhagic lesion. There is no midline shift.Focal encephalomalacia seen on t... | Post craniotomy follow-up CT scan shows right frontal lobe edema without definitive mass lesion. Brain MRI can be considered for further imaging evaluation.No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | Clinical question: Slurred speech and dragging left lower extremity since before 09 today. Signs and symptoms: As above. Nonenhanced head CT:No detectable acute intracranial hemorrhage, edema, mass effect, midline shift or hydrocephalus. CT however is insensitive for early detection of acute nonhemorrhagic ischemic str... | Extensive age-indeterminate small vessel ischemic strokes. |
Generate impression based on findings. | Clinical question: Concern for stroke versus hemorrhage versus edema. Signs and symptoms: Acute alteration of mental status. Nonenhanced head CT:There is no evidence of acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Minimal periventricular low attenuat... | 1.No acute intracranial process.2.Findings suggestive of mild age-indeterminate small vessel ischemic strokes. |
Generate impression based on findings. | Clinical question: Status post pituitary surgery. Signs and symptoms: Transsphenoidal surgery for pituitary microadenoma, right eye blurry vision. Nonenhanced head CT:Examination demonstrates expected post operative changes of transsphenoidal hypophysectomy. There is no intracranial postprocedural pneumocephalus or hem... | 1.No evidence of an acute intracranial process.2.Expected postoperative changes of transsphenoidal hypophysectomy.3.Residual pituitary macroadenoma in the sella on the left and the left basal cistern is detected. |
Generate impression based on findings. | altered mental status No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The osseous structures ar... | No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | altered mental status There is left PCA territorial encephalomalacia indicating prior ischemic infarction.However, there is no evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are unremarkable. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acut... | Left PCA chronic ischemic infarction with encephalomalacia.No acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | Clinical question: 56 year old female of nifedipine 2 days ago, now with hypertension, blurry vision, headache and dizziness, assess for hypertensive emergency/urgency. Signs and symptoms: Hypertension, blurry vision headache and dizziness. Nonenhanced head CT:There is no detectable acute intracranial process. CT howev... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | dizziness. NONCONTRAST CT HEADNo evidence of acute ischemic or hemorrhagic lesion on this scan.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The ... | 1. No evidence of acute ischemic or hemorrhagic lesion.2. Normal head and neck CT angiography |
Generate impression based on findings. | Female 57 years old; Reason: r/o abscess History: 2wk post op chole, vomiting abd pain fevers ABDOMEN:LUNG BASES: Calcified hilar and mediastinal lymphadenopathy is incompletely imaged. Right lower lobe calcified granuloma.LIVER, BILIARY TRACT: Cholecystectomy clips noted. There is extrahepatic biliary duct dilatation ... | 1.No evidence of intra-abdominal abscess or other findings to explain patient's symptoms.2.Diverticular disease without CT evidence of diverticulitis. |
Generate impression based on findings. | Clinical question: Rule out mass. Signs and symptoms: Increasing headache, tactile hallucination. Nonenhanced head CT:Examination demonstrates mild ectopia of cerebellar tonsils at the level of foramen magnum with subtle flattening deformity of the tonsils.There is no detectable acute intracranial hemorrhage, mass effe... | 1.No acute intracranial process.2.Mildly ectopic cerebellar tonsils with subtle flattening deformity.3.Unremarkable exam otherwise. Considering provided clinical information follow up with an MRI and CSF flow study is recommended. |
Generate impression based on findings. | Male 8 years old Reason: r/o effusion, fracture, dislocation History: left knee pain after twistingVIEWS: Left knee AP, lateral and oblique 5/5/2015 (3 views) Joint effusion with no fracture or malalignment. | Left knee joint effusion with no fracture. |
Generate impression based on findings. | Hand pain. Fracture? I see no acute fracture. Moderate osteoarthritic changes affect the hand and wrist. There is calcification of the triangular fibrocartilage, and cysts within multiple bones may reflect superimposed CPPD arthropathy. | Arthritic changes without fracture evident. |
Generate impression based on findings. | 78 year old female with diagnosis of HHT, SOB, pulmonary hypertension. Evaluate for pulmonary AVM's. LUNGS AND PLEURA: No evidence of pulmonary AVM's. Right upper lobe 4 mm micronodule unchanged most likely a benign intrapulmonary lymph node. Bibasilar scarring. No pleural effusion or pneumothorax. MEDIASTINUM AND HILA... | No evidence of pulmonary arteriovenous malformations. |
Generate impression based on findings. | Left upper extremity painVIEWS: Left forearm AP and lateral and left wrist AP, lateral and oblique 5/5/2015 (5 views) There is no evidence of fracture, malalignment, joint effusion or soft tissue swelling. | Normal examination. |
Generate impression based on findings. | Male 65 years old; Reason: to assess for stones in the bladder, native kidneys, or graft kidney; this will also assess for anatomic anomalies that might be causing the recurrent infections History: to assess for stones in the bladder, native kidneys, or graft kidney; this will also assess for anatomic anomalies that mi... | 1.Atrophic native kidneys, incompletely characterized on this noncontrast study with punctate nonobstructing calculus in the left native kidney. No specific cause for patient's recurrent infections is identified.2.Cholelithiasis. |
Generate impression based on findings. | Male 7 years old Reason: 7 yo attacked by pitbull this PM, right arm pain and limited ROM History: limited ROM, painVIEWS: Right forearm and arm AP, lateral and oblique 5/5/2015 (4 views) There is no evidence of fracture or malalignment. Subcutaneous emphysema around the soft tissues of the right elbow are consistent w... | Subcutaneous emphysema with no fracture or malalignment. No radiopaque foreign body |
Generate impression based on findings. | Status post fracture.VIEWS: Left wrist AP and lateral 5/5/2015 at 2127 hours. (2 views) Interval alignment and casting of distal both left forearm bones fractures. | Anatomic alignment after casting of left forearm fractures. |
Generate impression based on findings. | follow up after right frontal ICH evacuation Redemonstration of the right frontal craniotomy and air densities within the right frontal ICH, no change since prior exam.Minimal midline shift and local mass effects are again do not show any interval change since prior exam.Minimal IVH also appears to be stable.There is n... | Post right frontal ICH evacuation status, no change in terms of local mass effects and minimal midline shift since prior exam.No evidence of new ischemic or hemorrhagic lesion. |
Generate impression based on findings. | Female, 26 years old. Reason: Assess free air and obstructive gas pattern History: LLQ pain, constipation Nonobstructive bowel gas pattern. Below average stool burden.No free air seen on upright imaging.Retained enteric contrast material within the colon from recent prior examination. | Nonobstructive bowel gas pattern. No free air. |
Generate impression based on findings. | Pain and swelling.VIEWS: Left shoulder internal/external rotation (two views) 05/05/15 The humeral head is well directed to the glenoid fossa. No fracture is present. | Normal examination. |
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