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Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. No suspicious masses, microcalcifications or ar... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Reason: Please provide bi-dimensional measurements per RECIST 1.1 criteria History: Pleural mesothelioma CHEST:LUNGS AND PLEURA: Almost complete opacification of left hemithorax with minimal residual aerated lung secondary to extensive pleural tumor and underlying atelectasis. A small amount of pleural effusions presen... | 1.Progression of tumor measurements in the chest.2.Increased pericardial effusion. |
Generate impression based on findings. | Reason: h/o laryngeal ca and CRT, compare to previous, measurements pls History: none 90 CHEST:LUNGS AND PLEURA: Scarring is present along the minor fissure, but the lungs are otherwise unremarkable.Mild centrilobular emphysema is present.There is no evidence of pulmonary or pleural metastases.MEDIASTINUM AND HILA: No ... | No evidence of metastases, or other significant abnormality. |
Generate impression based on findings. | Clinical question: Bodytom. Signs and symptoms: Bodytom. Treatment planning nonenhanced head CT:There is a stereotactic device secured to patient's calvarium and without evidence of complication.Extensive metallic streak artifact partially obscures the exam in particular through posterior fossa. Acute intracranial hemo... | 1.Unremarkable nonenhanced head CT performed prior to placement of bilateral DBS.2.Post bilateral DBS placement head CT demonstrate expected postprocedural pneumocephalus and unremarkable exam otherwise. |
Generate impression based on findings. | 49-year-old male Reason: Evaluate for progression of metastatic disease; compare to previous scan History: None CHEST:LUNGS AND PLEURA: Interval progression in size and number of pulmonary nodules. A reference left lower lobe pulmonary nodule currently measures 5.4 x 3.9 cm (series 5, image 80) and previously measured ... | 1.Interval progression in size and number of pulmonary metastases as described above.2.New hepatic bilobar hyperattenuating foci suggestive of metastatic disease.3.Stable to slightly increased right hilar metastatic disease.4.Stable enhancing soft tissue mass in the left nephrectomy bed. |
Generate impression based on findings. | Female 94 years old Reason: eval aorta History: aortic thrombus CHEST:LUNGS AND PLEURA: Punctate granuloma right lung. No other nodules. No effusions.MEDIASTINUM AND HILA: Moderately heavy atherosclerotic calcifications aorta and coronary arteries. Proximal descending aorta shows irregularities consistent with ulcerate... | Heavy atherosclerotic disease. At least 2 areas of focally extensive mural thrombus as described above; one of them at the proximal abdominal aorta and proximal thoracic aorta.Partial intrathoracic stomach. |
Generate impression based on findings. | 44 year old male with history of colon cancer. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules. Micronodule along the right major fissure is stable, likely representing an intrapulmonary lymph node. No focal consolidation or pleural effusion.MEDIASTINUM AND HILA: Heart size is normal with no pericardial effusio... | 1.Wall thickening in the location of the patient's known primary colonic neoplasm near the hepatic flexure continues to improve, with no remaining measurable disease. 2.No specific evidence of metastatic disease. |
Generate impression based on findings. | History of T1N0 SCC L retromolar trigone s/p WLE 8/2012 p/w with T4N2b SCC L upper gingiva s/p surgery and induction chemotherapy with carboplatin/paclitaxel, s/p TFHX 5/5 completed 5/21/2014. Compare to prior studies. Redemonstrated are postoperative findings related to partial left maxillectomy with resection of the ... | 1. Extensive post surgical findings including partial left maxillectomy and soft tissue grafting, left neck dissection, with unchanged wide fistulous communication between the left maxillary antrum, nasal cavity and oral cavity. No discrete soft tissue mass to suggest local regional tumor progression; however, there is... |
Generate impression based on findings. | FractureVIEWS: Left elbow AP and lateral There are multiple K wires stabilizing the supracondylar fracture in near anatomic alignment. The overlying cast obscures fine bony detail. | Postoperative fixation of supracondylar fracture as described above. |
Generate impression based on findings. | Ring finger pain 3 views of the right ring finger reveal a nondisplaced mallet fracture that is unchanged from the previous exam. There is also some narrowing of the DIP joint consistent with osteoarthritis. | Mallet fracture unchanged |
Generate impression based on findings. | FractureVIEWS: Left elbow AP and lateral There has been interval healing of the supracondylar fracture in near anatomic alignment. There is periosteal reaction along the distal humerus. The overlying cast has been removed in the interval. | Healing supracondylar fracture in near anatomic alignment. |
Generate impression based on findings. | Male 7 years old with abdominal pain and loss of appetite. LIVER:The liver has a smooth contour, is normal in echogenicity and echotexture, and measures 11.5 cm in length. No focal hepatic mass is identified. The main portal vein is patent and demonstrates normal directional flow with a peak velocity of 0.4 m/s. There ... | Normal examination. |
Generate impression based on findings. | Foot pus The bones are demineralized suggesting osteopenia/osteoporosis. Evaluation of the phalanges is limited as the MTP joints are held in extension in the interphalangeal joints are held in flexion. Given this limitation, I see no focal osteolysis to confirm osteomyelitis. There is mild deformity of the fourth meta... | Degenerative changes and other findings as described above; I see no specific radiographic features of osteomyelitis. If further imaging evaluation is clinically warranted, MRI may be considered. |
Generate impression based on findings. | Female, 44 years old. Reason: dysphagia, h/o gastric bypass History: dysphagia Scout radiograph of the chest showed no mediastinal widening, abnormal pulmonary opacities, or pleural effusions.Single contrast evaluation of the esophagus and gastric pouch revealed:Postsurgical changes of a Roux-en-Y gastric bypass, with ... | Changes of a Roux-en-Y gastric bypass without other anatomic abnormality, significant esophageal dysmotility, or gastric reflux. If there is continued concern for gastritis, upper endoscopy may be useful for further evaluation. |
Generate impression based on findings. | Female 49 years old Reason: 50 yr old patient with ovarian cancer s/p22 cycles of Avastin. Hx of breast cancer with treatment in 2002. Compare to 8-4-15 scan. eval disease process History: none CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Port-A-Cath tip in proximal right atrium.CORONA... | No new sites of disease. Measured lesions roughly stable as measured above. |
Generate impression based on findings. | History of cervical laminectomy C3-7. Evaluate stability of spine. Surveillance imaging. Again seen is diffuse bony sclerosis indicating widespread metastatic disease. The patient is status post multilevel laminectomy. There is an anterior plate with screws entering the C3, C4, C5, and C6 vertebrae. One or both of the ... | Postoperative changes and findings compatible with diffuse osseous metastatic disease appearing similar to the prior study. |
Generate impression based on findings. | Mr. Pantajo is a 47 year old male presenting with a palpable right breast mass for the past one month. He denies any overlying skin changes, breast trauma or nipple discharge. Three standard views of both breasts with two spot compression views of the right breast were performed digitally and reviewed with the aid of R... | Benign gynecomastia of the right breast. No additional workup is necessary at this time. All results were relayed to the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: T - Take Appropriate Action - No Letter. |
Generate impression based on findings. | Reason: eval for PE, hx PE History: tachycardia, cp, palp, sob, R leg pain PULMONARY ARTERIES: Technically adequate study. No evidence of pulmonary embolus. Enlarged pulmonary artery measures 3.3 cm, compatible with pulmonary hypertension.LUNGS AND PLEURA: Minimal lingular scarring and right middle lobe atelectasis/sca... | No evidence of pulmonary embolus. Bronchial thickening may be due to bronchitis or asthma. |
Generate impression based on findings. | ConstipationVIEW: Abdomen AP There is mild amount of fecal burden. Disorganized nonobstructive bowel gas pattern. No abnormal bowel dilation. No evidence of pneumatosis or pneumoperitoneum. | Mild amount of fecal burden without obstruction. |
Generate impression based on findings. | Female 81 years old Reason: STAGE III RECTAL CANCER AND QUESTIONABLE HEPATIC MET. EVALUATE FOR INTERAVL CHANGE History: RECTAL CANCER CHEST:LUNGS AND PLEURA: Asymmetric apical pleural scarring right greater than left, unchanged. Scattered micronodules unchanged. No suspicious lesions. No effusions.MEDIASTINUM AND HILA:... | Stable spiculated soft tissue in rectal area. Stable appearance of the left chest wall with a small soft tissue nodule is slowly increased in size compared to 2012.Liver lesions with characteristics of simple cysts and are unchanged.Other findings as above. |
Generate impression based on findings. | Female 68 years old; Reason: met breast cancer History: met breast cancer CHEST:LUNGS AND PLEURA: There are multiple bilateral pulmonary lesions. The reference right upper lobe pulmonary lesion measures 0.8 x 0.8 cm (image 27/series 4) previously, 0.9 x 0.7 cm.The reference left upper lobe pulmonary lesion in the lingu... | 1.Increase in the size and number of hepatic lesions.2.New right pleural effusion. |
Generate impression based on findings. | Right foot pain. Evaluate for fracture. The bones appear demineralized, suggesting osteopenia/osteoporosis. I see no fracture. However, there is ulceration of the soft tissues medial to the first metatarsal head, and portions of the medial cortex of the first metatarsal head are poorly defined, highly suspicious for os... | Soft tissue ulceration and findings highly suggestive of osteomyelitis of the first metatarsal head. |
Generate impression based on findings. | DiarrheaVIEW: Abdomen AP Mild amount of fecal burden in the ascending colon. Disorganized nonobstructive bowel gas pattern. No abnormal bowel dilation. No evidence of pneumatosis or pneumoperitoneum. | Mild amount of fecal burden without obstruction. |
Generate impression based on findings. | 46 year-old female. Patient returns for short interval follow-up mammogram for a left breast focal asymmetry. Three standard views of both breasts and an additional right MLO view were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unc... | Left benign breast asymmetry is stable from 2010. 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 Ma... |
Generate impression based on findings. | Pain after MVA. I see no fracture or malalignment. There is partial sacralization of L5. Vertebral body heights and intervertebral disc spaces are maintained. Calcifications within the pelvis likely reside in a uterine fibroid. | No acute abnormality to account for the patient's pain; other findings as described above. |
Generate impression based on findings. | Status post MIS TLIF. Implant position? There are posterior rods with screws entering the L4, L5, and S1 vertebrae. I see no hardware complications. There are intervertebral spacer devices at L4-5 and L5-S1 with bone graft. Mild degenerative disc disease affects L3/4. Severe degenerative disc disease affects T11/12. Th... | Postoperative changes of lumbosacral fusion as described above. |
Generate impression based on findings. | Male, 65 years old. Reason: NGT placement History: see above Dobbhoff tube tip in the region of the gastroesophageal junction.Nonobstructive bowel gas pattern.Pleural effusions and basilar pulmonary opacities partially visualized. See same day chest radiograph for additional findings. | Dobbhoff tube tip in the region of the GE junction. This is adjusted on followup imaging. |
Generate impression based on findings. | Kyphosis history of arthrogryposisVIEWS: Thoracolumbar spine PA and lateral There is dextroscoliosis of the lumbar spine from L1 to L5 measuring approximately 24 degrees. There is mild kyphosis centered at the thoracolumbar junction. There is central beaking of the lumbar vertebral bodies. | Mild kyphosis centered at the thoracolumbar junction. |
Generate impression based on findings. | Female, 63 years old. Reason: DX esophageal cancer History: Pre-surgery Scout radiograph show no abnormal pulmonary opacity. The left renal collecting system was visualized likely secondary to recent contrast enhanced CT examination. On later fluoroscopic views, the right collecting system was also visualized.Using dil... | Limited study with irregular circumferential narrowing of the distal esophagus as above consistent with the patient's known diagnosis of esophageal cancer. |
Generate impression based on findings. | Male, 65 years old. Reason: Dobbhoff History: as above Dobbhoff tube tip in the region of the proximal gastric body, mildly twisted near the tip.Partially visualized nonobstructive bowel gas pattern.Pleural effusions and basilar pulmonary opacities partially visualized. See same-day chest radiograph for additional find... | Dobbhoff tube tip in the region of the proximal gastric body. This has been adjusted on followup imaging. |
Generate impression based on findings. | Acute on chronic bilateral foot pain. Evaluate for gout flare. 3 views of the left foot are provided. Evaluation is slightly limited due to inability to optimally position the patient. There are erosions along the medial aspect of the first metatarsal head and base of the first proximal phalanx compatible with the stat... | Findings compatible with gout as described above. |
Generate impression based on findings. | Male, 65 years old. Reason: NGT adjustment History: see above Dobbhoff tube tip in the region of the proximal gastric body, tightly curled near the tip, possibly kinked.Partially visualized nonobstructive bowel gas pattern.Pleural effusions and basilar pulmonary opacities partially visualized. See same-day chest radiog... | Dobbhoff tube tip tightly curled in the region of the proximal gastric body, possibly kinked. |
Generate impression based on findings. | 72-year-old female. History left breast lumpectomy for multifocal ILC in 3/2013. No current breast complaints. Three standard views of both breasts and two spot magnification views of the left breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which ... | Expected post-surgical 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 - Diag... |
Generate impression based on findings. | Genu valgus. VIEWS: Lower extremities standing/mechanical axis 05/12/15 The opening wedge osteotomy of the distal right femur has healed. The plate and screws device appears intact.Mild genu valgus is present on the left. Moderate to marked genu valgus is present on the right. The right knee joint and right hip joint a... | Worsening right genu valgus. |
Generate impression based on findings. | Pain in the back after fall 2 weeks ago. Spinal tenderness. Rule out compression fracture. 2 views of the thoracic spine are provided. The bones are demineralized suggesting osteopenia/osteoporosis. There is a mild dextroscoliosis of the thoracic spine. There is mild to moderate multilevel degenerative disc disease, bu... | Degenerative arthritic changes and other findings as described above without acute fracture evident. |
Generate impression based on findings. | Restaging large B-cell non-Hodgkin's lymphoma status post radiation and 6 cycles of chemotherapy.RADIOPHARMACEUTICAL: 10.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 100 mg/dL. Today's CT portion of the neck demonstrates no significant pathology. Please see diagnostic CT reports for details of the chest... | 1.Complete interval resolution of previous extensive hypermetabolic tumor activity without FDG avid tumor currently in the neck, chest, abdomen or pelvis.Diagnostic CTs of the chest, abdomen, and pelvis also performed at today's visit will be reported separately. |
Generate impression based on findings. | Male, 71 years old. Reason: 71 year-old male with dysphagia to solids x 6 months, esophagram to further evaluate History: as above Double contrast evaluation of the esophagus revealed no mucosal or mural abnormalities to suggest gastritis. A small hiatal hernia was identified. Fluoroscopic examination of esophageal mo... | 1.Mild esophageal dysmotility disorder.2.Spontaneous gastroesophageal reflux.3.Small hiatal hernia. |
Generate impression based on findings. | Female 63 years old Reason: preop MVR History: SOB VESSELS:Mild calcific arteriosclerotic disease affects the infrarenal abdominal aorta.INFRARENAL ABDOMINAL AORTA: 1.3 X 1.3 cmRIGHT COMMON ILIAC ARTERY: 0.7 X 0.7 mmRIGHT EXTERNAL ILIAC ARTERY: 0.6 X 0.6 mmRIGHT COMMON FEMORAL ARTERY: 0.6 X 0.7 mmLEFT COMMON ILIAC ARTE... | 1.Vascular measurements as detailed above. |
Generate impression based on findings. | Shoulder injury. Evaluate for fracture. Decreased range of motion and pain. I see no fracture or dislocation. There is minimal elevation of the distal clavicle relative to the acromion process which could conceivably represent a low-grade acromioclavicular joint separation if the patient complains of pain at this site;... | No fracture evident. Minimal elevation of the distal clavicle relative to the acromion process could conceivably represent a low-grade acromioclavicular joint separation if the patient complains of pain at this site; however this may simply reflect normal anatomy for this patient. If further imaging evaluation is clini... |
Generate impression based on findings. | l Male 77 years old Reason: 77 yo with borderline resectable pancreatic cancer has been on chemotherapy pre-op needs pancreas protocol CT Scan to evaluate extent of disease History: abdominal pain. ABDOMEN:LUNG BASES: Basilar interstitial changes right greater than left. Somewhat worse compared to the prior exam.LIVER,... | Minimal soft tissue abutting the splenic artery at the level of the previously visualized tumor. The tumor is no longer measurable. Portal lymph node decreased in size.Interstitial disease lung bases right greater than left, slightly more prominent. |
Generate impression based on findings. | Female, 63 years old, with neck pain and right upper extremity weakness. A very slight scoliotic curvature of the cervical spine is seen which may be positional. Trace anterolisthesis of C3 on C4 and C4 on C5 which were seen on the prior examination are not as clearly evident on today's study.Vertebral body height is p... | 1.Significant multilevel facet degeneration, particularly on the right, and particularly at C3-4 where erosive change seems to have mildly progressed.2.Scattered foraminal narrowing, moderate to severe at some levels, unchanged.3.No high-grade spinal canal stenosis or obvious cord impingement. Mild spinal canal narrowi... |
Generate impression based on findings. | Back pain. History of lumbar fusion. Evaluate hardware and fusion. Again seen are posterior stabilization rods with screws entering L3, L4, and L5. Screw fragments are again noted within L4 and L5. There is mild angulation of one of the L3 pedicle screws with respect to the closure top, but this may simply reflect a no... | Postoperative changes appearing similar to those seen on the prior study. |
Generate impression based on findings. | Reason: stones History: stones RIGHT KIDNEY: Right kidney measures 12.0 cm in length. No hydronephrosis or shadowing renal calculus.LEFT KIDNEY: Left kidney measures 11.5 cm in length. No hydronephrosis or shadowing renal calculus.URINARY BLADDER: Mildly underdistended bladder, however no significant abnormalities are ... | No renal calculus or hydronephrosis bilaterally. |
Generate impression based on findings. | Reason: is there progressing hydronephrosis? Evidence of worsening urinary obstruction? History: AKI RIGHT KIDNEY: The right kidney measures 14.5 cm in length. Mild dilation of the right renal collecting system, which is improved when compared to the prior examination. Renal stent is identified. No shadowing renal calc... | 1.Mild dilatation of the right collecting system which is improved when compared to the prior exam. 2.No shadowing renal calculus is identified. |
Generate impression based on findings. | 7-year-old male with history of cavus foot reconstruction.VIEWS: Right foot AP and lateral (2 views) 5/12/2015 at 15:51 The cast has been removed. The bones are diffusely osteopenic. A dorsal metallic clip affixes the proximal first metatarsal osteotomy in anatomic alignment. There is mild surrounding periosteal reacti... | Healing osteotomy in anatomic alignment. |
Generate impression based on findings. | Widespread prostatic metastases AP and lateral views of the left femur reveal widespread sclerotic metastatic disease from the patient's known prostate cancer. I do not see any superimposed fractures.AP and lateral views of the left hip reveal sclerotic metastasis throughout the proximal femur and the left sided innomi... | Widespread sclerotic metastases. No acute abnormalities. |
Generate impression based on findings. | 55-year-old female with pain. Evaluate for RA Right hand: 3 views of the right hand reveal juxta-articular osteoporosis. There are erosions involving the third, fourth and fifth metacarpal heads as well as the ulnar styloid consistent with Rheumatoid Arthritis.Left hand: 3 views of the left hand reveal juxta-articular ... | 1. Juxta-articular osteoporosis of the hands.2. Rheumatoid arthritic changes of the right hand. 3. Suggestion of joint effusion or synovitis about the elbows. 4. Mild osteoarthritis of the AC joints and other findings as above. |
Generate impression based on findings. | 14-year-old male status post reduction of fifth finger fracture.VIEWS: Right fifth digit PA and lateral (2 views) 5/12/2015 at 15:59 Overlying splint material limits evaluation of fine bone detail. A K wire affixes a fracture of the base of the fifth proximal phalanx in near-anatomic alignment. | Fixation of fifth proximal phalanx fracture. |
Generate impression based on findings. | Female, 19 years old. Reason: Assess for SMA syndrome (previously diagnosed in March) History: Nausea/vomting The scout film shows a nonobstructive bowel gas pattern. Single contrast evaluation of the esophagus showed no morphologic abnormalities. Fluoroscopic evaluation of the esophageal peristalsis demonstrated a nor... | Findings suggesting a with mild superior mesenteric artery syndrome which are not significantly changed since prior study. |
Generate impression based on findings. | Injured fifth distal phalanx 3 days ago. 3 views of the right hand reveal a comminuted intra-articular fracture of the distal phalanx that extends into the distal interphalangeal joint. There is volar displacement of the proximal fragment . | Fracture of the fifth distal phalanx that extends into the DIP joint |
Generate impression based on findings. | Male 57 years old; Reason: s/p TEVAR, EVAR, visceral debranching; Annual Surveillance study History: none CHEST:LUNGS AND PLEURA: Mild subpleural emphysema. There is mucus within the right mainstem airway.No dominant lung lesion. Pleural spaces are clear.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusi... | 1.Postsurgical changes from endovascular suprarenal aortic stent graft placement occluding the celiac artery aneurysm.2.Unchanged GDA aneurysm |
Generate impression based on findings. | 31-year-old female with injury with exercise, favoring right arm, not using left arm, c/o pain. 2 views of the left shoulder reveal no acute fracture or dislocation. Vague lucency noted in the proximal humeral diaphysis adjacent to the bony protuberance of the deltoid insertion It is unclear if this is a real finding. | Vague lucency in the proximal humeral diaphysis adjacent to the bony protuberance of the deltoid insertion is noted. It is unclear if this is a real finding. If patient has symptoms in this location, MRI may be considered for further evaluation. |
Generate impression based on findings. | Male 72 years old; Reason: renal cell cancer please compare measurements History: renal cell cancer. CHEST:LUNGS AND PLEURA: Index nodule right middle lobe series 5 image 49, 2-mm. Previously 4 mm. Pleural-based nodular thickening lateral aspect right middle lobe series 5 images 59-60, unchanged.Index left lobe, lingul... | 1.No new sites of disease. Index lesion measurements as above. Increase in size of right renal mass. Nonobstructive left inguinal hernia. |
Generate impression based on findings. | Club footVIEWS: Right tibia and fibula AP and lateral There is periosteal reaction along the diaphysis of the tibia likely representing a healing fracture. There is mild bowing deformity to the fibula. | Healing tibia fracture with periosteal reaction. |
Generate impression based on findings. | Crohn's disease on therapy. Inflammatory markers decreasing. Started unrestricted diet last week. Formerly had been on liquid diet.EXAMINATION: MR enterography without and with IV contrast 05/12/15 ABDOMEN:LIVER, BILIARY TRACT: Normal in appearance. No biliary ductal dilatation. Gallbladder is distended and normal in a... | Worsening appearance of the distal and terminal ileum with increased dilation and increased enhancement. The dilation is most likely as a result of a stricture just proximal to the ileocecal valve. |
Generate impression based on findings. | Reason: h/o left neck melanoma History: s/p surgery, r/o mets. CHEST:LUNGS AND PLEURA: Stable calcified and noncalcified pulmonary micronodules. No new or suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: Small amount of residual thymic tissue. Small nonenlarged mediastinal and hilar ly... | No specific evidence of metastases. |
Generate impression based on findings. | IrritabilityVIEW: Abdomen AP NG tube tip in the stomach. Disorganized nonobstructive bowel gas pattern. There is no abnormal bowel dilation. No pneumatosis or pneumoperitoneum. | Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Status post MVC, tender to palpation at the midshaft. Evaluate for acute fracture. There is a transverse fracture through the distal ulnar diaphysis with minimal medial angulation of the distal fracture fragment. The wrist and elbow joints are unremarkable. | Distal ulnar fracture. |
Generate impression based on findings. | Fall. AMS. Abrasion over mid shaft. Evaluate for fracture. The AP view of the pelvis shows no fracture or malalignment. Degenerative arthritic changes affect the lower lumbar spine.2 views of the right tibia/fibula show no fracture. Components of a right total knee arthroplasty device are situated in near-anatomic alig... | No fracture evident. |
Generate impression based on findings. | 58 year old female s/p LAR for rectal cancer on chemotherapy. Pls compare to prior. CHEST:LUNGS AND PLEURA: Stable scattered bilateral pulmonary micronodules, some calcified. No suspicious pulmonary nodules. No focal consolidation or pleural effusion.MEDIASTINUM AND HILA: Heart size is normal with no pericardial effusi... | No specific evidence of recurrence or metastases.Interval right lower quadrant ostomy takedown and reanastomosis. |
Generate impression based on findings. | Reason: 68yo F with history of LLL nodule, follow-up History: - LUNGS AND PLEURA: Calcified nodules in the right lower lobe consistent with previous granulomatous infection, unchanged.No suspicious nodules.MEDIASTINUM AND HILA: No significant lymphadenopathy.No pericardial effusion.CORONARY ARTERY CALCIFICATION: None. ... | Stable calcified nodules consistent with previous infection. No suspicious nodules.No further CT follow-up is recommended for these nodules. |
Generate impression based on findings. | Reason: RUL cavitary lesion, aspergillosis; please assess for interval changes History: cough LUNGS AND PLEURA: Right upper lobe thick-walled cavitary lesion with adjacent atelectasis and bronchiectasis, not significantly changed.Extensive reticular and nodular opacities elsewhere, mainly in the upper lung zones, with ... | Extensive chronic upper zone disease with a large right upper lobe cavity, bronchiectasis and reticulonodular opacities, consistent with granulomatous infection, with no significant interval change. |
Generate impression based on findings. | Reason: r/o appy, acute abdomen History: severe abdomen pain. ABDOMEN:LUNG BASES: Bibasilar atelectasis.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Nonobstructing... | 1.Normal appendix.2.Heterogeneous bilateral adnexal regions without definite abscess. Mild pelvic lymphadenopathy, likely reactive. This could be further evaluated with pelvic sonography.3.Nonobstructing right renal calculus. |
Generate impression based on findings. | History of back pain and weakness. History of L4-5, S1 laminectomy. Evaluate spine stability, scoliosis, sagittal balance. Evaluation of the spine is limited on several of the views due to motion artifact and other technical factors. On the AP view, there is approximately 15 degrees of dextroscoliosis of the lumbar spi... | Scoliosis and degenerative changes as described above. |
Generate impression based on findings. | HypoxiaVIEW: Chest AP ET tube has been removed in the interval. Left subclavian central line with tip at the confluence of the brachiocephalic veins. Cardiothymic silhouette normal. Patchy atelectasis left lower lobe. The left hemidiaphragm is elevated. The right lung is clear. | Patchy atelectasis in the left lower lobe. |
Generate impression based on findings. | 48-year-old male with shortness of breath, tachycardia, hypoxia. Rule out PE. The comparison chest radiograph performed on 5/12/2015 demonstrates no focal pulmonary opacities or pleural fluid. The ventilation images show significant ventilation defects throughout both lungs with eventual equilibration on wash-in images... | 1.Evidence of severe mixed restrictive and obstructive ventilatory disease bilaterally with extensive matched perfusion defects.2.While there are no significant mismatched perfusion defects identified to specifically suggest PE, given the extent of the ventilation (and resulting perfusion) abnormalities the sensitivity... |
Generate impression based on findings. | FractureVIEWS: Right knee AP and lateral Healing fracture involving the distal femur again noted. There is periosteal reaction along the medial aspect of the distal femur. The alignment is anatomic. No knee joint effusion. | Healing distal femur fracture in anatomic alignment. |
Generate impression based on findings. | 7-year-old male, evaluate fracture.VIEWS: Right forearm AP and lateral (2 views) 5/12/2015 at 14:00 Cast material obscures fine bone detail. Again seen are healing transverse fractures of the distal radius and ulna with periosteal reaction and progressive callus formation. Alignment appears similar to the prior study w... | Healing fractures of the distal radius and ulna. |
Generate impression based on findings. | Reason: Assess for interstitial changes, concern for hypersensitivity pneumonitis History: recurrent COPD exacerbations LUNGS AND PLEURA: Left upper lobe subpleural slightly lobulated solid nodule (series 6/126 measures 10 x 14 mm, not significantly changed from from 9 x 14 mm on the previous scan and clearly increased... | 1.Suspicious left upper lobe nodule with interval growth since 2011. A negative PET scan suggested a benign etiology, however. Continued surveillance is recommended with a follow-up scan in approximately 6 months time.2. Diffuse emphysema with bronchial thickening and basilar subpleural atelectasis. No specific finding... |
Generate impression based on findings. | Respiratory failureVIEW: Chest AP and abdomen AP Cardiothymic silhouette normal. Minimal atelectasis left lower lobe. No pleural effusion or pneumothorax. Gastrostomy tube in place. Multiple mildly dilated loops of bowel in the midline. No pneumatosis or pneumoperitoneum. | Minimal atelectasis left lower lobe. Multiple mildly dilated loops of bowel in the midline. |
Generate impression based on findings. | Female, 14 years old, status post fall. Hit the back of her head on concrete with loss of consciousness. Mild posterior subgaleal thickening is seen. No evidence of skull fracture is detected. The cerebral and cerebellar hemispheres and brainstem are normal in attenuation and morphology. No intracranial hemorrhage or a... | 1.Mild posterior scalp injury. No evidence of skull fracture.2.No acute intracranial abnormality. |
Generate impression based on findings. | 67-year-old female with gait disorder, falling, small steps, cogwheeling, tardive dyskinesia. Evaluate for evidence of Parkinson's disease. Normal symmetric activity is seen in the basal ganglia. | Normal examination. No evidence of nigrostriatal dopaminergic deficit to indicate Parkinson's disease. |
Generate impression based on findings. | Female, 51 years old, with stroke The cerebral and cerebellar hemispheres and brainstem are normal in attenuation and morphology. No intracranial hemorrhage or abnormal extra-axial fluid is seen. There is no evidence of mass effect or parenchymal edema. The ventricular system is normal in size and morphology. The visua... | No acute intracranial abnormality. |
Generate impression based on findings. | Female, 79 years old, history of falls, with weeklong history of blurry vision. Minimal punctate hypoattenuation is seen within the left basal ganglia. Otherwise no significant attenuation abnormalities, parenchymal edema, mass effect or loss gray-white distinction are seen. No intracranial hemorrhage or any abnormal e... | 1.No acute intracranial abnormality. At most there may be minimal age-indeterminate lacunar disease in the left basal ganglia, but this is equivocal.2.New opacification of the nasal sinuses may reflect sinus mucosal inflammatory debris. Hyperattenuation of the opacifying material may reflect inspissated secretions, les... |
Generate impression based on findings. | 83-year-old male with history of lymphoma status post chemotherapy.RADIOPHARMACEUTICAL: 11.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 104 mg/dL. Today's CT portion grossly demonstrates multiple bilateral enlarged paratracheal and hilar lymph nodes as well as extensive coronary and atherosclerotic calc... | 1.Symmetric bilateral hilar and mediastinal lymph nodes are somewhat progressed in size, number, and activity since the prior study. Although progressed, this appearance is again felt to more likely represent benign granulomatous disease. Tumor activity is conceivable but considered less likely. 2.No suspicious FDG avi... |
Generate impression based on findings. | 27 year-old female kidney donor. The patient’s weight of 74.5 kg and height of 157.5 cm were used for all calculations.Raw GFR = 131 mL/minBSA = 1.84 m2Estimated GFR/m2 = 71 mL/min/m2Estimated GFR/m2 * 1.73 m2 (average adult BSA) = 123 mL/min (adult GFR equivalent) | GFR measurements as above. |
Generate impression based on findings. | Swelling and pain status post hitting wall There is an oblique fracture through the distal diaphysis of the fifth metacarpal with approximately 3 mm of volar and radial displacement and 40 degrees of volar angulation of the distal fracture fragment. I suspect that there is also a minimally displaced and likely intra-ar... | Fifth metacarpal fracture and probable fracture of the base of the fourth metacarpal as well. These findings were discussed with Dr. Sarmiento at the time of dictation. |
Generate impression based on findings. | Evaluation of bony growth on right wrist. No pain, just unsightly. There is mild soft tissue swelling along the radial aspect of the wrist, but I see no bony excrescence. Mild osteoarthritis affects the interphalangeal joints. Degenerative arthritic changes also affect the third metacarpophalangeal joint and to a lesse... | Degenerative arthritic changes as described above. I see no bony excrescence. Mild soft tissue swelling along the radial aspect of the wrist is nonspecific. |
Generate impression based on findings. | Minor blunt head trauma. No evidence of acute ischemic or hemorrhagic lesion.Patchy scattered bilateral low attenuations on periventricular white matter indicate nonspecific small vessel disease.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is... | No evidence of acute ischemic or hemorrhagic lesion.Minimal to mild nonspecific small vessel disease |
Generate impression based on findings. | Gait instability and headache No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The osseous struc... | No evidence of acute ischemic or hemorrhagic lesion.Minimal nonspecific small vessel disease. |
Generate impression based on findings. | Ataxia and history of fall No evidence of acute ischemic or hemorrhagic lesion.The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass effect, edema, midline shift, intra- or extra-axial fluid collection/acute hemorrhage. The osseous structur... | No evidence of acute ischemic or hemorrhagic lesion.Nonspecific minor small vessel disease. |
Generate impression based on findings. | Altered mental status. No evidence of acute ischemic or hemorrhagic lesion.Scattered patch bilateral periventricular white matter indicate nonspecific small vessel disease, minimal to mild degree.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.Nonspecific small vessel disease, minimal to mild degree. |
Generate impression based on findings. | Headache, history of lymphosarcoma Previously shown left intraorbital soft tissue mass is not demonstrated on today's CT scan.For more precise imaging evaluation, dedicated orbit MRI with and without contrast can be considered.There is no evidence of acute ischemic or hemorrhagic lesion on this scan.Bilateral maxillary... | Interval improvement of left intraorbital soft tissue mass as described above.Dedicated orbit MRI can be considered for further imaging evaluation if clinically necessary.No evidence of acute ischemic or hemorrhagic lesion on this scan. |
Generate impression based on findings. | Altered mental status No evidence of acute ischemic or hemorrhagic lesion.Bilateral distal vertebral artery show extensive calcifications indicating atherosclerotic changes.Patchy low attenuations on bilateral periventricular white matter indicating minimal nonspecific small vessel disease.The ventricles, sulci, and ci... | No evidence of acute ischemic or hemorrhagic lesion.Minimal nonspecific small vessel disease. |
Generate impression based on findings. | Clinical question: Headache, shunt revision. Signs and symptoms: Headache. Nonenhanced head CT:There is no detectable acute intracranial process.Dysmorphic supratentorial ventricular system demonstrate subtle interval decreased size since prior study.Stable right posterior temporal approach ventricular catheter with th... | 1.No detectable acute or new finding since prior exam.2.Subtle interval decreased size of dysmorphic supratentorial ventricular system with stable ventricular catheter. |
Generate impression based on findings. | Clinical question: Rule out intracranial abnormality. Signs and symptoms: Headaches x2 weeks on the left side status post fall. Nonenhanced head CT:There is no detectable acute intracranial process. CT is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sul... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Treatment/surgical planning nonenhanced head CT for epilepsy. Signs and symptoms: Epilepsy. Nonenhanced head CT:Examination is performed with a stereotactic device secured to the patient's calvarium and without detectable complication.There is no detectable acute intracranial process. Ventricular sys... | 1.Surgical planning nonenhanced head CT as detailed.2.Post surgical nonenhanced head CT demonstrate expected postoperative changes of left temporal lobe electrode placement as detailed. |
Generate impression based on findings. | Clinical question: Evaluate for ICH. Signs and symptoms: Plavix, acute onset of headache. Nonenhanced head CT:There is no detectable acute intracranial process. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF sp... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Worsening of right-sided weakness with history of multiple sclerosis There are subtle low attenuation lesions on bilateral subcortical white matter especially on the left trigone area in the left frontal lobe.There is no evidence of acute hemorrhage lesion on this scan.The ventricles, sulci, and cisterns are symmetric ... | Bihemispheric subcortical patch low attenuation lesions with variable size indicating multiple sclerosis lesions.No evidence of hemorrhage lesion. |
Generate impression based on findings. | Clinical question: Staging of newly diagnosed NSCLC. Signs and symptoms: None Enhanced head CT:Examination demonstrates unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and gray-white matter differentiation. There is no detectable abnormal parenchymal or leptomeningeal enhancement to suggest... | Negative enhanced head CT. |
Generate impression based on findings. | Clinical question: Headache and nausea, evaluate for ICH. Signs and symptoms: Headache. Nonenhanced head CT:There is no detectable acute intracranial hemorrhage, edema, mass effect, midline shift or hydrocephalus. CT however is insensitive for early detection of acute nonhemorrhagic ischemic strokes.Unremarkable cerebr... | Unremarkable nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Status post cranioplasty. Signs and symptoms: Headache. Nonenhanced head CT:Large focus of encephalomalacia in the right cerebellum without evidence of change since prior exam.Postoperative changes of a large left frontal cranioplasty is noted. There is extra-axial primarily low density epidural coll... | 1.Status post left sided cranioplasty.2.Primarily low density epidural collection under the craniotomy flap measuring maximum of 21 mm thick with resultant mass effect and 4 mm rightward deviation of midline.3.Stable nondilated ventricular system.4.Age-indeterminate small vessel ischemic strokes grossly similar to prio... |
Generate impression based on findings. | Clinical question: 64-year-old male status post fall, evaluate for hemorrhage. Signs and symptoms: None. Nonenhanced head CT:There is no evidence of an acute posttraumatic intracranial, calvarial or soft tissues of the scalp findings.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and great... | 1.No detectable acute posttraumatic intracranial, calvarial or soft tissues of the scalp findings.2.Unremarkable intracranial contents.3.Extensive opacification of mastoid air cells and bilateral middle ear cavities without detectable bony changes and concerning for otitis. |
Generate impression based on findings. | 48-year-old male patient with a AKI, bilateral hydronephrosis. Assess for anatomy and cause of post renal obstruction. Evaluation of vascular structures and solid parenchymal organs is limited without IV contrast.ABDOMEN:LUNG BASES: Minimal dependent basilar atelectasis.LIVER, BILIARY TRACT: Within limits of a non-enha... | 1. Drainage catheter outside of a heterogeneous collection in the presacral space which appears to extend to a different, additional loculated low-attenuation collection encircling the prostate and the bladder. These findings most likely represent infection with loculated abscess formation.2. Moderate bilateral hydrour... |
Generate impression based on findings. | Female 34 years old; Reason: r/o pancreatitis History: elevated lipase and epigastric pain ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Gallstone in a nondistended gallbladder. Mild biliary intrahepatic dilatation. Common bile duct is not dilated however with a maximal dimension of about ... | 1.Cholelithiasis, possible choledocholithiasis and mild intrahepatic biliary dilatation. Punctate gas in the common bile duct might be explained by recently passed gallstone. These findings might explain the elevated lipase. Correlate with MRCP. Given body habitus ultrasound is not likely to be optimal for evaluating c... |
Generate impression based on findings. | Status post mechanical fall secondary to right knee pain. The bones appear slightly demineralized suggesting osteopenia. Tiny osteophytes indicate mild osteoarthritis. I see no fracture or malalignment. I see no joint effusion. There is perhaps mild soft tissue swelling anterior to the proximal tibia. | Mild osteoarthritic changes without fracture evident. |
Generate impression based on findings. | 21 year old female with RLQ abdominal pain, s/p appy, s/p recent psoas abscess drain. Eval for psoas abscess (r), colon flare. LUNG BASES: Trace right pleural effusion and minimal right basilar atelectasis. No focal consolidation. No suspicious pulmonary nodules.LIVER, BILIARY TRACT: Liver enhances homogenously without... | 1.Large psoas abscess with fistulization to inflamed cecum.2.Mild splenomegaly3.Trace right pleural effusion. |
Generate impression based on findings. | Male 16 years old Reason: rule out fracture of foot History: trauma to right 4th and 5th digit yesterday, increased pain and swelling, difficulty ambulatingVIEWS: Right foot AP, oblique, and lateral (3 views) 5/12/2015 at 17:04 No acute fracture or malalignment. | No fracture. |
Generate impression based on findings. | Evaluate olecranon fracture post ORIF with plate A plate and screw device affixes an olecranon fracture in near anatomic alignment. I see no hardware complications. The fracture line is indistinct which may reflect some healing. A 1 cm wedge-shaped fracture fragment is noted on the external rotation view along the prox... | Orthopedic fixation of olecranon fracture as above. |
Generate impression based on findings. | 57-year-old female with ankle pain, swelling. Evaluate for fracture 3 views of the left ankle show diffuse soft tissue swelling. No fracture is evident. There is an approximately 4 mm density within the plantar soft tissues beneath the anterior aspect of the calcaneus that may represent a small foreign body but is of q... | 1. Diffuse soft tissue swelling without fracture evident.2. Possible small foreign body in the plantar soft tissues of questionable current clinical significance. |
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