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Generate impression based on findings. | Male 66 years old; Reason: evaluate for lymphedema History: edema to bilateral legs. Bilateral lower leg surgeries.RADIOPHARMACEUTICAL: The bilateral feet, specifically the web spaces between the first-second and second-third digits of both feet were prepared in a sterile manner. 2 syringes were prepared each containin... | 1.Regional fairly symmetric obstruction to lymphatic flow below the knees bilaterally, most prominently along the medial aspects of the proximal tibial levels.2.No evidence of lymphatic obstruction proximal to the knees. |
Generate impression based on findings. | 58 year-old female with history of right fifth toe pain. There is a minimally displaced comminuted fracture through the fifth proximal phalanx extending to the articular surface with mild dorsal angulation of the distal fracture fragment. Mild callus formation indicates healing. There is mild soft tissue swelling about... | Healing fifth toe fracture as above. |
Generate impression based on findings. | Male; 73 years old. Reason: r/o metastases, questionable HCC, History: 8mm by 8mm nodule left posterior costophrenic angle series on recent scan, please evaluate, Cirrhosis, questionable HCC LUNGS AND PLEURA: No focal air space opacities. 12-mm nodule in the left posteromedial costophrenic angle (image 91, series 5), s... | No evidence of metastatic disease in the chest, left lower lobe nodule unchanged for nearly two years. |
Generate impression based on findings. | 45-year-old female with history of pain. Left knee: There are tricompartmental osteophytes, subchondral cyst formation, and joint space narrowing worse in the medial compartment compatible with moderate to severe osteoarthritis. There is no evidence of acute fracture or dislocation. There is a small joint effusion.Righ... | Osteoarthritis as above. |
Generate impression based on findings. | Reason: Hx Larynx CA S/P CRT compare to previous scans, measurements please. History: none CHEST:LUNGS AND PLEURA: Stable 5-mm nodule in the right lower lobe compatible with a lymph node, unchanged and scattered micronodules elsewhere, also unchanged.No suspicious nodules.Consolidation and atelectasis in the right midd... | 1. Increased opacities in the right middle lobe and right lower lobe consistent with recurrent aspiration.2. No specific evidence of metastatic disease. |
Generate impression based on findings. | 62-year-old female with history of seronegative arthropathy and DIP swelling. Left hand: There is no evidence of bony erosions. Mild degenerative disease affects the second DIP. No acute fractures. The soft tissues are unremarkable.Right hand: There is no evidence of acute bony erosions. There are tiny lucencies with s... | No evidence of acute osseous erosions. Other findings as above. |
Generate impression based on findings. | Female, 59 years old.RFO No RFO is identified. Scattered surgical clips noted. No obstructive bowel gas pattern. | No RFO is identified. Postsurgical changes. Finding discussed with Dr. Yamada at the time of dictation. |
Generate impression based on findings. | 61-year-old male with left elbow pain, rule out fracture Mild osteoarthritis affects the elbow. No fracture or joint effusion is evident. | Mild osteoarthritis without evidence of fracture. |
Generate impression based on findings. | Male; 60 years old. Reason: eval for lymphadenopathy History: night sweats LUNGS AND PLEURA: No focal pulmonary opacities. No suspicious pulmonary or masses. No pleural effusions.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Normal heart size without pericardial effusion. Severe atherosclerotic calcifi... | Severe coronary artery atherosclerotic calcifications, otherwise unremarkable examination. |
Generate impression based on findings. | 79-year-old female with pain, preoperative evaluation There is approximately 6 degrees valgus deformity of the knee relative to the neutral mechanical axis. Moderate to severe osteo arthritis affects the knee. | Osteoarthritis and valgus deformity. |
Generate impression based on findings. | 58 years, Female. Reason: r/o SBO, constipation History: RUQ and RLQ ab pain/tenderness, no BM x2 weeks Nonobstructive bowel gas pattern. No definite evidence of free air. Moderate stool burden. | Nonobstructive bowel gas pattern. No definite evidence of free air. Moderate stool burden. |
Generate impression based on findings. | 73-year-old female with history of fall, right leg pain Small osteophytes are present along the anterior vertebral bodies as well as mild degenerative disk disease affecting L3/4 and L4/5. Vertebral body heights are maintained. There is a mild rightward curvature of the lumbar spine. Right upper quadrant surgical clips... | Mild degenerative changes without fracture. |
Generate impression based on findings. | Male; 63 years old. Reason: Hx lung CA, status post chemo. Pls compare to previous and measurements pls. History: none CHEST:LUNGS AND PLEURA: Mildly decreased size of the mass in the anterior segment of the right upper lobe with chest wall and mediastinal invasion, which measures 38 x 26 mm, previously 45mm x 34mm (im... | 1. Mildly decreased right upper lobe mass and right hilar nodule or conglomeration of nodules. 2. Stable left upper lobe partly cystic lesion and multiple additional small ground glass and solid nodules.3. No evidence of metastatic disease in the abdomen. |
Generate impression based on findings. | 65-year-old male with lumbar back pain with radiation to left greater than right lower extremity Multilevel degenerative disk disease most severely affecting L3/4, L4/5 and L5/1. There small anterior vertebral body osteophytes and mild to moderate facet joint osteoarthritis. | Degenerative arthritic changes as described above. |
Generate impression based on findings. | Ms. Kaba is a 53 year old female with a personal history of left excisional biopsy in Dec 2006for diabetic mastopathy and history of right breast biopsy for hyalinized fibrous tissue in Oct 2007. Family history of breast carcinoma in maternal aunt. Three standard views of both breasts along with four magnification view... | Two clusters of high probability benign calcifications in the left breast. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended in 6 months to ensure stability of these calcifications. Results and recommendation were discussed with the patient.BIRADS: 3 - Pro... |
Generate impression based on findings. | 87 year-old male with history of fifth metacarpal fracture Deformity of the base of the fifth metacarpal is again visualized consistent with a nondisplaced fracture. The fracture line is indistinct, suggesting some interval healing. No additional fractures are noted. | Nondisplaced fifth metacarpal fracture as described above. |
Generate impression based on findings. | Reason: pulm lesion seen on CT a/p, needs f/u History: pt has no pulm symptoms LUNGS AND PLEURA: Rounded, smoothly marginated soft tissue nodule in the lingula contiguous with the left cardiac border measuring 14 x 15 mm, unchanged since the previous scan from more than two months ago. No reliable evidence of fat or ca... | Stable 15 mm soft tissue nodule in the lingula with morphology suggestive of a benign etiology such as hamartoma. If previous outside CT scans can be obtained to demonstrate stability, no further follow-up may be required.Otherwise, a follow-up CT examination is recommended in approximately 9 to 12 months to confirm st... |
Generate impression based on findings. | 61-year-old female with ongoing pain in the setting of patellofemoral syndrome, pain and bony prominence at base of left thumb evaluate for degenerative joint disease, spur or tendinitis Hand: Mild osteoarthritis affects the basilar joint. Alignment is anatomic. No discrete soft tissue abnormality is noted.Knees: Four ... | Mild basilar joint osteoarthritis and normal appearing knees. |
Generate impression based on findings. | 77-year-old female, evaluate fracture A side plate with screws including two syndesmotic screws affixes a distal fibular fracture in near-anatomic alignment without evidence of complication. A healing posterior malleolus fracture is noted. The bones are demineralized. | Orthopedic fixation and ankle fractures as described above without evidence of complication. |
Generate impression based on findings. | 45 year old female with history of JIA. Left foot: There is mild osteoarthritis affecting the midfoot. Moderate degenerative changes affects the tibiotalar joint.Left ankle: There are deformities of the distal fibula and tibial diaphyses compatible with healed fractures. Moderate osteoarthritis affects the tibiotalar j... | Postsurgical changes and degenerative disease as above. |
Generate impression based on findings. | Again seen are postoperative changes from laminectomies involving C6 to T3. There is redemonstration of a circumscribed area of CSF signal intensity along the dorsal aspect of the cord likely relating to the surgical cavity, extending from C5-C6 through T3-T4. 2 mm focus of enhancement at the left T1-2 level (axial po... | 1. Stable postoperative changes of cervicothoracic ganglioglioma resection. No definite evidence of residual or recurrent tumor. 2 mm nodular focus of enhancement in the surgical bed at the left T1-T2 level is unchanged since 12/26/2013 and may be postsurgical. Recommend continued attention on follow-up.2. Stable focal... |
Generate impression based on findings. | 70 year-old female with knee and left hip pain Mild osteoarthritis affects the left hip. Degenerative arthritic changes affect the visualized lower lumbar spine.Moderate osteoarthritis affects the right knee, particularly the patellofemoral joint. | Osteoarthritis as described above. |
Generate impression based on findings. | 35-year-old male with right leg pain Femur: An intramedullary rod affixes a mid diaphyseal fracture. The proximal interlocking screw is intact, but the two distal interlocking screws are fractured. There is extensive callus formation about the mid diaphyseal fracture indicating attempted healing.Knee: The distal aspect... | Orthopedic fixation of femoral and tibial fractures as described above with fractured distal interlocking femoral screws. |
Generate impression based on findings. | Exam is limited due to streak artifact from the surrounding stereotactic frame. The previously identified electrodes have all been removed, with remaining burr holes. Focal abnormal low density is seen in right greater than left occipital lobes and right frontal lobe relating to previous electrode tracts. There are mi... | 1. Interval removal of depth electrodes with placement of a right parietal occipital region approach laser fiber placement with tip in the mesial right temporal lobe.2. Trace left greater than right subdural presumed postprocedural blood products.3. Areas of abnormal low density within the brain periphery in areas of p... |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is almost entirely fatty, unchanged in pattern and distribution. Scattered benign calcifications are seen in the left breast. No suspic... | 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. | T3N2c HPV+ left tonsillar squamous cell carcinoma on OPTIMA trial. Head: There is no evidence of intracranial mass or abnormal enhancment. The ventricles are unchanged in size and configuration. There is no midline shift or herniation. There is partial opacification of the maxillary sinuses with suggestion of air-fluid... | 1. Interval decrease in size of the left palatine tonsillar mass, indicating treatment response.2. No evidence of significant cervical lymphadenopathy.3. No evidence of intracranial metastases.4. Nonspecific bilateral thyroid nodules.5. Suggestion of acute sinusitis. |
Generate impression based on findings. | Reason: head and neck cancer/ post induction scans History: see above CHEST:LUNGS AND PLEURA: No evidence of pulmonary or pleural metastases, or other significant pulmonary abnormality. MEDIASTINUM AND HILA: There is no mediastinal or hilar lymphadenopathy.Mild coronary calcifications are present, the heart and pericar... | No evidence of metastases, or other significant abnormality. |
Generate impression based on findings. | 13-year-old female with ankle painVIEWS: Right ankle AP, oblique, lateral (3 views) and right tibia-fibula, AP/lateral (two views) 01/15/15 No acute fracture or malalignment is evident. Minimal soft tissue swelling over the lateral malleolus. | Minimal soft tissue swelling without evidence of acute fracture or malalignment |
Generate impression based on findings. | Male 32 years old; Reason: H/o DLBCL s/p chemotherapy. Now returns 6 months later. Will consider to be initial staging for lymphoma History: RUQ pain, fatigue, night sweats, fevers, weight lossRADIOPHARMACEUTICAL: 15 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 92 mg/dL. Today's CT portion grossly demonst... | 1.Interval resolution of the right perihilar tumor focus with near complete resolution of the tumor foci in the liver without new significantly FDG avid activity noted. Region of mild FDG activity in the medial left lobe may reflect mild residual tumor vs. inflammation. 2.Mild, slightly increased FDG activity involving... |
Generate impression based on findings. | 40 year-old female, history of proximal forearm fracture There is a comminuted intra-articular radial head fracture with approximately 1 mm cortical step off and mild impaction of the fracture fragment. A joint effusion is noted. The ulna appears intact. | Intra-articular radial head fracture as described above. |
Generate impression based on findings. | 54-year-old male with dysphagia, weight loss. New diagnosis of distal esophageal cancer. Esophageal stent recently placed and removed yesterday.RADIOPHARMACEUTICAL: 7.094 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 52 mg/dL. Today's CT portion grossly demonstrates a large, circumferential distal esophage... | 1.Markedly hypermetabolic distal esophageal soft tissue mass, consistent with known esophageal carcinoma.2.Numerous markedly hypermetabolic thoracic and abdominal lymph nodes extending from the level of the carina to 4 cm above the aortic bifurcation, consistent with regional lymph node metastases.3.Additional right up... |
Generate impression based on findings. | Reason: Patient with hx of SCCA of the left buccal mucosa. Treated with CRt, then had ORN. S/P resection and flap reconstruction. Neck tightness and dysphagia History: Patient with hx of SCCA of the left buccal mucosa. Treated with CRt, then had ORN. S/P resection and flap reconstruction. Neck tightness and dysphagia L... | 1. No evidence of metastases or other significant abnormality.2. Severe native coronary artery calcifications, status post CABG.3. Stable basilar bronchial wall thickening with bronchiectasis. |
Generate impression based on findings. | 34-year-old male, evaluate for osteomyelitis of second metatarsal and second proximal phalanx Interval decrease in soft tissue swelling. The previously noted periosteal reaction involving the proximal phalanges of the second and third toes has resolved. There is no osteolysis or other evidence of osteomyelitis. | No evidence of osteomyelitis. |
Generate impression based on findings. | 58-year-old female with history of pain. Left knee: There are tricompartmental osteophytes and joint space narrowing worse in the medial compartment with near bone-on-bone apposition compatible with moderate to severe osteoarthritis. There is a mild varus deformity. There are scattered arterial calcifications.Right kne... | Severe degenerative arthritic changes and other findings as above. |
Generate impression based on findings. | Reason: pulmonary nodule eval History: pulmonary nodule seen on liver CT LUNGS AND PLEURA: 6-mm nodule noted within the superior segment of the left lower lobe (image 33 series 4).Micronodule identified within the right middle lobe (image 59 series 4).6-mm subpleural nodule identified posteriorly in the right lower lob... | Several nonspecific pulmonary nodules and micronodules. In the absence of a known primary neoplasm these most likely are postinflammatory. However, follow up examination in 6 months to one year is recommended. |
Generate impression based on findings. | 50 year-old female with history of multiple call backs from screening examinations presents for routine annual mammogram. No current breast related complaints. No family history of breast cancer. Family history of breast carcinoma in her mother at age 61. Three standard views of both breasts and a spot compression view... | 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: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Male; 56 years old. Reason: re-assess interval improvement of loculated empyema, with pigtail catheter History: SOB LUNGS AND PLEURA: Small loculated right pleural effusion has mildly decreased since prior, particularly at the posterior costophrenic angle. Scattered small locules in the posterior right mid lung are not... | 1. New left lower lobe and right middle lobe opacities suggestive of aspiration or infectious bronchiolitis.2. Small loculated right pleural effusion has mildly decreased since prior study status post Pleurx catheter placement.3. Severe emphysema. |
Generate impression based on findings. | Frontal sinus: The frontal sinuses are developmentally diminutive. There is trace mucosal thickening in the frontoethmoidal recesses.Anterior ethmoids: There is moderate patchy opacification of anterior ethmoid air cells.Maxillary sinuses: There is mild mucosal thickening in both maxillary sinuses. The right ostiomeat... | 1. Mild-moderate scattered paranasal sinus disease as detailed above, with opacification of the left sphenoethmoidal recess and ostiomeatal unit.2. No significant polyploid abnormality identified within the nasal cavity. Nasal turbinates are relatively well visualized, with only minimal nonspecific density noted abutti... |
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 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 distributio... | 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. | 17 year old, with sudden onset chest pain, evaluate for thorax.VIEWS: Chest AP/lateral (two views) 1/15/2015 No pneumothorax, pleural effusion or displaced rib fractures evident. No focal air space opacity. The aortic arch, cardiac apex the stomach a left-sided. Cardiothymic silhouette is normal. | Normal examination. |
Generate impression based on findings. | Postoperative changes are again seen from previous anterior surgical fusion of C5 and C6. Resultant susceptibility artifact limits evaluation of surrounding structures. The cervical spine is in normal alignment, with straightening of the normal cervical lordosis. The vertebral body are well-maintained. There is mild t... | Postoperative changes from previous C5-C6 fusion. No significant interval change in minimal spondylotic changes at C4-C5 and C6-C7, except for possible mild interval progression of a left paracentral component of disk protrusion at C6-C7. Indentation of the ventral thecal sac and ventral cord at C6-C7 in the right para... |
Generate impression based on findings. | Female; 72 years old. Reason: follow up post radiation treatment History: follow up CHEST:LUNGS AND PLEURA: No significant interval change. Postsurgical changes status post right lower and left upper lobectomy. Radiation fibrosis in the right paramediastinal region is unchanged. Scattered nonspecific micronodules are a... | No evidence of metastatic disease or significant interval change. |
Generate impression based on findings. | 5 lumbar-type vertebral bodies are designated for numbering purposes. The bone marrow signal intensity is unremarkable throughout. There is low termination of the cord at the L3-L4 level appearing similar to the prior exam. Again seen are adhesions including at the surgical site at of lower cord/neural placode to the ... | Again seen is evidence of prior lipomyelomeningocele repair and cord untethering. Again seen is termination of cord at L3-L4 level with adhesions/arachnoiditis involving the cauda equina nerve roots. No anterior motion of the distal cord or cauda equina is seen on the prone sequence. Enhancing tissue at the L5-S1 level... |
Generate impression based on findings. | Brain injury, 3 month follow up. There is extensive encephalomalacia in the right cerebral hemisphere with associated Wallerian degeneration and ex vacuo dilation of the right lateral ventricle. There is no evidence of acute intracranial hemorrhage or mass. There is no significant midline shift or herniation. The image... | 1. Extensive right cerebral hemisphere encephalomalacia related to prior hemorrhage and infarction.2. Suggestion of sinonasal polyposis. |
Generate impression based on findings. | 13 year old female with chest pain and dysphagia evaluate for pneumomediastinum.VIEWS: Chest AP/lateral (two views) 1/15/2015 No focal air space opacities seen. No pneumothorax or displaced rib fracture is evident. There is no evidence of pneumomediastinum. | Normal examination. |
Generate impression based on findings. | Reason: pulmonary nodule on recent chest CT, and enlarged hilar LN History: asymptomatic LUNGS AND PLEURA: Interval clearing of the right middle lobe subsegmental atelectasis.Persistent elevation of the right hemidiaphragm.5-mm groundglass nodule in the superior segment left lower lobe is almost completely resolved and... | Interval resolution of right middle lobe subsegmental atelectasis and near resolution of a left lower lobe ground glass nodule which most likely was inflammatory in origin. |
Generate impression based on findings. | 27-year-old female with history of chronic diarrhea and fat malabsorption with history of prolonged travel to the tropic. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: Normal parenchyma without atrophy. Pancrea... | No abnormality seen to account for patient's symptomatology. |
Generate impression based on findings. | 83-year-old male with history of right lower back pain. Lumbar spine: There is moderate to severe degenerative disc disease affecting the lumbar spine. There is a grade 1 anterolisthesis of L4 on L5. There is moderate facet hypertrophy. There is a mild dextroscoliosis. Scattered arterial calcifications are present.Left... | Degenerative arthritic changes as above. |
Generate impression based on findings. | 88-year-old female with abdominal pain status post Gram patch for perforated duodenal ulcer, January 10, 2015. ABDOMEN:LUNG BASES: Marked cardiomegaly seen. Right pleural effusion and atelectasis with milder left basilar atelectasis.LIVER, BILIARY TRACT: Heterogeneous parenchymal enhancement pattern with dilated hepati... | 1. Postoperative changes about the duodenum with small, 2.5-cm fluid collection in hepatoduodenal ligament without other associated signs to suggest infection, although CT cannot definitively characterize fluid collections. 2. Small amount of ascites about the liver with several foci of pneumoperitoneum, two levels see... |
Generate impression based on findings. | 55 year old female with history of left rib pain. Radiopaque skin markers overlie the left rib cage. There is no evidence of displaced rib fracture. There are surgical clips in the left axilla and chest wall. Scattered tiny radiopaque fragments project over the abdomen. | No evidence of displaced rib fracture. |
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. No suspicious masses, microcalcifications or areas of architectural distortion are pre... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is 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: 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. There has been interval decrease in size of the... | 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. | 13 year old female, evaluate for scoliosis.VIEWS: Thoracolumbar spine AP and lateral (two views) 1/15/2015 There is 56 degrees of levoscoliosis between L1 and T8, and 26 degrees of dextroscoliosis between T7 and T2. Postoperative changes related to resection of the spinous processes of L3 through L5 and L4 laminectomy ... | 1.Scoliosis as above.2.Postoperative changes of the lumbar spine. |
Generate impression based on findings. | 100-year-old female with history of elbow fracture. The bones are demineralized. Redemonstrated is a displaced supracondylar fracture with medial displacement of the distal fracture fragment without significant interval change. The radiocapitellar and ulnar-trochlear articulations are maintained. | Distal humerus fracture without significant interval change. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Family history breast carcinoma in her sister at age 64. 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 dist... | 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 with tomosynthesis and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. An asymmetry is present with... | Left breast asymmetry. Further evaluation with spot compression views, and ultrasound if necessary, is recommended.BIRADS: 0 - INCOMPLETE; Need additional imaging evaluationRECOMMENDATION: EB - Additional Mammo/Ultrasound Workup Required. |
Generate impression based on findings. | Reason: eval for small bowel mass or AVM History: chronic iron def anemia, EGD and colonoscopy negative ABDOMEN:LUNG BASES: Intrathoracic stomach results in left lower lobe atelectasis and volume loss.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant ... | Intrathoracic stomach and findings consistent with mesentero-axial gastric volvulus. |
Generate impression based on findings. | 57-year-old male with history of knee pain. There are tricompartmental osteophytes, subchondral cyst formation, and joint space narrowing worse in the lateral compartment compatible with severe osteoarthritis. There is a mild valgus deformity. No evidence of acute fracture. Severe osteoarthritis affects the left knee a... | Severe osteoarthritis as above. |
Generate impression based on findings. | 42-year-old male status post left total hip arthroplasty Hardware components of a total left hip arthroplasty device are situated in near-anatomic alignment without evidence of complication. A drain and foci of gas in the soft tissues reflect recent surgery. | THA without evidence of complication. |
Generate impression based on findings. | Seven month old male status post ETT repositioning.VIEW: Chest AP (one view) 1/15/2015, 15:10 Endotracheal tube tip in the proximal right mainstem bronchus. Nasogastric tube with tip in the body of the stomach. New complete left upper lobe collapse secondary to endotracheal tube positioning. Additional right-sided atel... | Right mainstem intubation with complete left upper lobe collapse. |
Generate impression based on findings. | 65-year-old female with pain and lateral elbow swelling There is minimal osteoarthritis affecting the elbow. No effusion or fracture is evident. | Minimal osteoarthritis without joint effusion or fracture. |
Generate impression based on findings. | 23 year-old female, pain, with weight-bearing Alignment is anatomic. No fracture is evident. | No fracture or malalignment. |
Generate impression based on findings. | Male 77 years old Reason: restaging CT stomach cancer recurrent in liver, evaluate interval change prior to starting palliative chemotherapy. History: none CHEST:LUNGS AND PLEURA: Stable8mm groundglass nodule in the left upper lobe. Stable calcified micronodules. Fibrotic changes in the lung bases are unchanged.MEDIAST... | Slight interval increase in the size of hepatic lesion. |
Generate impression based on findings. | 57 year-old female, evaluate for shoulder dislocation Severe degenerative changes affect the glenohumeral joint with remodeling of the glenoid appearing similar to prior exams. A large joint effusion is noted containing calcific debris within the axillary recess. There is a cortical defect or erosion along the inferior... | 1. Severe glenohumeral osteoarthritis as described above without acute dislocation.2. Cortical defect involving the inferior humeral head may represent erosion or possible small cortical fracture.3. Moderate glenohumeral joint effusion.4. Large right pleural effusion.5. Anasarca. |
Generate impression based on findings. | As demonstrated by recent ultrasound there is severe enlargement of the right greater than left air gland, including the isthmus. This is due to the presence of numerous masses which are heterogeneous in appearance and better delineated on ultrasound. There are few punctate calcifications as well as areas of more foca... | Large heterogeneous multinodular thyroid goiter. Associated mass effect upon the patent airway, with tracheal deviation to the left. |
Generate impression based on findings. | Neuroendocrine carcinoma of the lung,establish baseline prior to new systemic therapy. Head: There are postsurgical changes of prior right frontoparietal craniotomy. There is area of nodular enhancement involving the right posterior frontal lobe precentral gyrus measuring 15x12 mm in the axial plane. There is surroundi... | 1. Abnormal enhancement involving the right posterior frontal lobe which may represent sequela of prior treatment versus residual tumor. No prior CT or MRI studies of the brain are available for comparison. Otherwise no other mass or mass effect is seen in the remainder of the brain. 2. No definite evidence of osseous ... |
Generate impression based on findings. | Male, 66 years old, history of metastatic prostate cancer to the bone, now with new left sided swelling and numbness along the jaw line. Evaluation of the visualized soft tissue structures of the neck is within normal limits. No evidence of significant stranding, soft tissue thickening or fluid is detected. No patholog... | 1. The mandible is intact with no evidence of fracture or lytic lesion. Sclerosis is seen compatible with metastatic disease within the mandibular condyles, right side more than left, and perhaps the mandibular rami.2. Sclerosis compatible with metastatic disease is evident within the greater and lesser sphenoid wings ... |
Generate impression based on findings. | 63 year old female status post lumpectomy right for carcinoma in 2009 followed by radiation therapy, presents today for routine follow up. No current breast complaints. Family history of breast carcinoma in her maternal grandmother. Three standard views of both breasts with additional left CC and MLO views were perform... | Stable postsurgical changes of the right 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 - Diagno... |
Generate impression based on findings. | 3-year-old male with elevated IgE, evaluate for possible pneumatoceleVIEWS: Chest AP/lateral (two views) 01/15/15 Cardiothymic silhouette is normal. No pleural effusion or pneumothorax. No focal pulmonary opacities. Mild peribronchial cuffing suggestive of reactive airway disease/bronchiolitis pattern. | Reactive airway disease/bronchiolitis pattern. |
Generate impression based on findings. | 58 years, Female. Reason: check if contrast still in GI tract History: study with contrast on 1/11/15, needs to be clear for next test Nonobstructive bowel gas pattern. Moderate stool burden. No retained contrast noted in the bowels. Cholecystectomy clips noted. | Nonobstructive bowel gas pattern. No retained contrast. |
Generate impression based on findings. | Patient with squamous cell carcinoma of the left buccal mucosa treated with chemoradiotherapy, then osteoradionecrosis, status post resection and flap reconstruction. There are post-treatment findings in the neck, including partial left mandibulectomy and flap reconstruction. There is osteolysis of the remaining left m... | Extensive post-treatment findings in the neck with osteolysis of the remaining left mandibular ramus and left maxillary alveolus is compatible with osteoradionecrosis, although superimposed infection or underlying neoplasm cannot be entirely excluded based on imaging alone. Associated loosening of the mandibular surgic... |
Generate impression based on findings. | Female 91 years old Reason: 2 year BL hx knee pain, eval OA History: same Right knee: Bone mineralization is decreased. Moderate to severe osteoarthritis affects the right knee worse in the lateral and extensor compartments. No acute fracture or malalignment.Left knee: Bone mineralization is decreased. Moderate to seve... | Moderate to severe bilateral knee osteoarthritis. |
Generate impression based on findings. | 63-year-old male with hip pain Mild osteoarthritis affects both hips without evidence of inflammatory arthritis. Surgical clips project over the pelvis. | Osteoarthritis without evidence of inflammatory arthritis. |
Generate impression based on findings. | 55-year-old male status post THA Hardware components of a left hip hemiarthroplasty are situated in near-anatomic alignment. Heterotopic bone formation is noted about the hip. No fracture is evident. | Left hip hemiarthroplasty as described above. |
Generate impression based on findings. | 68-year-old male with RCC, new back pain Spinal alignment is within normal limits. A left chest wall ICD is noted. Bilateral nephroureterostomy catheters extend to the pelvis. Vertebral body height is maintained. No discrete lytic lesion is identified. Mild degenerative disease affects the thoracic and lumbar spine. | Mild degenerative changes without lytic lesion visualized to indicate osseous metastasis. |
Generate impression based on findings. | Male 22 years old Reason: severe pain after basketball injury History: knee pain Surgical changes in the medial aspect of the right tibia with sideplate and screws affixing a bone graft.Portion of the medial femoral condyle has been resected. There are chronic changes in the medial tibial plateau.Moderate to severe deg... | Postsurgical changes as detailed above. |
Generate impression based on findings. | 36-year-old male, history of shoulder dislocation, now with pain There is apparent anterior dislocation of the humeral head without discrete fracture visualized. | Anterior dislocation of the humeral head. |
Generate impression based on findings. | A patient submitted outside study for review. Submitted for review are right breast ultrasound dated November 20, 2014, and screening mammogram dated November 17, 2014 performed at Methodist Hospital in Merrillville, Indiana. For comparison, screening mammogram dated September 16, 2013 is available. Bilateral Screening... | Benign appearing cluster of cysts at the 3 o'clock position of the right breast, corresponding to the mammographic finding. A 6-month follow-up ultrasound may be considered to ensure stability. BIRADS: 2 - Benign finding.RECOMMENDATION: T - Take Appropriate Action - No Letter. |
Generate impression based on findings. | Female 71 years old; Reason: RT breast cancer s/p chemo, now scheduled lumpectomy, no masses palpable-Need T-99 for SLbX procedure on 1-15-2015-patient wt =138 1bs History: Right breast cancer-surgery in DCAM 1-15-15 at 10:00 amRADIOPHARMACEUTICAL: The right breast was prepared in a sterile manner. A total of 0.476 mCi... | Successful right breast injection for intraoperative identification of sentinel lymph node. |
Generate impression based on findings. | There is mild leftward convexity of the lower lumbar spine with apex of curvature at L2-L3. There is mild left lateral translation of L4 on L5 There is 5-mm grade 1 anterolisthesis of L4 on L5. The scout lateral view and the sagittal reformatted images demonstrate the lumbar spine to be otherwise in normal alignment, ... | 1. Degenerative grade 1 anterolisthesis of L4 on L5. Uncovering of the disk with superimposed disk bulge at this level resulting in moderate-severe central spinal canal stenosis as well as moderate to severe right and moderate left foraminal narrowing.2. Additional moderate to severe right foraminal narrowing at L3-L4.... |
Generate impression based on findings. | Male 56 years old; Reason: assess blood flow without Diamox History: Strokes There is a small to medium-sized region of mild decreased perfusion involving the right posterior frontal/right anterior parietal lobes. There is a minimally decreased perfusion involving the majority of the right temporal lobe. There are no a... | Mild decreased perfusion involving the right posterior frontal and anterior parietal lobes as well as minimally decreased involving the majority of the right temporal lobe. Consider follow up exam with Diamox for evaluation of potential diminished cerebrovascular flow reserve. |
Generate impression based on findings. | Female 60 years old Reason: right knee pain History: right knee pain Severe osteoarthritis affects the right knee particularly in the lateral and extensor compartments where there is moderate to severe joint space narrowing.There are tricompartmental osteophytes.Genu valgus is suggested on the AP view. There is a small... | Severe right knee osteoarthritis. |
Generate impression based on findings. | Female; 50 years old. Reason: mets lung cancer, s/p adrenalectomy for mets. s/p cycle 34 of Nivolumab, bones mets. Pls c/w previous study and evaluate tx response. History: lung cancer CHEST:LUNGS AND PLEURA: Right apical spiculated nodule with some internal calcifications measures 11 x 10 mm (image 17/116), unchanged.... | 1. No significant change in right apical nodule.2. Other findings including subtle T5 lesion are also stable with no new sites of disease evident. |
Generate impression based on findings. | Ms. Najieb is a 53 year old female presenting for a short-term follow-up for a right breast asymmetry. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. Foca... | Stable right asymmetry and bilateral ductal ectasia. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 12 months, and if stable at that time, the patient could probably thereafter return to routine screening. Results an... |
Generate impression based on findings. | Reason: ILD, compare to 2011 History: worsening shortness of breath LUNGS AND PLEURA: Focal patchy areas with linear scar like opacities ground glass components, slightly improved from previous.Mild bilateral lower lobe bronchiectasis with associated ground glass opacity, also slightly improved.Intervening areas of the... | Patchy mainly peri-bronchovascular reticular and groundglass opacities with traction bronchiectasis but no sign of honeycombing, with slight interval improvement in the ground glass components compared to the previous examination. The pattern is nonspecific but consistent with the previous pathological diagnosis of fib... |
Generate impression based on findings. | Reason: evaluate ILD History: cough soboe fibrosis LUNGS AND PLEURA: Moderate to severe interstitial lung disease present throughout the lungs, with only a mild basilar predominance if present at all.Extensive peripheral honeycombing is present as well as subpleural reticular opacities and traction bronchiectasis.Altho... | Moderate to severe interstitial lung disease, but the pattern consistent with UIP although consideration should be given to hypersensitivity pneumonitis given the presence of a distinct mosaic attenuation pattern. |
Generate impression based on findings. | Female; 47 years old. Reason: evaluate for PE History: SOB, hypoxia PULMONARY ARTERIES: No acute pulmonary embolus. Normal caliber of the main pulmonary artery. No evidence of right heart strain.LUNGS AND PLEURA: Significant interval increase in multifocal groundglass and mixed density airspace consolidations, greatest... | 1. Marked multifocal groundglass and mixed density air space consolidations, suspicious for hemorrhage or possibly infection. 2. No acute pulmonary embolus.3. interval increased confluent mediastinal and bilateral hilar lymphadenopathy causing new marked narrowing of the bronchus intermedius.4. Numerous pulmonary metas... |
Generate impression based on findings. | 36-year-old female with relapsed Hodgkin's lymphoma in the mediastinum and right supraclavicular nodes status post XRT tear this is worse once.RADIOPHARMACEUTICAL: 14.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 86 mg/dL. Today's CT portion grossly demonstrates new bilateral paramediastinal lung densiti... | 1.Complete interval resolution of previously markedly hypermetabolic lymph nodes in the right upper thorax, without convincing FDG avid lymphoma currently. New bilateral paramediastinal pulmonary parenchymal FDG activity correlating with pulmonary opacities on CT is compatible with postradiation inflammatory changes.2.... |
Generate impression based on findings. | 66 years Female with history of seizure, rule out intracranial bleed. No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No mass, midline shift or uncal herniation. Gray-white differentiation is maintained. Sulci and ventricles are within normal limits for age, without evidence o... | No evidence of intracranial hemorrhage. Age-indeterminant small vessel ischemic changes Please note CT is insensitive for the detection of acute non-hemorrhagic infarcts, and MRI should be considered if there is continued clinical suspicion. |
Generate impression based on findings. | 35-year-old female, assess lateral calcaneal and medial cuneiform fusion A side plate and screws affix the calcaneus fracture with cystic changes and sclerosis noted about the fracture site. A single proximal screw is fractured with the screw head displaced within the lateral soft tissues. There is adjacent lateral sof... | Postoperative fixation as described above with fractured proximal calcaneal plate screw and adjacent lateral soft tissue swelling and thickening of the peroneal tendons near the displaced screw head.Sclerosis and cystic changes at the fracture line of the calcaneus. |
Generate impression based on findings. | Male 61 years old Reason: eval for gouty erosions History: gout Right hand: There is joint space narrowing at the interphalangeal joints. Findings of a possible small erosion is noted at the distal aspect of the middle phalanx of the third digit. There are multiple areas of soft tissue swelling about the metacarpophala... | Soft tissue swelling and erosive changes as detailed above. |
Generate impression based on findings. | Reason: 45 F w/ pulmonary infiltrate, immunosuppression, ?vasculitis - did it resolve History: hypoxia LUNGS AND PLEURA: Several linear and scarlike opacities are present laterally, unchanged or slightly decreased from previous.A focal area of ground glass and nodular opacities described on the previous scan in the rig... | Interval resolution of focal nodular and ground glass opacity, likely due to infection.Mild residual scarlike opacities but no sign of active disease. |
Generate impression based on findings. | 36-year-old male, assess reduction Interval shoulder reduction with the glenohumeral joint alignment now appearing anatomic. Irregularity of the inferior glenoid is suggestive of a Bankart lesion. | Reduction glenohumeral joint with humeral head now in anatomic alignment. Findings are suggestive of an associated Bankart lesion, consider follow up dedicated imaging. |
Generate impression based on findings. | Reason: 63f, cachexia, hx of pacreatitismelena with ulcer but no active upper gib, assess for malignancy History: melena, weight loss ABDOMEN:LUNG BASES: Subsegmental scarring/atelectasis in the lung bases.LIVER, BILIARY TRACT: No focal hepatic lesions or biliary ductal dilation. Partially collapsed gallbladder with ch... | 1. Pancreatic head calcification and multifocal ductal prominence may represent sequela of chronic pancreatitis and/or stricture. MRI/MRCP is recommended for further evaluation and to exclude a small occult malignancy. 2. Pelvic ascites and borderline enlarged mesenteric and retroperitoneal lymph nodes are of unknown e... |
Generate impression based on findings. | Male 66 years old Reason: establishing baseline for participation in a clinical trial, IRB 13-0936. Please provide bi-dimensional measurements per RECIST v1.1 History: neuroendocrine carcinoma of the lung ABDOMEN:LUNG BASES: Chest section will be dictated separately.LIVER, BILIARY TRACT: Several hypodense lesions in th... | Interval progression of disease with interval development of hepatic and retroperitoneal metastases interval increase in the size of the left adrenal, right renal and right lower quadrant mesenteric adenopathy.Heterogeneous mass in the pancreas is grossly unchanged. |
Generate impression based on findings. | 88-year-old female with a history of right heart strain. Evaluate for pulmonary embolism. PULMONARY ARTERIES: No evidence of acute pulmonary embolus. Pulmonary arterial web in the right lower lobe pulmonary artery consistent with prior episodes of pulmonary embolism. Pulmonary artery measures 30 mm which may suggest bo... | 1. No evidence of acute pulmonary embolism.2. Pulmonary arterial hypertension and right heart strain likely secondary to prior episodes of pulmonary embolism.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Positive. |
Generate impression based on findings. | 7 month old male, ex-preemie, with history of prolonged intubation and NICU course now with adenovirus infection with abdominal distentionVIEW: Abdomen AP (one view) 1/15/15 Enteric tube tip terminates in the stomach. Right lower extremity central venous catheter is at the confluence of the iliac veins.Nonobstructive b... | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 76-year-old male status post endovascular aortic repair. Assess for Endo leak. ABDOMEN:LUNG BASES: Diffuse emphysematous changes without other significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLAN... | 1. Endovascular repair of abdominal aortic aneurysm with aorto bi-iliac endovascular stent.. No evidence of Endo leak. 2. Sigmoid diverticulosis without complication. |
Generate impression based on findings. | 2 year old female with colonic dysmotilityVIEW: Abdomen AP (one view) 1/15/15 Gastrostomy tube is present and unchanged. Disorganized, featureless, air distended bowel loops. No evidence of obstruction. No free intraperitoneal air, pneumatosis intestinalis, or portal venous gas. | Nonspecific bowel gas pattern. No evidence of obstruction. |
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