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Generate impression based on findings. | Age: 55 years. Sex : Female. Reason for study: Reason: Is there aspiration or penetration? History: Aspiration pneumonia. 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. Single static image wa... | Positive for vestibular penetration but negative for aspiration.Please see separate speech pathologist's report for additional details. |
Generate impression based on findings. | Reason: bleed? History: somnolence on coumadin There is no evidence of intracranial hemorrhage. The gray-white matter differentiation appears to be maintained. The ventricles and basal cisterns are normal in size and configuration. There is no mass effect or herniation. Stable scattered areas of hypoattenuation in the ... | No significant interval change. No evidence of intracranial hemorrhage or mass effect. 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. | Pain 4 views of the left knee are provided. Mild osteoarthritis affects the knee. There may also be a small joint effusion.Mild osteoarthritis also affects the right knee as seen on the frontal views. | Mild osteoarthritis. |
Generate impression based on findings. | Female 55 years old Reason: 55 y/o lady w/ TIPS please eval History: Abdominal distention LIVER: The liver is shrunken in size and measures 11.7 cm in diameter. The parenchyma is coarse in echotexture with a nodular liver contour compatible with patient's known cirrhosis. There is a moderate to severe amount of abdomin... | 1.Patent TIPS with expected portal venous flow direction. 2.Hepatic artery velocities are unchanged from the prior exam.3.Moderate to severe amount of abdominopelvic ascites. |
Generate impression based on findings. | Fell playing soccer yesterday. Heard crack. Right neck pain. Fracture? There is a mild leftward curvature of the cervicothoracic spine, but I see no fracture on this study. I see no spondylolisthesis. Neural foramina are grossly patent. The prevertebral soft tissues are within normal limits. | Mild spinal curvature but no fracture evident. If there is strong clinical concern for fracture, then CT is recommended. |
Generate impression based on findings. | Age: 79 years. Sex : Male. Reason for study: Reason: stroke History: stroke. 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. Single static image was obtained. The exam was positive for vestibu... | Positive for vestibular penetration and tracheal aspiration.Please see separate speech pathologist's report for additional details. |
Generate impression based on findings. | Shoulder pain. Status post fall 3 views of the right shoulder reveal no evidence of any fractures or dislocations. There are some mild degenerative changes at the acromioclavicular joint. In addition there is an ossification seen in the soft tissues adjacent to the humeral diaphysis that most likely represents heteroto... | No fractures or dislocations. |
Generate impression based on findings. | Male, 54 years old. Reason: 54 year male , hx esophageal cancer, patient finished chemo two weeks ago, please to test and evaluate for any abnormalities History: weigh loss and dysphagia Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions. Right chest port, t... | 1.No contour abnormality corresponding with the patient's known esophageal cancer is clearly seen on this exam.2.No other anatomic abnormality, esophageal dysmotility, or gastroesophageal reflux identified. |
Generate impression based on findings. | Right little finger fracture Again seen is a comminuted fracture of the proximal phalanx with extension to the MCP joint. Mild displacement of the proximal fracture fragments is similar to that seen on the prior study. I see no specific radiographic features of healing at this time. There is old posttraumatic deformity... | Proximal phalangeal fracture appearing similar to that seen on the prior study. |
Generate impression based on findings. | Male 62 years old; Reason: Intrahepatic cholangiocarcinoma please assess and provide index lesion History: As above ABDOMEN:LUNGS BASES: Small dependent basilar atelectasis. Small pericardial effusion. Portal veins, splenic vein and SMV patent. Small ventral abdominal and perigastric varices visualized.LIVER, BILIARY T... | 1. Lobulated heterogeneously enhancing mass seen in the central liver, adjacent capsular retraction. Mass demonstrates avid heterogeneous arterial enhancement with central necrosis suggested, washout seen on subsequent delayed imaging. Patient has reported history of cholangiocarcinoma but these imaging characteristics... |
Generate impression based on findings. | 52-year-old female. Reason: Evaluation of small bowel from dilatation or obstruction, history of sigmoid volvulus. History: Episodic abdominal pain, cramping and bleeding. The scout film shows a nonobstructive bowel gas pattern. Right upper quadrant surgical clips are noted.Transit time to the terminal ileum was 30 to ... | Normal small bowel follow-through. The patient can be reevaluated during an acute exacerbation as the patient's pain could be could be secondary to intermittent internal hernias or volvulus. The reported changes at the splenic fracture could be secondary to vascular or inflammatory etiology. |
Generate impression based on findings. | Female 19 years old Reason: history of histoplasmosis - follow up study History: chest pain LUNGS AND PLEURA: Right upper lobe linear scars are again noted. Right upper, right lower and left lower lobe nodules are no longer present. No effusions or pneumothorax.MEDIASTINUM AND HILA: Slight increase in the size of the r... | Interval resolution of nodules of the lung parenchyma with increasing in the size of the mediastinal lymph nodes. |
Generate impression based on findings. | Male, 27 years old. Reason: s/p buccal urethroplasty 4/15/15 check for extravasation of urine History: s/p buccal urethroplasty 4/15/15 check for extravasation of urine A cystogram was performed and serial spot films were obtained.The cystogram was performed using the patient's indwelling suprapubic catheter. Scout fil... | Postsurgical changes of a urethroplasty, with a linear focal leak off the left posterior aspect of the posterior urethra as described above. |
Generate impression based on findings. | 26-year-old female. Reason: Weight loss, abdominal pain, and vomiting. Evaluate for SMA syndrome. History: Abdominal pain, nausea, evaluate for SMA syndrome. The scout film shows a nonobstructive bowel gas pattern. Transit time to the terminal ileum was 2.5 hours. This may be within normal limits as metoclopramide was ... | 1. Findings consistent with mild SMA syndrome.2. No finding to suggest inflammatory bowel disease. |
Generate impression based on findings. | 54-year-old with strong family history of breast cancer. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. No dominant mass, suspicious microcalcifi... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Given her breast density, screening with tomosynthesis should be considered, in addition to her screening MRI. Results and recommendation were discussed with the p... |
Generate impression based on findings. | Status post fracture right middle finger 3 views of the right middle finger reveal the bones to be in anatomic alignment. The previously seen fracture in the distal aspect of the proximal phalanx is not clearly visualized and this is most likely secondary to healing. | Healing nondisplaced fracture right third digit |
Generate impression based on findings. | Pain and swelling status post 2 falls. Is there a fracture or dislocation? There is a comminuted but predominantly transverse fracture through the patella with 2 to 3 cm of distraction of the superior and inferior fracture fragments. There is soft tissue swelling anteriorly as well as a joint effusion. Overall, the bon... | Patellar fracture as above. |
Generate impression based on findings. | Male 64 years old; Reason: eval for carcinoid in pt with elevated urine 5HIAA History: elevated 5HIAA CHEST:LUNGS AND PLEURA: Postsurgical changes and scarring in the left upper lobe.Scattered calcified pulmonary micronodules.MEDIASTINUM AND HILA: Sternotomy wires and postsurgical changes in the mediastinum. Mildly pro... | 1.Indeterminate hypoattenuating liver lesion in the inferior right hepatic lobe. Liver MRI is recommended for further evaluation if clinically warranted.2.Cholelithiasis. |
Generate impression based on findings. | Sudden onset of right neck pain and occipital headache; no history of prior migraines or headaches. Brain MRA: There is no evidence of significant steno-occlusive lesions. There is a prominent infundibulum at the ACOM complex, but otherwise no evidence of saccular aneurysms.Neck MRA: There is no evidence of significant... | No evidence of steno-occlusive lesions in the head and neck. |
Generate impression based on findings. | ORIF right ankle fracture. Evaluate for healing. Again seen is a side plate and screw device affixing the distal fibula in near-anatomic alignment. The fracture itself is indistinct, suggesting healing, appearing similar to the prior study. Also again seen are 2 orthopedic screws affixing the medial malleolus in near a... | Orthopedic fixation of healing ankle fractures as above. |
Generate impression based on findings. | 39-year-old male with hip total arthroplasty primary uncement (right hip) Acetabular component and femoral stem/neck components of a total hip arthroplasty device are situated in near anatomic alignment. The distal aspect of the stem is not included on the field of view. Surgical wound is noted laterally. | Right total hip arthroplasty components in near anatomic alignment. |
Generate impression based on findings. | Male, 69 years old. Reason: 69 y/o M with dysphagia, weight loss. Esophagram to evaluate for possibility of achalasia History: as above Single contrast evaluation of the esophagus and gastric cardia/fundus revealed: The distal esophagus is hypoperistaltic, markedly dilated, with a sigmoid appearance. The classic beak l... | Narrow gastroesophageal junction, with delayed retention, and dilation/dysmotility of the distal esophagus. These findings are compatible with partially treated achalasia. |
Generate impression based on findings. | 58 years old Female. Reason: RUQ discomfort. History: history of recurrent ovarian cancer, now with rising CA 125 and RUQ discomfort. This study was performed for restaging.RADIOPHARMACEUTICAL: 12.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 89 mg/dL. Today's CT portion of the neck demonstrates no signi... | 1.New FDG avid tumor in the right lower chest wall /perihepatic space and pericardium.2.Interval resolution of previously identified hypermetabolic tumor in the right upper quadrant of the abdomen.Diagnostic CTs of the chest, abdomen, and pelvis also performed at today's visit will be reported separately. |
Generate impression based on findings. | 36-year-old female. Reason: Status post duodenal switch reversal now with malnutrition and dysphagia. History: Abdominal pain, dysphagia, malnutrition. The scout film shows a nonobstructive bowel gas pattern. Surgical suture is present overlying the epigastrium with postsurgical changes likely from prior hernia repair ... | Distortion and narrowing of the proximal body of the stomach which is likely the cause of the patient's symptoms.Mild esophageal dysmotility disorder.Findings were discussed by telephone with Dr. Potts at 3:45 PM on 5/11/2015. |
Generate impression based on findings. | Chronic sinusitis. Possible dental source. I see no findings to suggest infection. The teeth appear normal, although please note that evaluation of the midline structures is limited due to blurring artifact inherent to Panorex technique. | No specific findings to account for the patient's chronic sinusitis. |
Generate impression based on findings. | Evaluate fracture 3 views of the right thumb reveal a Salter II fracture at the first metacarpal phalangeal joint. No change in position from the previous examination. | Salter II fracture of in anatomic alignment. |
Generate impression based on findings. | 63 year old female with mitral valve prolapse and severe mitral regurgitation.CPT: 75572 Aortic and Aortic Root. There is a left sided aortic arch with normal brachiocephalic branching pattern. No thoracic aortic dissection or aneurysm is noted. The thoracic aorta has minimal tortuosity. No protruding aortic atheroma o... | 1. Mitral valve thickening with bileaflet mitral valve prolapse. 2. Left atrial dilation. 3. Normal thoracic aortic anatomy. 4. No left atrial appendage thrombus. 5. No coronary calcification.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and upper abdo... |
Generate impression based on findings. | Limp and right leg swelling. Rule out septic hip.VIEWS: Pelvis AP/frog leg (two views) 05/11/15 The femoral head ossification centers are well directed toward normally formed acetabula. No fracture is identified. | Normal examination. |
Generate impression based on findings. | Female, 72 years old. Reason: 72 year female, hx ofHTN, evaluate for any abnormalities History: esophageal diverticula Double contrast evaluation of the esophagus and gastric cardia/fundus revealed a pulsion diverticulum arises from the anterolateral right aspect of the the mid-distal esophagus. The diverticulum measur... | 1. A pulsion diverticulum arising from the anterior-right aspect of the the mid-distal esophagus as detailed above.2. Mild esophageal dysmotility. No other anatomic abnormality or significant gastroesophageal reflux. |
Generate impression based on findings. | Female 58 years old; Reason: patient with history of recurrent ovarian cancer, now with rising CA 125 and RUQ discomfort History: RUQ discomfort CHEST:LUNGS AND PLEURA: Right middle lobe traction bronchiectasis and scarring.MEDIASTINUM AND HILA: No significant abnormality noted.CHEST WALL: No significant abnormality no... | 1. Findings compatible with new metastatic disease.2. Rounded heterogeneous precaval soft tissue focus, suspicious for metastatic lymphadenopathy and appears new from prior exam. 3. New metastatic hepatic subcapsular/soft tissue implants as described.4. Please refer to concomitant PET/CT exam from same day for addition... |
Generate impression based on findings. | 54-year-old female with RA Right hand: Again seen are findings compatible with erosive rheumatoid arthritis affecting the wrist and MCP joints similar to prior study without evidence of progression. Persistent soft tissue swelling about the wrist and dorsal to the MCP joints is evident.Left hand: Again seen are finding... | Findings compatible with rheumatoid arthritis with no evidence of disease progression since prior study. |
Generate impression based on findings. | Ms. Willis is a 39 year old female with a personal history of benign left breast biopsy in August 2014 for PASH. 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 distribu... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | 74-year-old male with history of lung cancer. Exam is limited by streak artifact from streak artifact metallic orthopedic hardware in the upper extremities as well as by bilateral femoral head and neck screws and intramedullary rods.LUNG BASES: Multiple bilateral rib fractures and chest wall deformity are redemonstrate... | No specific evidence of metastatic disease in the abdomen or pelvis.Dedicated chest CT report dictated separately. |
Generate impression based on findings. | Right humerus fracture below ORIF, evaluate for healing/displacement Again seen is a plate and screw device with cement affixing the proximal humerus. Also again seen is a nondisplaced oblique mid diaphyseal fracture that appears similar to that seen on the prior study accounting for slight positional differences. | Nondisplaced humerus fracture and other findings as above appearing similar to the prior study. |
Generate impression based on findings. | Female 49 years old Reason: 49F s/p OLT now with large fluid collection on CT. R/o hematoma. History: Large fluid collection on CT 13.1 x 12.3 x 15.4 cm heterogeneous fluid collection in right upper quadrant with debris and internal echoes, difficult to delineate exact location but when compared to prior CT imaging app... | As seen on prior CT imaging, large hepatic subcapsular fluid collection, sonographic appearance most consistent with hematoma. |
Generate impression based on findings. | Reason: 33yo M w/ hx CF presenting w/ CF exacerbation, ?PNA History: cough, SOB, wheezing LUNGS AND PLEURA: Moderate to severe bronchiectasis consistent with known cystic fibrosis.Patchy regions of tree-in-bud opacities with focal consolidation in both lower lung zones and anteriorly in the right upper lobe are consist... | Cystic fibrosis, with multiple areas of mucoid impaction, tree-in-bud opacities and frank consolidation suggestive of multifocal infection. |
Generate impression based on findings. | Blunt trauma. Deformity.VIEWS: Right forearm AP/lateral (two views) 05/11/15, 1548 and 1549 A both bones fracture of the distal forearm is present. Lateral angulation of the distal fracture fragments is seen. Overriding of the radius and lateral displacement are noted as well. Soft tissue swelling is associated with th... | Both bones fracture of distal forearm. |
Generate impression based on findings. | Swelling, pain. Trauma to right foot now with difficulty weightbearing. I see no fracture or dislocation. I see no findings to account for the patient's pain. | No findings to account for the patient's pain are evident. |
Generate impression based on findings. | Robotic pyeloplasty for left UPJ obstruction. BLADDER Wall Thickness: Normal Contents: Nephroureteral stent is noted in the bladder. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Not observed Left: Not observedKIDNEYS Cortical Echogenicity: Normal Medullary Echogenicity: Normal Pelvical... | Left pyeloplasty without evidence of complication.*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 thinning. **... |
Generate impression based on findings. | Right distal fibula osteomyelitis. Evaluate for recurrent infection. Again seen is mild deformity of the distal fibula with cortical thickening appearing similar to that seen on the prior study. Poorly defined intramedullary lucency also appears similar or perhaps less pronounced than that seen on the prior study. I se... | Mild fibular deformity as described above compatible with stated history of prior osteomyelitis; I see no specific findings to suggest recurrent infection. |
Generate impression based on findings. | Fever. History of bowel surgeries.VIEWS: Chest AP/lateral (two views) 05/11/15 Right-sided central line tip is at junction of superior vena cava and right atrium. Multiple upper abdominal surgical clips are present.Cardiothymic silhouette is normal. No focal lung opacity is present. | No pneumonia. |
Generate impression based on findings. | Hand fracture Again noted are buckle type fractures of the bases of the proximal phalanges of the index and middle fingers. There is new periosteal bone formation adjacent to the fractures indicating an attempt at healing. Deformity of the distal radius and ossific densities in the vicinity of the ulnar styloid are com... | Healing phalangeal fractures and other findings as above. |
Generate impression based on findings. | Pedestrian versus motor vehicle.VIEWS: Pelvis AP/frog leg (two views) 05/11/15 The femoral head epiphyses are well directed into normally formed acetabula. No fracture is present. The bones are normal in appearance. | Normal examination. |
Generate impression based on findings. | Pedestrian versus motor vehicle. VIEWS: Right femur AP/lateral (two views) 05/11/15 The bones are normal in appearance. No fracture is seen. | Normal examination. |
Generate impression based on findings. | Shoulder pain. Evaluate shoulder alignment. 3 views of the right shoulder are provided. Small glenohumeral joint osteophytes indicate mild osteoarthritis. The previously seen calcification along the posterolateral aspect of the humeral head suggesting calcific infraspinatus tendinopathy is no longer evident. Tapering o... | Mild osteoarthritis and other findings as above. |
Generate impression based on findings. | Metastatic thyroid cancer 2 views of the right femur reveals a total knee arthroplasty with a long femoral stem. There is been resection of the distal one half of the femur. No evidence is seen hardware failure or recurrence.2 views of the right knee again reveal a total knee arthroplasty without complications. Note is... | No evidence of hardware failure or tumor recurrence. |
Generate impression based on findings. | Anasarca and hypoproteinemia. Pericardial effusion. Acute Epstein-Barr virus infection. Rule out eosinophilic fasciitis.EXAMINATION: MR right tibia fibula, MR left tibia fibula without contrast 05/11/15 The skin and subcutaneous tissues are abnormal bilaterally. Lacelike edema is seen with significant subcutaneous and ... | Abnormal skin and subcutaneous tissues. No evidence of fasciitis or muscle inflammation. |
Generate impression based on findings. | Evaluate for fracture of the fourth left digit. 25 pound weight fell on it. I see no fracture or malalignment. | No fracture evident. |
Generate impression based on findings. | Pain. Osteoarthritis/RA 3 views of the left foot are provided. The bones appear demineralized, suggesting osteopenia/osteoporosis. There is a moderate flat foot deformity. Osteoarthritic changes at the talonavicular joint appear to have progressed slightly when compared with the prior study. Deformity of the fifth PIP ... | Arthritic changes as described above that appear predominantly degenerative in etiology. |
Generate impression based on findings. | Evaluate for fracture. Evaluate for degenerative disease. 4 views of the left knee reveals the patient be somewhat demineralized. No significant degenerative changes are seen.4 views of the right knee reveal marked deformity of the metaphysis of the distal femur most likely secondary to an old fracture. No significant ... | No significant joint disease. Marked deformity of the right distal femur from an old fracture. |
Generate impression based on findings. | Index finger pain. 3 views of the right index reveal a dorsal intra-articular fracture fragment from the proximal middle phalanx. No previous exams | Dorsal fracture at the proximal inner phalangeal joint of the index finger |
Generate impression based on findings. | Status post total knee arthroplasty AP and lateral views of the right knee reveal a total knee arthroplasty in anatomic alignment. No evidence of fractures or dislocations. Note is made of surgical drains and skin staples. | Right total knee arthroplasty in anatomic alignment. |
Generate impression based on findings. | Twisted left knee 3 weeks ago. Tenderness at medial side of the patella. Right middle finger stiffness after hitting hand on furniture. 4 views of the left knee are provided. Mild osteoarthritis affects the knee. I see no fracture, malalignment, or large joint effusion.3 views of the right middle finger are provided. M... | Mild osteoarthritis. I see no fracture. |
Generate impression based on findings. | Dyspnea on exertion. The comparison chest radiograph performed on 5/11/15 demonstrates an elevated right hemidiaphragm with minimal basilar atelectasis. Otherwise, no focal pulmonary opacities or pleural fluid is identified. The ventilation images show a uniform distribution of activity on single-breath and wash-in ima... | Minimal matched ventilation and perfusion defect in the right lower lobe, compatible with a very low probability of pulmonary embolism. |
Generate impression based on findings. | Allograft reconstruction after resection of osteogenic sarcoma 2 views of the left tibia and fibula reveal a sideplate bridging the allograft reconstruction. The osteotomy lines both proximally and distally are indistinct consistent with healing. The bones are in anatomic alignment. No change in position from the previ... | No evidence of recurrence or hardware failure. |
Generate impression based on findings. | Follicular lymphoma.RADIOPHARMACEUTICAL: 14.3 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 108 mg/dL. Today's CT portion grossly demonstrates surgical clips in the right axilla. A Port-A-Cath is noted in the right chest terminating in the right SVC/RA junction. The nodular left thyroid lobe appears simila... | 1. New focus of radiotracer activity in the spleen, likely representing malignancy.2. Stable appearance of the hypermetabolic mesenteric lymph nodes compatible with malignancy. 3. Focus of increased radiotracer activity in the pituitary gland, possibly representing a pituitary lesion such as an adenoma. Dedicated pitui... |
Generate impression based on findings. | 64 years old male. Reason: evaluating recurrence. History: New wrist pain. RADIOPHARMACEUTICAL: 13.9 mCi F-18 fluorodeoxyglucose (FDG) injected through the left arm.BLOOD GLUCOSE (FASTING): 101 mg/dL. Today's CT portion grossly demonstrates new mucosal thickening in the bilateral ethmoid and maxillary sinuses. Stable p... | 1.Hypermetabolic lesions in the right distal ulna and right distal fibula, highly suspicious for tumor. A focus of increased activity in the right wrist is also suspicious for tumor.2.Focus of increased activity in the nasal cavity, suspicious for tumor.3.Multifocal soft tissue uptake in both thighs, which can be due t... |
Generate impression based on findings. | Fell on stairs on Friday. Right knee pain and swelling. Rule out fracture.VIEWS: Right knee AP/lateral/oblique (three views) 05/11/15 The bones are normal in appearance. No fracture is present. There may be a small joint effusion. | No fracture. Possible small joint effusion. |
Generate impression based on findings. | Patient had CT with contrast injected today. Evaluate for flow through spine. Back pain, syrinx, hardware. Questionable tethered cord. 2 views of the cervical spine are provided. Posterior rods and screws affix C2 to the occiput. The cervical spine is slightly hyperlordotic. Narrowing of the C4/5 intervertebral disc sp... | Postoperative changes and scoliosis as described above. I see no contrast within the spinal canal. |
Generate impression based on findings. | Fell on left ankle. Rule out fracture.VIEWS: Left ankle AP/lateral/oblique (three views) 05/11/15 Moderate soft tissue swelling is noted laterally. A joint effusion is present.A vertical lucency is identified in the medial aspect of the tibial epiphysis at the junction of medial malleolus and rest of the tibia. An obli... | Triplane fracture. |
Generate impression based on findings. | Spinal fusion postopVIEWS: Thoracic spine AP (one view), lumbar spine AP (one view) 05/11/15, 1649 and 1651 Spinal fusion instrumentation extends from T3 to L3. Rods, hooks, and pedicle screws are intact in this single plane. Residual right thoracic and left lumbar curves are noted. | Postoperative changes without evidence of complication. |
Generate impression based on findings. | PICC placement. Cystic fibrosis.VIEW: Chest AP (one view) 05/11/15, 1659 Right upper extremity PICC tip is at junction of superior vena cava and right atrium.Cardiac silhouette size is normal. Bronchiectasis, peribronchial thickening and scattered parenchymal opacities are unchanged in the interval. | Right PICC tip at junction of superior vena cava and right atrium. |
Generate impression based on findings. | Evaluate for esophageal stricture, dysphagia, history of esophageal stricture formation Single contrast evaluation of the esophagus demonstrated partial obstruction at level of gastroesophageal junction with only small amount of ingested barium traversing GEJ. Majority of ingested contrast remained in mildly dilated es... | Findings suspicious for focal stricture at level of gastroesophageal junction with resultant partial obstruction as described. |
Generate impression based on findings. | Left hip pain. Left hip femoroacetabular impingement. There is a borderline CAM deformity of the anterior aspect of the femoral head/neck junction. There is also retroversion of the acetabulum superiorly.MEASUREMENTS: CAM location : 2 to 3 o'clockAlpha angle : 55 degreesCoronal center-edge angle : 34 degreesSagittal ce... | Measurements as listed above are compatible with the suspected diagnosis of combined femoroacetabular impingement.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report. |
Generate impression based on findings. | 64 year old man s/p pacemaker lead placement with pocket infection. Patient referred to evaluate cardiovascular structures prior to possible lead extraction. CPT: 75572 Left Ventricle: The left ventricle is severely dilated. There is a small apical thrombus noted in the left ventricle. . An epicardial device lead is lo... | 1. The relationship between the device leads and the vascular structures can not be determined due to severe beam hardening artifact from the device leads. 2. Device lead positions as described above. 3. Severe LV dilation with evidence of small apical thrombus. 4. Severe left atrial dilation with calcification of un... |
Generate impression based on findings. | Female 48 years old Reason: eval for perforated viscous History: abdominal pain, distention. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Hepatic steatosis.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNE... | .1. No evidence of perforated viscus as clinically queried. No specific cause for patient's abdominal pain is identified.2. Hepatic steatosis.3. The cervix appears bulky . Correlate with clinical examination. |
Generate impression based on findings. | headache, hypertension No evidence of acute ischemic or hemorrhagic lesion.There is subtle low attenuation on the left parietal lobe white matter indicating age indeterminate ischemic lesion (series 3, image 19/31).Considering similar lesions on the right frontal lobe and left parietal lobe, these lesions may indicate ... | 1. No evidence of acute ischemic or hemorrhagic lesion.2. Non specific small vessel ischemic disease as described above, brain MRI can be considered for further evaluation. |
Generate impression based on findings. | blurry vision, right eye No evidence of acute ischemic or hemorrhagic lesion.Patchy scattered low attenuations on bilateral periventricular white matter indicate non specific small vessel lesions.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There i... | No evidence of acute ischemic or hemorrhagic lesion.Non specific small vessel ischemic disease.Brain MRI can be considered for further evaluation if clinically indicated. |
Generate impression based on findings. | worst headache of life, family history of aneurysm. No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrh... | No evidence of acute ischemic or hemorrhagic lesion. |
Generate impression based on findings. | Male 35 years old; Reason: ? Infectious source History: fever, distended abdomen, hx pancreatitis 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: Trace bilateral pleural effusions, left greater... | 1.Severe acute pancreatitis with extensive peripancreatic fluid and new peripancreatic/gastric wall hematoma. Evaluation for the complications of pancreatitis is severely limited the absence of intravenous contrast.2.Hypoattenuating liver lesions are incompletely evaluated but may represent hepatic infarcts.3.Small bow... |
Generate impression based on findings. | worst headache of life, family history of aneurysm. NONCONTRAST CT HEADNo evidence of acute ischemic or hemorrhagic lesion on this scan.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axia... | No evidence of intracranial aneurysm.No significant intracranial arterial stenosis.Left Pcom artery shows an infundibulum. |
Generate impression based on findings. | 64-year-old male patient status post fall. There is no evidence for acute intracranial hemorrhage. The ventricles and basal cisterns are unchanged in size and configuration. There is no mass effect or herniation. The skull and extracranial soft tissues are unremarkable. There is mild-to-moderate mucosal thickening in t... | 1.No evidence for acute intracranial hemorrhage mass effect or edema. CT is insensitive for the early detection of acute nonhemorrhagic cerebral infarction.2.Paranasal sinus opacification is increased compared to the prior examination. This is likely inflammatory in origin. |
Generate impression based on findings. | 77 years, Female. Reason: Confirm placement of OGT History: FT placement The exam is limited by honeycombing artifact from overlying material. Enteric tube is coiled within the stomach with side-port projecting over the gastric fundus and tip projecting over the mid gastric body. Nonobstructive bowel gas pattern. Chole... | Enteric tube tip projecting over the proximal gastric body. |
Generate impression based on findings. | 79-year-old female post MVC, evaluate for fracture. Right wrist: There is a minimally displaced intra-articular fracture of the distal radius predominantly involving the radial styloid but probably comminuted. There is also a mildly displaced fracture through the ulnar styloid. Severe osteoarthritis of the basilar join... | 1. Comminuted right intertrochanteric fracture.2. Right distal radial and ulnar styloid fractures.3. Step-off along the right radial neck is equivocal for nondisplaced fracture. The distal humeral fat pads do not appear displaced arguing against hemarthrosis. This could be further evaluated with a 4 view elbow radiogra... |
Generate impression based on findings. | Fracture.VIEWS: Right forearm PA/lateral (two views) 05/11/15, 1900 and 1903 The fractures have been reduced. A cast has been applied.No residual angulation is present. Alignment is near-anatomic. | Both bones fracture of distal forearm in near-anatomic alignment. |
Generate impression based on findings. | Reason: 68 yo female with history of MDS; pre-allo SCT evaluation History: evaluate LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: No significant abnormality noted.CORONARY ARTERY CALCIFICATION: None. CHEST WALL: No significant abnormality noted.UPPER ABDOMEN: Absence of IV and enteric contras... | No evidence of infection. |
Generate impression based on findings. | 77-year-old female patient status post cardiac arrest with 30 minutes of no pulse and unresponsive. Evaluate for evidence of intracranial bleeding or signs of intracranial injury leading to nonresponsiveness. There is no evidence of intracranial hemorrhage. The ventricles and basal cisterns are normal in size and confi... | 1.No evidence for acute intracranial hemorrhage or significant mass effect. Gray-white matter distinction is subdued, which may represent early ischemic changes due to global anoxic injury. Follow-up CT scan or MRI can be obtained for further evaluation if clinically indicated. |
Generate impression based on findings. | 47-year-old male with 10 cm tender epigastric mass is palpable when lying flat. Newly diagnosed chronic myeloid leukemia on dasatinib for 4 weeks. Now in hematologic remission. LUNG BASES: No suspicious pulmonary nodules. No focal consolidation or pleural effusion. Minimal basilar scarring.LIVER, BILIARY TRACT: Liver e... | Large hypoattenuating splenic lesion measuring up to 24 cm has increased in size from limited survey images obtained on recent cardiac MRI. Other smaller areas of infarct are also demonstrated. The large lesion may represent a liquefying infarct, and given its size, there is risk of rupture. Given the free fluid and su... |
Generate impression based on findings. | Reason: r/o sdh History: dizziness and h/o fall yesterday There is no evidence of intracranial hemorrhage. The gray-white matter differentiation 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 masto... | No evidence of intracranial hemorrhage or mass effect. |
Generate impression based on findings. | Reduction of triplane fracture. Soft tissue swelling and joint effusion are present. There is subcutaneous emphysema. A cast has been applied.The triplane fracture is comminuted. It consists of a posterior and medial Salter IV fracture, a posterior lateral Salter II fracture, and an anterolateral Salter III (juvenile T... | Comminuted triplane fracture with displacement. |
Generate impression based on findings. | 37 years, Female. Reason: upright please, looking for free air History: abd pain Mildly distended bowel loops without obvious obstruction. No evidence of intraperitoneal free air. Lung bases are clear. | Nonobstructive bowel gas pattern without evidence of free air. |
Generate impression based on findings. | Male, 74 years old. Reason: eval ngt position History: ngt Enteric tube tip in the region of the gastric body. Sidehole is in the region of the GE junction.The pelvis is excluded from the field-of-view. No evidence of obstruction. Enteric contrast within the small bowel from recent prior exam.Right pleural effusion. | Enteric tube sidehole in the region of the GE junction. This can be advanced. |
Generate impression based on findings. | Clinical question: Status post craniotomy. Signs and symptoms, headache. Nonenhanced head CT:Examination is status post left frontal and anterior temporal craniotomy. Expected small epidural collection under the craniotomy flap containing air and small amount of hemorrhage and resultant subtle mass effect is noted. A w... | Expected postoperative changes of left frontal-temporal craniotomy for removal of lesion as detailed. |
Generate impression based on findings. | Reason: R/O ICH or fracture History: Pediatric Trauma There is no evidence of intracranial hemorrhage. The gray-white matter differentiation appears to be maintained. The ventricles and basal cisterns are normal in size and configuration. There is no mass effect or herniation. Mild mucosal thickening and small retentio... | 1.No evidence of intracranial hemorrhage or mass effect. 2.No calvarial fracture is identified. |
Generate impression based on findings. | Reason: 58 yo male with history of MDS; pre-allo SCT evaluation History: evaluate LUNGS AND PLEURA: Scattered benign-appearing micronodules, but no evidence of infection or malignancy.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy noted.CORONARY ARTERY CALCIFICATION: Moderate. CHEST WALL: No significant ... | No significant abnormality. No evidence of malignancy or infection. |
Generate impression based on findings. | 65 years, Male. Reason: LVAD w/ Dobhoff History: feeding on hold to check for dobhoff placement Feeding tube with tip projecting over the region of the gastric antrum. No definite bowel obstruction given the limited view.Cardiomegaly. Multiple incompletely imaged support devices including central venous catheter, ICD a... | Feeding tube with tip in the distribution of the gastric antrum. |
Generate impression based on findings. | Increase oxygen requirementVIEW: Chest AP Cardiothymic silhouette normal. Patchy subsegmental atelectasis in the right lower lobe and left lower lobe. No pleural effusion or pneumothorax. The stomach is dilated. | Patchy bilateral atelectasis in the right lower lobe and left lower lobe. |
Generate impression based on findings. | Reason: unexplained hypoxemia History: hypoxemia; history of alcohol abuse presenting with mental status change with right frontal intracranial hemorrhage. PULMONARY ARTERIES: Technically adequate study. Pulmonary embolus in the right middle lobe and subsequent segmental arteries.LUNGS AND PLEURA: Small right pleural e... | 1.Acute pulmonary embolus the right middle lobe artery 2.Lucent lesions in the ribs and right clavicle as above. Pathologic fracture through the right clavicular head. Correlate with history of malignancy, but these lesions are benign appearing and likely represents bone cysts or enchondromas.PULMONARY EMBOLISM: PE: Po... |
Generate impression based on findings. | Cystic fibrosis. PICC placementVIEW: Chest AP Cardiothymic silhouette normal. Right upper extremity PICC with tip at the right brachiocephalic vein. Bilateral bronchiectasis again noted. Patchy atelectasis left lower lobe. No pleural effusion or pneumothorax. | Right upper extremity PICC with tip at the right brachiocephalic vein. |
Generate impression based on findings. | syncope and collapse NONCONTRAST CT HEADNo evidence of acute ischemic or hemorrhagic lesion on this scan.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorr... | Multifocal wall calcifications and various degreed luminal stenosis as described above indicating atherosclerotic changes.The left paraclinoid segment ICA demonstrated more than 70% of luminal stenosis with wall calcifications.No aneurysm was seen.Prosthetic right eye glove.No evidence of acute ischemic or hemorrhagic ... |
Generate impression based on findings. | Clinical question: Evaluate for stability of intracranial hemorrhage. Signs and symptoms: ICH, needs anticoagulation for PE. Nonenhanced head CT:There is no convincing evidence of any significant change in the size, extent or the density of acute hemorrhagic changes in the right frontal lobe and associated edema. Findi... | 1.Stable acute left frontal lobe acute hemorrhage, surrounding edema and its associated mass effect with trace deviation of midline to the left.2.Stable normal size of ventricular system.3.Slight interval decreased intraventricular hemorrhage on the right since prior exam. |
Generate impression based on findings. | Gunshot woundVIEWS: Right humerus AP and lateral Again noted metallic bullet within the anterior soft tissues of the right upper arm. No acute fracture or dislocation. | Metallic bullet within the soft tissues of the right upper arm without acute fracture. |
Generate impression based on findings. | 24-year-old female patient with left peripheral visual field cut in the left eye. Evaluate for stroke. There is no evidence of intracranial hemorrhage. The ventricles and basal cisterns are normal in size and configuration. There is no mass effect or herniation. The imaged paranasal sinuses and mastoid air cells are cl... | 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. | No acute facial bone fracture is identified. The temporomandibular joints are intact. No orbital fracture is identified. The globes are intact. There is no evidence of intraorbital hematoma or stranding.Frontal sinus: The frontal sinus and frontoethmoidal recesses are clear.Anterior ethmoids: Mucosal thickening of the... | Nonspecific mild scattered pansinus mucosal thickening, without specific evidence of acute sinusitis. |
Generate impression based on findings. | FeverVIEW: Chest AP Cardiothymic silhouette normal. Peribronchial wall thickening with some subsegmental atelectasis in the right lower lobe and left lower lobe. No pleural effusion or pneumothorax. | Bronchiolitis or reactive airway disease. |
Generate impression based on findings. | Male, 54 years old, with history of recurrent left parotid gland adenoid cystic carcinoma status post total parotidectomy and radiation, status post chemotherapy. Extensive surgical and treatment related findings are again seen including left neck dissection with resection of the parotid and submandibular glands, flap ... | 1. Redemonstration of extensive surgical and treatment related findings. Soft tissue thickening through the left neck operative bed has not significantly changed. Likewise, scattered nodularity through the left posterior triangle is unchanged.2. No evidence of pathologic adenopathy in the neck.3. A left apical lung nod... |
Generate impression based on findings. | 17 year old male with right food pain, evaluate for fractureVIEWS: Right foots AP, oblique and lateral (3 views) 5/11/2015 at 19:00 Oblique fracture of the medial aspect of the base of the first metatarsal extends into the metatarsal-cuneiform joint space. A 2 mm ossicle seen projecting along the dorsal aspect of the f... | Intraarticular fracture of the base of the first metatarsal. |
Generate impression based on findings. | 55 year old male with xx of colonic perforation in Dec 2011; p/w recurrent LAP similar to that event tho not very tender; he is on immunosuppressants for his lungs transplant (2001) and kidney transplant (2012). Rule out bowel perforation vs partial bowel obstruction. LUNG BASES: Pericardial calcifications suggest prio... | 1.2 mm stone at the native right ureterovesicular junction with associated mild hydronephrosis of the native right kidney.2.Nonobstructing 9 mm stone of the left native kidney.3.Transplant kidney in the right iliac fossa, unremarkable.Findings were related by the radiology resident on call with Dr. Howes at 2139 hours ... |
Generate impression based on findings. | PainVIEWS: Left ankle AP, oblique and lateral No acute fracture or dislocation. The ankle mortise joint is normal. There is soft tissue swelling about the ankle joint. | No acute fracture or dislocation. |
Generate impression based on findings. | 43-year-old male with cough. LUNGS AND PLEURA: There is interval resolution of the previously described pleural-based hematoma along the anterior aspect of the right middle lobe. Interval resolution of the previously described bilateral pleural effusions.There is bilateral groundglass opacities most pronounced in the r... | Interval development of bilateral groundglass opacities suspicious for atypical infection such as pneumocystis or viral etiologies. Atypical pulmonary edema or pulmonary hemorrhage are considered differential considerations.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this r... |
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