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Generate impression based on findings. | 70 year-old female with right upper extremity pain. Evaluate for fracture. Comminuted supracondylar fracture of the distal humerus involving both lateral and medial condyles with minimal posterior angulation of the distal fragment. Overlying splint material is noted.Reverse ball and socket arthroplasty of the right sho... | Comminuted supracondylar fracture of the distal humerus involving both lateral and medial condyles with minimal posterior angulation of the distal fragment. |
Generate impression based on findings. | Headache, altered mental status, conjunctivitis. Evaluate for signs of encephalitis or acute intracranial abnormality. Again seen are postoperative changes of left frontal temporal craniotomy. No significant change in large left predominantly anterior temporal cystic encephalomalacic cavity with surrounding areas of hy... | 1. No evidence of acute intracranial hemorrhage, edema, or mass effect. If there is continued suspicion for encephalitis, consider MRI with contrast for further evaluation.2. Redemonstrated are changes of previous left frontotemporal craniotomy from prior meningioma resection (per history on 2004 comparison study). The... |
Generate impression based on findings. | : headache, HIV- assess for mass occupying lesions The CSF spaces are appropriate for the patient's stated age with no midline shift.A hypodense focus in the right basal ganglia has similar density to spinal fluid. There appears to be some adjacent enlargement of the temporal horn of the right lateral ventricle. No abn... | 1.No evidence for acute intracranial hemorrhage mass effect or edema. CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction.2.Please note that compared to CT MRI is more sensitive in detecting lesions associated with HIV.3.A small lesion in the right basal ganglia is nonspecific. Althoug... |
Generate impression based on findings. | Male 52 years old Reason: abdominal pain, immunocompromised History: abdominal pain, immunocompromised ABDOMEN:LUNG BASES: Mild bibasilar dependent subsegmental atelectasis. Central venous catheter tip near the superior cavoatrial junction.LIVER, BILIARY TRACT: Contracted gallbladder with minimal pericholecystic fluid.... | 1. Contracted gallbladder with minimal pericholecystic fluid, which may be related to mild generalized, nonspecific ascites. If there is clinical concern for acute cholecystitis, ultrasound is recommended. |
Generate impression based on findings. | Female 69 years old; hemorrhage of rectum and anal sphincter tear. Rectal pain. Rectal bleed. Constipation. The absence of intravenous contrast limits evaluation of the solid organs and of the bowels. Given these limitations, the following observations were made:ABDOMEN:LUNG BASES: No significant abnormality noted.LIVE... | 1.Within the limitations of this noncontrast study no evidence of rectal hematoma or specific findings to explain patient's rectal pain. |
Generate impression based on findings. | Elbow injury.VIEWS: Right elbow AP/lateral (two views) 05/11/15 A joint effusion is not present. The bones are normal in appearance. No fracture is seen. | Normal examination. |
Generate impression based on findings. | Status pos gunshot to the right leg Subcutaneous emphysema and a bullet fragment with comminuted fracture of the proximal diaphysis of the right femur is noted. The femoral head and neck are intact and well directed to a normal acetabulum. No joint effusion or hemarthrosis. | No evidence of neck or femoral head fractures. |
Generate impression based on findings. | Male 5 months old with right lower moiety hydronephrosis. BLADDER Wall Thickness: Normal Contents: Distended and normal. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: Not observedKIDNEYS Cortical Echogenicity: Normal Medullary Echogenicity: Normal Pelvicaliceal System... | Duplicated right ureters with increasing dilation of the lower pole pelvis.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4: Grade 3 and... |
Generate impression based on findings. | Merkel cell carcinoma of the right cheek. History of prior surgery, per patient.RADIOPHARMACEUTICAL: The right cheek was prepared in a sterile manner. A total of 0.529 mCi Tc-99m filtered sulfur colloid was injected in four perilesional injections. A focus of increased activity is noted in the medial right cheek, media... | Sentinel node identified in the medial right cheek, medial to the lesion. |
Generate impression based on findings. | Altered mental status The CSF spaces are appropriate for the patient's stated age with no midline shift.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portions of the paranasal sinuses are clear. The vi... | No evidence for acute intracranial hemorrhage mass effect or edema. CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction. |
Generate impression based on findings. | Head: There is no evidence of enhancing intracranial lesion or mass effect. The ventricles and basal cisterns are unchanged in size and configuration. There is no midline shift or herniation. There is minimal mucosal thickening of the bilateral maxillary sinuses. The remaining imaged paranasal sinuses are clear. The r... | 1. Redemonstration of treatment related findings in the neck without evidence of tumor progression. No cervical lymphadenopathy. 2. No intracranial metastatic disease.3. Sclerosis of the T2 vertebral body, which is unchanged from 3/30/2015, but not present on earliest prior study from 9/6/2014. Finding may represent a ... |
Generate impression based on findings. | 64-year-old male with left wrist pain and swelling 3 views of the left wrist demonstrate diffuse bone demineralization suggestive of osteopenia. Severe joint space narrowing, subchondral sclerosis, and osteophyte formation at the radiocarpal joint. There is increase in the scapholunate interval with proximal migration ... | SLAC wrist and degenerative changes as described above. |
Generate impression based on findings. | Fall. CT head:The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The visualized portions of the paranasal sinuses are clear. The visualize... | 1.No evidence for cervical spine fracture2.No evidence for acute intracranial hemorrhage mass effect or edema. CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction.3.There are multilevel degenerative changes present in the cervical spine which appear worse at C6-7 where there is subluxa... |
Generate impression based on findings. | Ms. Scheuermann is a 68 year old female with a personal history of right breast mastectomy in 2008 for DCIS. She has no current breast related complaints. Three standard views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandul... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, left unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 61-year-old female with history of gout, no trauma 3 views of the left wrist show no acute fracture. Alignment is anatomic. No osseous erosions. No significant soft tissue swelling. | No specific evidence of gout. |
Generate impression based on findings. | Male 68 years old; Reason: hx of ruptured appendiceal cancer, surveillance, compare to prior, ? peritoneal dz History: diarrhea ABDOMEN:LUNGS BASES: Mild interval improvement in trace pericardial effusion.LIVER, BILIARY TRACT: Diffuse hepatic steatosis. Essentially unchanged small perihepatic fluid. SPLEEN: No signific... | 1. Stable exam as above. Unchanged mild peritoneal nodularity/thickening, nonspecific, for example, in ventral abdomen, differential considerations include postoperative sequela/scarring or developing metastatic disease. However, no measurable focus delineated at this time. 2. Unchanged small perihepatic fluid. 3. Mild... |
Generate impression based on findings. | Reason: h/o met thyroid ca, compare to previous, measurements needed pls History: none CHEST:LUNGS AND PLEURA: Left upper lobe nodule (image 47 series 4) measuring 12 mm x 13 mm is unchanged from the prior exam.Scattered micronodules noted.Small left pleural effusion.MEDIASTINUM AND HILA: Status post thyroidectomy with... | 1.Soft tissue nodule posterior to the trachea and adjacent to the thyroid surgical bed as described on recent CT of the neck and compatible with recurrent neoplasia.2.Left upper lobe nodule unchanged from prior outside exam.3.Radiolucent lesion in the L3 vertebrae suspicious of an osseous metastasis. |
Generate impression based on findings. | 76-year-old male with internal rotation of the right lower extremity status post right hip fracture AP view of the pelvis shows a right hip hemiarthroplasty device in near-anatomic alignment without evidence of hardware complication. Overlying skin staples and small foci of subcutaneous gas reflect recent surgery. No a... | No acute fracture or malalignment is evident. No significant interval change. |
Generate impression based on findings. | Intracranial hemorrhage Evolving hematoma centered in the right thalamus, which appears slightly smaller in dimension when compared to recent prior. There is also near resolution of the hematoma centered in the left basal ganglia/anterior limb of the internal capsule. There is also decrease in amount of intraventricula... | 1. Evolving/decreasing intraparenchymal hemorrhages centered at the right thalamus and left anterior basal ganglia as well as decreasing intraventricular blood products. Left anterior basal ganglia hemorrhage is nearly resolved.2. Decrease in associated mass effect with residual effacement of the right lateral and thir... |
Generate impression based on findings. | Reason: altered mental status History: altered mental status There is no evidence of intracranial hemorrhage. The gray-white matter appears to be maintained. The ventricles and basal cisterns are normal in size and configuration. There is no mass effect or herniation. The imaged paranasal sinuses and mastoid air cells ... | No evidence for acute intracranial hemorrhage, edema or mass effect. Please note CT is insensitive for the early detection of acute non-hemorrhagic cerebral infarction. |
Generate impression based on findings. | Male 58 years old; Reason: NHL, re-eval and compare to previous History: NHL CHEST:LUNGS AND PLEURA: Paraseptal emphysema. Scattered pulmonary micronodules, some of which are calcified, are unchanged (for example series 6, image 29, image 74).MEDIASTINUM AND HILA: Interval removal of right-sided Port-A-Cath. Again seen... | 1.Stable examination with no new sites of disease. |
Generate impression based on findings. | History of anal cancer completed therapy September 2013. Evaluate for interval change. CHEST:LUNGS AND PLEURA: 10 x 7 mm nodule along the right minor fissure is unchanged and likely represents an intrapulmonary lymph node (series 4 image 172) no new or suspicious pulmonary nodules or masses. No pleural effusions..MEDIA... | No specific evidence of recurrence or metastases. |
Generate impression based on findings. | Minimal mucosal thickening is seen involving the left greater than right frontal sinuses at the frontoethmoidal recesses. There is mild opacification involving the bilateral anterior ethmoid air cells. The posterior ethmoid air cells are clear. There is mild mucosal thickening involving the right sphenoid sinus. Bilat... | 1. Minimal mucosal thickening involving the paranasal sinuses as described above.2. Limited examination of the intracranial structures demonstrates chronic right frontal lobe and right anterior inferior basal ganglia infarcts. |
Generate impression based on findings. | 62 year old female with multiple myeloma, progressive disease, screening for clinical trial, evaluate for myeloma lesions. SKULL: 2 views of the skull show no definite myelomatous lesions. CERVICAL SPINE: 2 views of the cervical spine show mild degenerative disc disease. We see no definite myelomatous lesions. Calcific... | Degenerative arthritic changes and other findings as above. We see no definite myelomatous lesions. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts and additional bilateral MLO views were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. Few scattere... | 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. | 66 years Female Reason: h/o aortic dissection seen arising from left subclavian and terminating above right renal artery. Eval for stability, also visualize appendix and gall bladder. History: Abdominal pain, back pain. +SIRS criteria CHEST:LUNGS AND PLEURA: Calcified micronodules suggest prior granulomatous disease. N... | 1.Previously seen aortic dissection is no longer evident. New outpouching of the aortic arch distal to the left subclavian artery is compatible with saccular pseudoaneurysm.2.Gallbladder wall thickening with stones and sludge and mildly hydropic morphology; correlate clinically and with same day right upper quadrant ul... |
Generate impression based on findings. | Male 51 years old; Reason: kidney cancer and thyroid cancer History: follow up and please compare with last scan CHEST:LUNGS AND PLEURA: Visualized lung fields without significant change. No suspicious lung nodule. Incidentally seen azygous lobe. MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Thoracic a... | Stable exam as above, including T8 severe compression deformity. No evidence of local disease recurrence or metastatic disease. However, please refer to concomitant nuclear medicine bone scan from same day for additional findings. |
Generate impression based on findings. | Female 66 years old; Reason: re-staging, evaluation, and follow-up for follicular dendritic cell sarcoma History: re-staging, evaluation, and follow-up for follicular dendritic cell sarcoma CHEST:LUNGS AND PLEURA: Left upper lobe mass is stable in size and measures 1.0 x 0.5 cm (series 5, image 22), previously 1.0 x 0.... | 1.Stable left upper lobe lesion, hepatic lesion and external iliac lymph node.2.A lesion in the midpole of the right kidney does not meet criteria for simple cyst and is indeterminate but warrants close attention on follow-up imaging. |
Generate impression based on findings. | Ms. Horton is a 54 year old female with a personal history of left breast lumpectomy in 2011 for DCIS followed by radiation therapy. Patient is BRCA 2 gene mutation positive. She has no current breast related complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9... | Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Male 6 years old evaluate left hydronephrosis after pyeloplasty. BLADDER Wall Thickness: Normal Contents: Distended and normal. The left nephroureteral stent is visualized within the bladder. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: Not observedKIDNEYS Cortical Echog... | Decreased fullness in the left renal pelvis after surgery.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4: Grade 3 and parenchymal thin... |
Generate impression based on findings. | Male, 75 years old. Reason: eval ngt placement History: ngt NG tube tip in the region of the pylorus.The lower pelvis is excluded from the field-of-view. Nonobstructed bowel gas pattern.AICD leads in place. Status post median sternotomy. | NG tube tip in the region of the pylorus. |
Generate impression based on findings. | Male 68 years old; Reason: 68 y/o male with colon ca. surveillance scan. History: see above CHEST:LUNGS AND PLEURA: Unchanged 7 mm left lower lobe pulmonary nodule and scarlike opacity in the right upper lobe.MEDIASTINUM AND HILA: Coronary artery cavitations.CHEST WALL: No significant abnormality notedOTHER: ABDOMEN:LI... | 1.No specific evidence of metastatic disease. Stable left lower lobe pulmonary nodule. |
Generate impression based on findings. | Female 59 years old; Reason: 59 y/o female with colon ca on chemotherapy- pls compare to prior CHEST:LUNGS AND PLEURA: Bilateral pulmonary nodules. Reference left lower lobe lung nodule unchanged accounting for differences in technique, measuring 1.3 x 1 cm, image 68 series 5, previously measured 1.2 x 1.2 cm. Another ... | 1. Enlarging hepatic metastases, pulmonary nodules stable to decreased in size, see above.2. Stable vague sclerosis involving T8 vertebral body, nonspecific but osseous metastatic disease not entirely excluded. Please note that nuclear medicine bone scan would be more sensitive for evaluation of bony metastatic disease... |
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. Stable benign appearing intramammary lymph node... | 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. | 70 years Male Reason: new abd pain, history of thoracic aortic aneurysm, HDS History: new abd pain CHEST:LUNGS AND PLEURA: No focal consolidation or pleural effusion. No suspicious pulmonary nodules. MEDIASTINUM AND HILA: Heart size is upper limits of normal with no pericardial effusion. Ascending aorta measures up to ... | 1.Gallbladder wall edema and pericholecystic fluid; right upper quadrant ultrasound may be considered if there is clinical suspicion for cholecystitis.2.No evidence of thoracic or abdominal aortic aneurysm or rupture.3.Variant hepatic arterial anatomy.4.Severe coronary artery disease and CABG noted. |
Generate impression based on findings. | Reason: S/P EVAR History: None. ABDOMEN:LUNG BASES: Bibasilar atelectasis.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: Arterial enhancing 1 centimeter lesion in the spleen likely represents a hemangioma and is likely unchanged due to differences in technique (series 10 image 82).PANCREAS: No significan... | 1.Infrarenal abdominal aortic aneurysm status post EVAR placement, slightly increased in size compared to prior. Persistent lumbar artery type II endoleak. Previously seen anterior IMA distribution type II endoleak is no longer visualized. 2.Right common iliac artery aneurysm, which is included in EVAR, has not changed... |
Generate impression based on findings. | Sudden onset of neck stiffness and occipital headache. Evaluate for subarachnoid hemorrhage. Streak artifact from earrings somewhat limits evaluation of the area. There is no evidence of acute intracranial hemorrhage or mass effect. The ventricles and basal cisterns are normal in size and configuration. There is no mid... | 1. No evidence of acute intracranial hemorrhage or mass effect.2. Focus of calcification/heterotopic ossification lateral to the tip of the dens on the right is partially visualized and may be related to remote trauma or inflammation. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree ... |
Generate impression based on findings. | 9 year old male with ALL in remission and HLH presenting for pre-transplant evaluation. HEAD: There is no evidence of acute intracranial hemorrhage. The ventricles and basal cisterns are unchanged in size and configuration. There are unchanged nonspecific patchy regions of low attenuation within the periventricular whi... | 1. No evidence of acute intracranial hemorrhage or mass effect.2. Stable ventricular size and mild global volume loss.3. No significant paranasal sinus disease. Findings are improved since 3/30/2015.4. Decreased but persistent fluid within the bilateral mastoid air cells.I personally reviewed the Images and/or procedur... |
Generate impression based on findings. | Male 6 years old left forearm injury VIEWS: Left forearm AP and lateral 5/11/2015 (2 views) There is an oblique/transverse fracture of the distal metaphysis of the left radius with minimal dorsal angulation. | Minimally displaced left radial fracture as described. |
Generate impression based on findings. | Seizures. Rule out kidney stones or other sources of pain.VIEW: Abdomen AP (one view) 5/11/2015 Gastrostomy tube is noted. Mild amount of fecal accumulation is present. No evidence of obstruction or free air. No radiopaque foreign bodies. | Mild amount of fecal accumulation. |
Generate impression based on findings. | Male 14 years old Reason: S/P THERASPHERE ADMINISTRATION/ HCC History: S/P THERASPHERE ADMINISTRATION/HCC CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: Normal heart size without pericardial effusion. Mediastinal or hilar lymphadenopathy. No visible coronary artery calcifications.CHEST WA... | Slightly decreased size of reference left hepatic lobe lesion and additional smaller arterially enhancing left hepatic lobe lesions, but otherwise, no significant interval change in diffuse multifocal hepatocellular carcinoma with tumor thrombus throughout the portal venous system. |
Generate impression based on findings. | Reason: eval for etiology of hemoptysis History: hemoptysis, known COPD and RUL mass LUNGS AND PLEURA: Right upper lobe mass is again seen now measuring 4.1 x 2.9 cm (series 4 image 23), previously 3.6 x 2.3 on CTA study. Calcified and noncalcified nodules. Centrilobular emphysema. Low lung volumes and lung base scarri... | 1.Interval increase in the size of the right upper lobe mass. 2.Thoracic aortic aneurysm without significant change from prior study.3.Small perihepatic and perisplenic ascites, new from prior study.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 59-year-old with history of left mastectomy for breast cancer presents for routine right follow-up. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 66-year-old female with facial plethora, HD line in the right IJ/SVC. Evaluate for subclavian vein thrombosis. LUNGS AND PLEURA: Bilateral pulmonary micronodules are unchanged.Persistent small right pleural effusion with underlying atelectasis.Bilateral upper lobe atelectasis/scarring.MEDIASTINUM AND HILA:Small mediast... | 1. Mild focal narrowing of the right brachiocephalic vein, as detailed above. No evidence of thrombus formation or occlusion. The SVC appears patent without evidence of thrombus, significant stenosis or occlusion. The right subclavian vein is nonopacified by contrast which may be related to the phase of contrast versus... |
Generate impression based on findings. | 55-year-old female with pain and swelling of left ring finger 3 views of the left ring finger demonstrate a volar plate avulsion fracture off the base of the middle phalanx with approximately 1 mm of volar and proximal displacement of the fracture fragment. | Volar plate avulsion fracture as described above. |
Generate impression based on findings. | 79-year-old female with left shoulder pain 3 views of the left shoulder show minimal osteophytes compatible with minimal osteoarthritis. No acute fracture or malalignment is evident. | No acute fracture or malalignment is evident. |
Generate impression based on findings. | Male, 54 years old, with history of T1 N2b squamous cell carcinoma of the right tonsil status post tonsillectomy and selective neck dissection, status post chemotherapy and radiation. Mild treatment related findings are again seen in the neck including infiltration of the fascial planes on the right. No evidence of any... | Stable treatment related findings with no evidence of recurrent primary tumor or pathologic adenopathy. |
Generate impression based on findings. | 60 years old Female. Reason: PTLD DLBCLymphoma History: 60 Yrs female s/p living-related donor kidney transplant complicated by PTLD (DLBCL - type) involving the CNS s/p chemotherapy in need of restaging. Please compare to prior. RADIOPHARMACEUTICAL: 14.9 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 97 mg... | 1.Stable increased metabolic activity in the pelvis, which can be due to tumor and posttherapy change.2.Increased metabolic activity in the bilateral proximal femurs, decreased in the right proximal femur as compared with prior study, which can be due to tumor and post-surgical change.3.New hypermetabolic lymph nodes i... |
Generate impression based on findings. | Ms. Whitefuse is a 71 year old female presenting for a short-term follow-up for calcifications in the left lumpectomy bed. She has a personal history left breast lumpectomy 1996 for breast cancer status post radiation and hormonal therapy. Family history of breast cancer in maternal aunt. She has no current breast rela... | High probability benign calcifications in the left upper outer breast. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months to confirm stability of these findings. All results and recommendation were discussed with the patient.BIRADS: 3 - Probably benig... |
Generate impression based on findings. | 71-year-old male. Metastatic glucagonoma to liver. s/p Therasphere administration. CHEST:LUNGS AND PLEURA:Stable scattered calcified and noncalcified micronodules, likely postinflammatory. No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy. Normal heart size without ... | 1. Overall, stable to slightly decreased size of hepatic metastases.2. Reference lesion in the right hepatic lobe is slightly decreased in size, but there is new mild, nodular-like enhancement seen at its superior aspect, which is nonspecific and potentially related to recurrent tumor. Attention to this area at follow-... |
Generate impression based on findings. | Reason: Eval for sternal integrity / Obvious fluid collections History: Sternal wound drainage after transplant / Immunocompromised Motion limits sensitivity.LUNGS AND PLEURA: Small pleural effusions and basilar atelectasis.MEDIASTINUM AND HILA: Minimal retrosternal soft tissue compatible with expected postsurgical cha... | Status post heart transplant. Median sternotomy is intact without evidence of diastasis or unusual fluid collections.Small pleural effusions and basilar atelectasis. |
Generate impression based on findings. | Reason: PTX? blebs? History: history fo PTX, chest pain, shortness of breath LUNGS AND PLEURA: Apical scarring, greater on the left with surgical staples in the left upper lobe.Moderate bronchial thickening in the left lower lobe suggestive of bronchitis.No sign of blebs or pneumothorax.MEDIASTINUM AND HILA: No signifi... | 1.Apical scarring and surgical staples compatible with previous left resection. No sign of pneumothorax or subpleural blebs.2. Low blood opacity suggestive of anemia. |
Generate impression based on findings. | Male, 56 years old, with intracranial hemorrhage. The large left frontoparietal hematoma has not significantly changed in size or morphology. The degree of surrounding edema and mass effect, with compression of the left lateral ventricle, rightward subfalcine herniation, and rightward midline shift, are also unchanged.... | 1.No significant interval change in the size of a large left cerebral parenchymal hematoma. Associated edema and mass effect is also unchanged.2.The quantity of intraventricular blood product may be mildly reduced, while the caliber of the lateral ventricles has increased slightly from prior.3.Scattered subarachnoid bl... |
Generate impression based on findings. | Initial staging. Lung cancer. Concern for Stage IV disease.RADIOPHARMACEUTICAL: 12.9 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 101 mg/dL. Today's CT portion grossly demonstrates a 2.1 x 1.7 cm mass in the right lung apex, compatible with malignancy. There are innumerable scattered micronodules. No pleu... | 1.Right apical lung mass compatible with lung carcinoma.2.Innumerable hypermetabolic lesions throughout the thorax, abdomen, and skeleton compatible with diffuse metastatic disease. |
Generate impression based on findings. | Reason: eval shunt malfunction, indirect signs of elevated ICP History: HA, hx of VP shunt Again seen is a ventriculostomy catheter coursing through the left parietal bone and terminating across the midline in the body of the right lateral ventricle. Similar appearing hypoattenuation along the course of the ventriculos... | 1.No evidence for acute intracranial hemorrhage.2.The lateral ventricles remain collapsed, without significant interval change. 3.Stable hypodensity surrounding the left-sided ventriculostomy tube, while nonspecific, may represent edema. If further evaluation is necessary, consider MRI of the brain.4.Unchanged findings... |
Generate impression based on findings. | Reason: What is the nodular opacity seen on chest x ray? History: Above LUNGS AND PLEURA: Scattered areas of subsegmental atelectasis/scarring unchanged from the prior exam.No new suspicious pulmonary nodules or masses.No pleural effusions.MEDIASTINUM AND HILA: Residual thymic tissue again noted.No hilar or mediastinal... | No suspicious nodules or masses. Mild scattered subsegmental atelectasis/scarring unchanged from the prior exam. |
Generate impression based on findings. | 58-year-old male with a history of lymphoma status post chemotherapy therapy with lung nodules. Repeat CT to reassess. LUNGS AND PLEURA: There is near complete interval resolution of the previously described left lower lobe pulmonary nodule which was likely postinflammatory in etiology. There is residual scarring/atele... | Interval resolution of the left lower lobe pulmonary nodule ,which may be postinflammatory in etiology. No new or suspicious pulmonary nodules are identified. No evidence of lymphadenopathy. Bronchial wall thickening can be seen in bronchitis.I personally reviewed the Images and/or procedure with the Resident/Fellow an... |
Generate impression based on findings. | Reason: Metastatic Parotid cancer; pre-clinical trial exam; please include measurements History: as above CHEST:LUNGS AND PLEURA: Interval increase in dimensions of multiple pulmonary metastases.A left upper lobe nodule (series 6/30) measures 8 mm, increased from 6 mm previously.Reference left lower lobe nodule (series... | Interval increase in size of pulmonary and mediastinal metastases. |
Generate impression based on findings. | 30-year-old male with inability to ambulate, pain Views of the right knee demonstrate no acute fracture. The patella appears slightly high riding. Extensor mechanism appears slightly thickened. No joint effusion. | Patella alta, correlate with physical exam. No acute fracture is evident. |
Generate impression based on findings. | Age: 53 years. Sex : Female. Reason for study: Reason: r/o aspiration. hx of scleroderma. History: aspiration pna. 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. A single static image was obt... | Trace penetration without aspiration. Please see speech pathologist's report for additional details. |
Generate impression based on findings. | Age: 77 years. Sex : Female. Reason for study: Reason: eval aspiration s/p esophageal dilatation History: cough, dysphagia. Fluoroscopic guidance was provided for an oropharyngeal motility study performed by the Speech Pathology section of the ENT service. The examination was recorded on videotape .Two static images we... | Positive for tracheal aspiration. Please see speech pathologist's report for additional details. |
Generate impression based on findings. | 86-year-old female with pain status post fall 3 views of the left shoulder demonstrate a transverse fracture through the humeral neck with approximately 1.4 cm of medial displacement and 5 mm of foreshortening of the distal fracture fragment. No dislocation is evident. | Surgical neck fracture of the humerus as described above. |
Generate impression based on findings. | 74-year-old male. Reason: Status post Heller myotomy and Dor fundoplication with esophageal perforation, evaluate for leak, use Gastrografin, patient should drink contrast (NGT). History: Esophageal perforation. Single contrast evaluation of the esophagus demonstrates esophageal dilatation with moderate to marked esoph... | Postsurgical changes with findings suggesting volvulus of the gastric fundus.Severe esophageal dysmotility disorder.Findings were discussed by telephone with Dr. Patti at 10:30 AM on 5/11/2015. |
Generate impression based on findings. | Ms. Spinelli is a 57 year old female with a personal history of right breast lumpectomy in 2012 for IDC grade II followed by chemotherapy, radiation and hormonal therapy. Family history of breast cancer in mother and paternal aunt. She has no current breast related complaints. Three standard views of the right breast, ... | 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. | 36 years Male with adenocarcinoma of the right colon diagnosed by biopsy on colonoscopy. LUNG BASES: No suspicious pulmonary nodules. No focal consolidation or pleural effusion.LIVER, BILIARY TRACT: Liver enhances homogenously without focal lesion. Gallbladder is unremarkable.SPLEEN: No significant abnormality noted.PA... | Outside exam interpretation.1.Diffuse, continuous inflammatory changes of the bowel distal to the mid ileum is suggestive of inflammatory bowel disease. Infectious enteritis is considered less likely.2.Focal concentric wall thickening of the ascending colon with associated mesenteric and retroperitoneal lymphadenopathy... |
Generate impression based on findings. | 86-year-old female with left shoulder pain x4 days, pain with external rotation Moderate osteoarthritis of the acromioclavicular joint. Well-corticated ossicles near the acromioclavicular joint. No acute fracture or malalignment is evident. | No acute fracture or malalignment is evident. Degenerative changes as described above. |
Generate impression based on findings. | Altered mental status. Evaluate for stroke or intracranial hemorrhage. There is diffuse cerebral white matter hypoattenuation. There is a focal chronic infarct in the left precentral gyrus as well as left inferomedial cerebellum. There is no evidence of acute intracranial hemorrhage or mass effect. There are scattered ... | No evidence of acute intracranial hemorrhage. Nonspecific diffuse cerebral white matter hypoattenuation which is nonspecific but compatible with chronic small vessel ischemic disease. Please note, non-contrast CT is insensitive for the detection of non-hemorrhagic acute infarct and MRI can be considered as clinically i... |
Generate impression based on findings. | Reason: assess tumor burden History: assess tumor burden CHEST:LUNGS AND PLEURA: Almost complete opacification of the right hemithorax by a large pleural effusion with underlying atelectasis.Moderately large left pleural effusion, new from previous with associated compressive atelectasis.Interval increase in left lung ... | Marked increase in pleural effusions with underlying tumor progression. |
Generate impression based on findings. | Male, 52 years old, with nasal congestion and discharge. Postoperative findings are again seen compatible with left ethmoidectomy and antrostomy.Mild soft tissue thickening persists along the left frontoethmoidal recess. The left frontal sinus is otherwise clear. An osteoma in the left frontal sinus is unchanged. The r... | 1.Stable postoperative findings.2.Stable scattered sinus mucosal thickening including a rind of tissue along the residual walls of the left maxillary sinus. |
Generate impression based on findings. | 60-year-old with history of left mastectomy for breast cancer. No current complaints. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No dominant mass,... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Female, 85 years old, status post fall last week with superficial abrasion, now complaining of nausea and feeling weak. A small area of scalp thickening is seen in the right posterior parietal region. The bones of the skull are intact.Mild patchy white matter hypoattenuation is seen, a stable and nonspecific finding. N... | 1.Mild right parietal scalp injury without evidence of skull fracture.2.No acute intracranial abnormality.3.Patchy white matter hypoattenuation is nonspecific but may reflect age indeterminate microvascular ischemic disease.4.Sequelae of chronic left frontal and maxillary sinus inflammation. |
Generate impression based on findings. | Elevated muscle enzymes and pain. Evaluate for muscle inflammation.EXAMINATION: MR pelvis without IV contrast 05/11/15 The muscles are normal in appearance. No inflammation is seen. No fluid collections are identified. | Normal examination. |
Generate impression based on findings. | Left wrist fracture. New cast appliedVIEWS: Left wrist AP and lateral 5/11/2015 at 1115 hours. (2 views) Cast material obscures fine bone details. Healing fractures of the distal radius and ulna with dorsal angulation are unchanged in alignment. | Healing fractures, unchanged in alignment after cast exchanged. |
Generate impression based on findings. | Ms. Frank is a 72 year old female with a personal history of left breast lumpectomy 1996 for cancer followed by radiation therapy. Personal history of benign right breast biopsy. She has no current breast related complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 C... | Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Male 74 years old; Reason: 74 y/o male with colon ca on chemo. compare to prior History: see above CHEST:LUNGS AND PLEURA: No significant change from prior study including stable micronodules and granulomas. Mild emphysema.MEDIASTINUM AND HILA: Unchanged small axillary lymph nodes measuring up to 11 mm on the right. Ca... | 1.Decreased size and conspicuity of hepatic metastatic lesions. |
Generate impression based on findings. | Ms. Pellicciotti is a 64 year old female with a personal history of right breast lumpectomy in 2003 for ILC followed by chemotherapy, radiation, and Arimidex therapy. She has no current breast related complaints. Three standard views of both breasts along with a laterally exaggerated right CC view were performed digita... | 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. | Frontal sinus: There is partial opacification of the left frontal sinus, which is improved since 2013. The right frontal sinus and bilateral frontoethmoidal recesses are clear.Anterior ethmoids: Minimal mucosal thickening.Maxillary sinuses: There is mild mucosal thickening of the right maxillary sinus with a patent ri... | 1. Mild to moderate mucosal thickening involving the paranasal sinuses as above, slightly improved since prior.2. Partially empty sella with a small hypoattenuating focus in the sella with Hounsfield unit compatible with fat. If there are no contraindications, MRI may be considered for further characterization if clini... |
Generate impression based on findings. | Status post fracture.VIEWS: Left wrist AP and lateral 5/11/2015 at 1003 hours. (2 views) Cast material obscures fine bone details. Healing fractures of the distal radius and ulna with dorsal angulation are unchanged in alignment. | Healing fractures, unchanged in alignment. |
Generate impression based on findings. | Female, 43 years old, with chronic postnasal drip, throat clearing and cough, history of asthma and allergic rhinitis. The paranasal sinuses are clear with no evidence of any significant mucosal thickening or accumulated secretions. The major sinus ostia are patent. The nasal septum is intact deviating gently towards t... | No evidence of any active sinus inflammatory disease. |
Generate impression based on findings. | Fracture.VIEWS: Right hand PA/lateral/oblique (three views) 05/11/15 A cast obscures bone detail. The fracture of the proximal middle finger metacarpal has slightly increased callus formation and sclerosis. Alignment is anatomic. | Continued healing of the middle finger metacarpal fracture. |
Generate impression based on findings. | Fracture.VIEWS: Left tibia fibula AP/lateral (two views) 05/11/15 The cast has been removed. The callus formation of the transverse fracture of the proximal tibial metaphysis has been incorporated. Alignment is anatomic. Multiple growth restart lines are present. | Continued healing of proximal tibial fracture. |
Generate impression based on findings. | History of mastoid tenderness. Evaluate for mastoiditis versus submandibular abscess. Neck: There is diffuse swelling and hyperattenuation of the right parotid gland with overlying soft tissue swelling and fat stranding, but no discrete rim-enhancing fluid collection. The thyroid and other major salivary glands are unr... | 1. Findings compatible with acute right sided otomastoiditis with overlying right neck cellulitis and parotitis, but no discrete fluid collection.2. Multiple dental caries.3. Mucosal thickening within the bilateral ethmoid and sphenoid sinuses may represent sinusitis. I personally reviewed the Images and/or procedure w... |
Generate impression based on findings. | Known right breast cancer on neoadjuvant therapy. Evaluation prior to planned surgery. Three standard digital views of the right breast 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. Biopsy clip again ... | Masses in the right breast are not visible mammographically. The biopsy clip could be mammographically localized prior to surgery. BIRADS: 6 - Known cancer.RECOMMENDATION: T - Take Appropriate Action - No Letter.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | History of right T2N2b right buccal squamous cell carcinoma, status post treatment. Compare to prior study. There are post-treatment findings related to resection of a right buccal squamous cell carcinoma with full-thickness skin graft to gingivobuccal sulcus, incisional release of scar contracture of gingivobuccal sul... | 1. Post-treatment findings without definite evidence of measurable buccal tumor recurrence, although streak artifact in this region limits evaluation.2. No evidence of significant cervical lymphadenopathy. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | Lacerations third fourth and fifth digits. Evaluate for glass 3 views of the right hand reveal no radiographic abnormalities. No fractures. No foreign bodies. | Negative right hand examination |
Generate impression based on findings. | Reason: 64 y/o F with neutropenic fever and new O2 requirement, please assess for evolving process History: fever LUNGS AND PLEURA: Multiple bilateral pulmonary metastases, not significantly changed.A reference right lower lobe nodule measures 25 mm in long axis diameter, not significantly changed from 23 mm.New small ... | Extensive metastatic disease, not significantly changed. New small pleural effusions but no sign of pneumonia. |
Generate impression based on findings. | Male 77 years old; Reason: bowel obstruction, pancreatitis History: hx of nec panc w/ pseudocyst, acute onset epigastric abdominal pain ABDOMEN:LUNGS BASES: Unchanged from prior study is rounded pleural-based opacity in right lower lobe, appearance suggestive of rounded atelectasis. Stable nonspecific 5 mm right middle... | 1. Stable to mild interval increase in degree of small bowel dilatation, with bowel measuring up to 2.5 cm. Appearance suggestive of ileus. Similar to earlier study is mildly prominent small bowel with gradual tapering seen in mid abdomen superiorly. From this point onward the small bowel further decreases in caliber a... |
Generate impression based on findings. | New onset tremors. There is no evidence of acute intracranial hemorrhage or mass. The grey-white matter differentiation appears to be intact. The ventricles are normal in size and configuration. There is no midline shift or herniation. The imaged paranasal sinuses and mastoid air cells are clear. The skull and scalp so... | No evidence of acute intracranial hemorrhage, mass, or cerebral edema. |
Generate impression based on findings. | s/p right buccal space foreign body removal in 2013, with subsequent intermittent right facial swelling, please eval right buccal/parotid space There is no evidence for metal foreign body within the patient's buccal space. Since the prior exam this is been removed.There are no fractures identified involving the maxillo... | No abnormal mass lesions are appreciated within the right buccal space. No metal foreign body is identified in the right buccal space. |
Generate impression based on findings. | There are postsurgical findings in the left retromolar region. There is no evidence of measurable mass lesions in the treatment bed. The salivary glands appear unchanged. There are multiple nodules within the thyroid gland, with interval development of calcifications in the dominant right lobe nodule, which appears to... | 1. Stable post-treatment findings in the left oral cavity region without evidence of measurable tumor recurrence or lymphadenopathy in the neck.2. Multiple thyroid nodules with interval development of calcification in a right lobe nodule, which appears to have increased in size. Further evaluation via ultrasound and pe... |
Generate impression based on findings. | Six months of back pain. Positive straight leg raise test on right.VIEWS: Lumbar spine AP/lateral/lumbosacral junction lateral (three views) 05/11/15 Minimal anterior loss of height of L1 and T12 is seen. Alignment is anatomic. No spondylolisthesis or spondylolysis is present.A moderate amount of feces is seen in the r... | Minimal anterior wedging of T12 and L1 may be related to acute or prior injury. |
Generate impression based on findings. | Reason: head and neck cancer/ per protocol scans History: see above CHEST:LUNGS AND PLEURA: Multiple small nodular and scarlike opacities in the right lung compatible with infection or aspiration, have not significantly changed.Status post right lower lobectomy.No new findings.MEDIASTINUM AND HILA: No significant lymph... | Stable small nodular and scarlike opacities which are most likely post inflammatory. |
Generate impression based on findings. | Right-sided weakness, history of HIV, seizures Again seen is encephalomalacia involving the left frontal lobe and mild ex vacuo dilatation of the left frontal horn. Small focus of encephalomalacia also noted in the superior medial aspect of the left thalamus. Small focus of encephalomalacia within the left anterior tem... | 1. No evidence of acute intracranial hemorrhage or mass effect. If there is significant suspicion for acute infarct or intracranial infection, consider MRI for further evaluation.2. Unchanged encephalomalacia in the left frontal lobe, superior medial aspect of the left thalamus, and in the left anterior temporal lobe. |
Generate impression based on findings. | Per VUS, there is an unknown structure just below the knee, medial, proximal calf. Rule out abnormality or foreign body. Patient is having pain in that area. 4 views of the right knee are provided. There is mild reticulation of the subcutaneous fat medially which may reflect mild edema, but I see no focal mass. Mild os... | Mild soft tissue edema, without a discrete mass evident. There is also mild osteoarthrosis of the knee with a small joint effusion. |
Generate impression based on findings. | T3N0 poorly differentiated SNUC status post surgical resection, 5-FU, and radiation. There are postoperative findings related to sinonasal tumor excisional biopsy. There is opacification of the left frontoethmoid recess and anterior ethmoid air cells. There is also persistent complete opacification of the left sphenoid... | 1. Post-treatment findings in the sinonasal region with persistent scattered nonspecific paranasal sinus opacification that is likely inflammatory, but no convincing evidence of gross residual tumor, although small amounts of tumor can be difficult to exclude in the setting of underlying inflammatory disease. Subsequen... |
Generate impression based on findings. | 55 year old woman with atypical chest pain referred to rule out coronary artery disease. CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of valsalva and bifurcates into the left anterior descending and left circumflex coronary arteries. There are no significant s... | 1. There are no significant coronary artery stenoses present. 2. No coronary artery calcification is noted. This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and upper abdomen will be interpreted by the attending chest radiologist and included as an addend... |
Generate impression based on findings. | Reason: h/o HNC, s/p CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Numerous small nodules and micronodules appear benign, some partially calcified, and unchanged as far back as 12/31/2012.Scattered peripheral tree-in-bud opacities involving the right middle and lower lobe appear infla... | Stable benign-appearing small nodules, and areas of tree-in-bud opacity which may be from inflammation or aspiration. No evidence of metastases, or other significant abnormality. |
Generate impression based on findings. | Right knee pain. 4 views of the right knee are provided. Mild osteoarthritis affects the knee, and there is perhaps a very small joint effusion. Arterial calcifications are noted within the soft tissues. | Mild osteoarthritis. |
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. There are no areas of abnormal attenuation. There is no extraaxial fluid collection. The visualized portions of the paranasal sinuses and mastoids/middle ears are grossly clear. | No acute intracranial abnormality. If there remains clinical concern for an acute ischemic event, MRI of the brain is recommended. |
Generate impression based on findings. | Back pain There is approximately 70 degrees of dextroscoliosis of the thoracic spine as measured from the superior endplate of T5 to the inferior endplate of T11. There is approximately 55 degrees of levorotoscoliosis of the thoracolumbar spine as measured from the superior endplate of T11 to the inferior endplate of L... | Scoliosis and degenerative disc disease as above. |
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