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Generate impression based on findings. | 82 years, Female. Reason: r/o obstruction History: pain and distention No definite evidence of free air. There is differential air-fluid level in the stomach on upright view. There is distended mid-abdomen small bowel loop on supine view with paucity of gas distally. There is small amount of gas in the proximal colon. ... | No definite free air. Findings consistent with early partial small bowel obstruction. |
Generate impression based on findings. | Male; 35 years old. Reason: evaluation preoperatively, ribs 1-4 LUL synovial sarcoma History: sob LUNGS AND PLEURA: Left superior sulcus tumor located posteriorly has significantly decreased in size since prior study and currently measures approximately 1.7 x 3.2 x 1.6 cm (AP by transverse by craniocaudal) (series 4/13... | Left superior sulcus tumor has significantly decreased in size as above. |
Generate impression based on findings. | Lumbar pain There are 5 lumbar vertebral bodies. The bones are demineralized. There is a slight leftward curvature of the lumbar spine. Mild facet arthropathy affects the lower lumbar spine. Hypertrophy of the lower lumbar spinous processes and associated degenerative changes are noted. | Degenerative disk disease and other findings as described above. |
Generate impression based on findings. | 64-year-old female status post ORIF A volar plate with screws affixes a distal radius fracture in near-anatomic alignment without evidence of hardware complication. Slight progression of callus formation along the radial aspect of the fracture indicates some interval healing. The bones are demineralized. There is sligh... | Orthopedic fixation of distal radius fracture as described above. |
Generate impression based on findings. | 70 year-old female with pain, evaluate left shoulder Right shoulder: Hardware components of a reverse total shoulder arthroplasty device are situated in near-anatomic alignment without evidence of complication.Left shoulder: Streaky calcifications along the superolateral aspect of the greater tuberosity suggest calcifi... | Right reverse total shoulder arthroplasty and left calcific rotator cuff tendinosis as described above. |
Generate impression based on findings. | 18 year-old male with lbp for a year with arching; wrestling. Evaluate for spondylolysis. No abnormal osseous foci are identified. | Normal examination with no evidence of spondylolysis. |
Generate impression based on findings. | Postoperative changes are seen from posterior surgical fusion of L4 and L5 with bilateral pedicle screws at these levels and intervening interbody spacer. There is suggestion of bilateral laminectomies and a left facetectomy.The lumbar spine is in normal alignment, with a normal lumbar lordosis. There is mild disk nar... | Postoperative changes at L4-L5 without significant central spinal canal stenosis at any level. Nonspecific abnormal signal in the left L4-L5 foramen which may relate to post operative changes. Postcontrast images of the lumbar spine may be helpful to evaluate for granulation tissue versus recurrent disk, if clinically ... |
Generate impression based on findings. | CLL on clinical trial. There is no evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. The major salivary glands are unremarkable. There is an unchanged appearance of the thyroid gland with multiple nodules. The major cervical vessels are patent. The osseous structures ar... | 1. No evidence of significant lymphadenopathy in the neck to suggest recurrent lymphoma.2. Unchanged appearance of thyroid gland with multiple nodules. |
Generate impression based on findings. | 29-year-old female with SOB. Evaluate for PE. The comparison chest radiograph performed on the same day demonstrates no focal pulmonary opacities or pleural fluid. Again seen is pulmonary artery enlargement compatible with pulmonary arterial hypertension.The ventilation images show a uniform distribution of activity on... | 1.Very low probability for pulmonary embolism.2.Scintigraphic findings in conjunction with chest radiograph findings compatible with pulmonary arterial hypertension.3.Findings suggestive of a right to left shunt with differential including Eisenmenger syndrome. |
Generate impression based on findings. | Esophageal cancer. CHEST:LUNGS AND PLEURA: Bronchiolitis pattern in the posterior right upper lobe, most likely related to aspiration.Scattered ground glass opacities in the right lung, some of which are new and may be the result of radiation therapy warmer post inflammatory. Peripheral opacity in the anterior right lo... | 1. Stable mildly enlarged high right tracheoesophageal lymph node.2. Nodular density in the right lower lobe and is now associated with some surrounding linear densities. Although this is of unclear etiology the appearance is atypical for a metastasis and a post inflammatory lesion, possibly related to radiotherapy, is... |
Generate impression based on findings. | Hodgkin's disease. Follow-up. CHEST:LUNGS AND PLEURA: Scattered micronodules as noted previously.MEDIASTINUM AND HILA: Unchanged reference left supraclavicular lymph node, measuring 2.2 x 0.9 cm (image 12; series 3). Anterior mediastinal soft tissue attenuation measures 3.9 x 2.0 cm (image 35; series 3), equivocally sm... | 1.Equivocal interval decrease in size of mediastinal mass; the mass appears unchanged compared to 3/5/2014 study.2.Stable decreased osseous mineralization. |
Generate impression based on findings. | 53 year-old female with lung cancer. The comparison chest radiograph performed on 1/21/2015 demonstrates known right upper lobe mass. The ventilation images show no uptake in the right upper lobe that correlates with the patient's known mass. Otherwise, there is uniform distribution of activity on single-breath and was... | Triple matched perfusion and ventilation defect involving the patient's known right upper lobe mass. Otherwise, normal symmetric ventilation and perfusion images as quantified above. |
Generate impression based on findings. | Female; 63 years old. Reason: ILD protocol, SLE with possible parenchymal disease History: DOE, hypoxemia LUNGS AND PLEURA: Respiratory motion limits evaluation of fine parenchymal detail. Within this limitation, no definite interstitial abnormalities are evident. Mild hazy opacity posteriorly in both lungs, most sugge... | 1. Limited evaluation of parenchymal detail due to respiratory motion. Within this limitation, no definite interstitial abnormality.2. Severe calcifications of the coronary arteries. |
Generate impression based on findings. | Female 79 years old; Reason: evaluate for cause of abd pain in 79yo female w PMH of enlarging AAA, recurrent c diff, multiple abd surgeries History: elevated WBC but no fevers, diarrhea ABDOMEN:LUNG BASES: Atelectasis/scarring is noted in the lung bases.LIVER, BILIARY TRACT: Moderate to severe intrahepatic and extrahep... | 1.New moderate to severe biliary duct dilation. A distal obstructing lesion cannot be excluded and correlation with ERCP should be considered. Ascending cholangitis should also be considered.2.Bowel wall thickening of the sigmoid colon and rectum likely represents colitis.3.No significant change in aneurysmal dilation ... |
Generate impression based on findings. | 75 years old male presents with a lung nodule. This study was performed to evaluate for mediastinal and extrathoracic involvement.RADIOPHARMACEUTICAL: 15.2 MCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 94 mg/dL. Today's CT portion grossly demonstrates a mass in the right upper lobe. Diffuse emphysematous c... | 1.Hypermetabolic tumor in the right upper lobe at perihilar region, consistent with a diagnosis of lung cancer.2.No definite evidence of regional nodal metastasis or distant metastasis.3.Symmetrical in the multifocal mild FDG uptake in both lung hila and mediastinal subcarinal and precarinal regions, which are nonspeci... |
Generate impression based on findings. | CLINICAL DATA: Age: 77 years. Sex : Male. Indication: Reason: Pancreatic pseudocyst s/p drainage History: Pancreatic pseduocyst. LUNG BASES: Interval decreased pleural effusions, with a small amount of right basilar dependent atelectasis remaining.LIVER, BILIARY TRACT: Cholecystectomy clips. No significant abnormality ... | 1.Interval decreased size, and near complete resolution, of the previously seen pancreatic pseudocyst.2.Interval decreased pleural effusions.3.Significant atherosclerosis as above. |
Generate impression based on findings. | Pain and swelling to proximal elbow, abrasion posteriorly, evaluate for fracture Right elbow:There is an oblique fracture through the proximal ulna and olecranon extending to the articular surface. There is elevation of the distal humeral fat pads compatible with a lipohemarthrosis.Right wrist: Three views of the right... | Proximal ulna/olecranon fracture as above. |
Generate impression based on findings. | CLINICAL DATA: Age: 61 years. Sex : Male. Indication: Reason: History of bladder cancer and renal lesion, monitor for stability or disease spread/recurrence History: Bladder cancer on surveillance and renal lesion. LUNG BASES: Scattered small calcified hilar lymph nodes, unchanged. Heart size within normal limits, no p... | Unchanged right renal lesion, and although stable is worrisome for renal cell carcinoma. |
Generate impression based on findings. | 40-day-old male with with abdominal distention. Is there dilation or pneumatosis?VIEW: Abdomen AP (one view) 1/21/2015, 1312 NG tube tip in the stomach. Bowel gas pattern is disorganized. Long segment of dilated bowel loop may represent colon in the left hemiabdomen. Bubbly appearance to the bowel contents in the pelvi... | Probable pneumatosis and less likely formed stool in the pelvis and right lower quadrant. |
Generate impression based on findings. | Female; 79 years old. Reason: Pleural mesothelioma. Please compare to prior exam per recist criteria. History: Pleural mesothelioma CHEST:LUNGS AND PLEURA: Left nodular pleural thickening is compatible with given diagnosis of mesothelioma is unchanged. Reference measurements are asfollows:1. At the level of aortic arch... | Stable mesothelioma with reference measurements as detailed above. |
Generate impression based on findings. | Ms. Williams is a 62 year old female recalled from screening mammogram for an asymmetry in the right breast. She has a personal history of multiple bilateral breast biopsies and aspirations. Family history breast cancer in maternal aunt. An ML view and two spot compression views of the right breast were performed digit... | 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. | Acute appendicitis, taken to the OR on 12/16/14. Case aborted because of a large phlegmon. Treated conservatively with antibiotics. Right lower quadrant abdominal pain. ABDOMEN:LUNG BASES: Mild left basilar atelectasis or scarring. Calcified right infrahilar lymph nodes.LIVER, BILIARY TRACT: Status post cholecystectomy... | Interval regression of findings which previously demonstrated acute appendicitis. The appendix remains dilated with surrounding inflammation. However, degree of distention and inflammatory change has lessened. No evidence of abscess. |
Generate impression based on findings. | 55-year-old female with history of urine leak and fluid collections who presents for evaluation. ABDOMEN:LUNG BASES: Bilateral basilar atelectasis.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnorm... | 1.Near complete resolution of fluid collection anterior and inferior to the transplanted kidney with residual soft tissue component. No significant interval change in pigtail catheter position.2.Mild interval decrease in the fluid collection seen anterior to the right psoas muscle as above. |
Generate impression based on findings. | Follow-up Side plate and screw device affixes a distal fibular fracture in near-anatomic alignment. The fracture line remains visible. A screw and pin affix a medial malleolar fracture in near-anatomic alignment. The fracture line remains visible. Additionally, there is a fracture of the "posterior malleolus" situated ... | Orthopedic fixation of distal tibial and fibular fractures as above. |
Generate impression based on findings. | Female 52 years old; Reason: rule out intraabdominal abscess History: fever leukocytosis, s/p tumor debulking omentectomy, HIPEC ABDOMEN:LUNG BASES: Centrilobular emphysema is seen in the lung bases. LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant... | 1.Right anterior abdominal wall skin thickening and underlying edema is present which may represent cellulitis. 2.No loculated fluid collection is seen to suggest abscess formation. |
Generate impression based on findings. | 72-year-old male with prostate cancer. Again seen are increased activity in within the right lateral 10th rib, L5 for tubal body, and left scapula, unchanged compared to prior. No new foci of increased activity.Scattered degenerative again noted. | Stable osseous metastases. No new foci of disease. |
Generate impression based on findings. | Mesothelioma status post-pleurectomy and decortication on observation. CHEST:LUNGS AND PLEURA: Post surgical changes right hemithorax. Minimal lateral pleural thickening near the costophrenic angle measures 5-mm, previously 6 mm at the 9 o'clock position (3/60). Minimal nodularity along the right major fissure appears ... | 1.No significant change in right lateral chest wall measurement and minimal residual pleural scarring.2.Left upper lobe ground glass nodules are stable and continued annual follow-up is recommended.3. Indeterminate hypoattenuating lesion in the liver is incompletely characterized and continues to slightly enlarge; cons... |
Generate impression based on findings. | Left lower chest wall pain Three views of the ribs show no fracture or other findings to account for the patient's left lower rib pain. Mild osteoarthritis affects the acromioclavicular joint bilaterally. | No findings to account for the patient's pain. |
Generate impression based on findings. | Reason: lung cancer History: 11 years after RUL lobectomy for NSCLC. Found to have FDG avid right lung nodule suspicious for cancer CHEST:LUNGS AND PLEURA: Right upper lobe nodule (image 54 series 5) slightly increased in size now measuring 17 mm x 19 mm previously measuring 17 mm x 17 mm.Left upper lobe poorly margina... | 1.Mild interval increase in size of right and left upper lobe nodules. 2.Minimally enlarged necrotic right hilar lymph node.3.Severe subchondral sclerosis involving multiple thoracic vertebrae may be degenerative or post-inflammatory in origin. |
Generate impression based on findings. | Check for lung nodules, adrenal mass and known primary adrenal neoplasm LUNGS AND PLEURA: Mild to moderate scattered emphysematous changes with calcified granulomata bilaterally no suspicious nodules or masses. No effusions.MEDIASTINUM AND HILA: No lymphadenopathyThe cardiac and pericardial appearance is unremarkableCH... | 1. Bilateral adrenal masses without evidence of pulmonary involvement.2. Cholelithiasis |
Generate impression based on findings. | Pain, evaluate for fracture Evaluation of fine bone detail is limited by overlying cast material. There is an oblique distal fibular fracture extending to the tibiotalar joint with 4 mm of lateral displacement of distal fracture fragment. There is medial translation of the talus with widening of the medial gutter compa... | Fractures of the distal fibula, posterior malleolus, and deltoid ligament injury as described above. |
Generate impression based on findings. | 4-year-old male with Dravet syndrome and intractable seizures. Rule out intracranial hemorrhage. There is no evidence of acute intracranial hemorrhage. The ventricles, basal cisterns, and sulci are diffusely prominent, suggestive of global atrophy. There is no mass effect or herniation. There is mucosal thickening in t... | 1. No evidence of acute intracranial hemorrhage. 2. Diffuse global atrophy is likely related to Dravet syndrome. A brain MRI may be useful for further evaluation of potential seizure foci.3. Apparent diffuse thickening of the skull base and maxillofacial skeleton of uncertain significance. |
Generate impression based on findings. | Back pain Again seen is a wedge compression fracture of the L1 vertebral body similar in appearance to the prior exam accounting for technical differences. There is no scoliosis. There is a negative sagittal balance measuring 2.5 cm. The remainder of the spine is unremarkable. | L1 compression fracture as described above. |
Generate impression based on findings. | Metastatic lung cancer check, compare to prior. Lung cancer CHEST:LUNGS AND PLEURA: Stable unchanged appearance including diffuse moderate emphysematous changes. The focal opacity observed in the right major fissure thought to represent scarring remains unchanged and again difficult to measure.Scattered traction bronch... | 1. Unchanged appearance without suspicious new abnormalities port or suggest recurrent or metastatic disease2. Chronic thrombus in the right main pulmonary artery |
Generate impression based on findings. | Ms. Davis is a 40 year old female recalled from screening mammogram for a focal asymmetry in the right upper inner breast. An ML view and three spot compression views of the right breast were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure s... | 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. | Subject in the EMPROVE clinical research trial 6 month follow-up for COPD. LUNGS AND PLEURA: No pneumothorax. Severe centrilobular emphysema unchanged. The left upper lobe remains collapsed and its airways contain endobronchial valves. Lung volumes appear unchanged.MEDIASTINUM AND HILA: Atherosclerotic calcification of... | Severe centrilobular emphysema without acute change. The left upper lobe remains collapsed, with endobronchial valves in place. Coronary artery calcifications. |
Generate impression based on findings. | 79-year-old female with shoulder swelling, rule out fracture The bones are demineralized. Moderate osteoarthritis affects the glenohumeral joint and mild osteoarthritis affects the acromioclavicular joint. A high riding humeral head suggests chronic rotator cuff tear. Multiple ossicles overlie the glenohumeral joint, l... | Osteoarthritis, with findings suggestive of chronic rotator cuff tear and possible subdeltoid bursitis. |
Generate impression based on findings. | 85 year-old female with left knee pain Large joint effusion. Osteoarthritis most severely affects the patellofemoral joint. There is chondrocalcinosis of the menisci. No erosions are noted. | 1. Degenerative arthritic changes and chondrocalcinosis, which may represent a combination of osteoarthritis and CPPD arthropathy.2. Large joint effusion.Findings text paged to Mark Myren (pager 1949). |
Generate impression based on findings. | 46-year-old male with right hand pain after injury There is a small step-off along the articular surface of the base of the distal phalanx of the fifth finger suggesting a nondisplaced subchondral fracture. No additional fracture is evident. | Findings suggestive of a nondisplaced fracture of the articular surface of the base of the distal phalanx of the fifth finger. The metacarpal is unremarkable. Findings discussed with David Landy (pager 3669) at the time of dictation. |
Generate impression based on findings. | 59 year-old female, assess fracture Again seen is an ununited fracture through the distal phalanx of the third toe appearing similar to the exam dated 1/14/15. Severe osteoarthritis affects the first MTP joint. | Third toe fracture appearing similar to the prior exam. |
Generate impression based on findings. | Thymoma. Benign neoplasm of the thymus. LUNGS AND PLEURA: New multi-focal clustered tree in bud opacities, peribronchial nodular opacities and groundglass opacities, mainly in the posterior and dependent lung fields, left greater than right. Confluent nodules measuring up to 18-mm with irregular borders in the left cos... | 1. Solid homogeneous 6.7 x 4.1 x 5.6 cm right anterior mediastinal mass consistent with provided diagnosis of thymoma. Extracapsular extension cannot be excluded.2. Enlarged high right tracheoesophageal lymph node, mildly enlarged right hilar lymph node and an enlarged low left paraesophageal lymph node are noted. Corr... |
Generate impression based on findings. | 70 year-old female with neck pain after fall Cervical spine: The C5 and C6 vertebral bodies appear fused. Severe degenerative disk disease affects C3/C4 and C5/C6. Moderate degenerative disk disease affects C4/5. There is straightening of the cervical spine and a grade 1 retrolisthesis of C3. There is narrowing of bila... | 1. Mild osteoarthritis and findings suggesting calcific tendinosis of the rotator cuff. No fracture evident.2. Severe degenerative disk disease without cervical spine fracture evident. If there is strong clinical concern for fracture, CT may be considered. |
Generate impression based on findings. | Male; 90 years old. Reason: suspected mesothelioma, on observation, eval EOD, compare to previous History: none CHEST:LUNGS AND PLEURA: Pleural calcifications and subpleural scarring bilaterally.Left hemithorax pleural thickening with reference measurements as follows (prior measurements from 8/27/14):Level of the aort... | 1. Slightly increased left pleural thickening since 8/27/14 with reference measurements as above.2. Increasing mediastinal lymphadenopathy since 8/27/14. |
Generate impression based on findings. | 10-week-old female with left PICCVIEW: Chest AP (one view) 01/21/15 Left upper extremity PICC with tip in the right atrium. ET tube is below the thoracic inlet and above the carina. NG tube tip is in the stomach.Cardiothymic silhouette is normal. No pleural effusion or pneumothorax. Bilateral patchy atelectasis is unch... | Left upper extremity PICC tip is in the right atrium. |
Generate impression based on findings. | The ventricles and sulci are prominent, consistent with mild global volume loss slightly greater expected for the patient's stated age. The cisterns remain patent. There is no midline shift or mass effect. There are no areas of abnormal signal or pathological enhancement. There is no diffusion abnormality. No extra-ax... | Essentially unremarkable contrast enhanced MRI brain. |
Generate impression based on findings. | 58-year-old female with metastatic melanoma. Patient is status post 4 cycles Ipilimumab. Please assess disease status and compared to previous imaging.RADIOPHARMACEUTICAL: 15.1 mCi F-18 fluorodeoxyglucose (FDG). BLOOD GLUCOSE (FASTING): 171 mg/dL. Today's CT portion grossly demonstrates multiple pulmonary nodules, whic... | Interval progression with increase in size and number of FDG-avid tumor in the chest, abdomen and pelvis as described above. Additional findings as above. |
Generate impression based on findings. | Multiple sclerosis and recent altered mental status and seizures. Evaluate for intracranial hemorrhage. No intracranial hemorrhage is identified. There are scattered areas of hypoattenuation in the periventricular and subcortical white matter. There is no intracranial mass or evidence of mass-effect. There is no mass, ... | 1. Scattered areas of hypoattenuation in the white matter are likely related to multiple sclerosis. 2. Severe diffuse global atrophy with resultant prominence of the ventricular system, which is likely related to known history of multiple sclerosis.3. No evidence of intracranial hemorrhage or mass effect. However, non-... |
Generate impression based on findings. | 17 year-old female with ankle pain status post sprain with swelling and painVIEWS: Right ankle AP, oblique, lateral (3 views) 01/21/15 at 1420 No acute fracture or malalignment is evident. Mild soft tissue swelling over the lateral malleolus. | Soft tissue swelling without evidence of acute fracture or malalignment. |
Generate impression based on findings. | Ms. TorresLopez is a 46 year old female recalled from screening mammogram for calcifications in the right lower inner breast. Family history of breast cancer in two maternal aunts and one maternal aunt. An ML view and three spot magnification views of the right breast were performed digitally and reviewed with the aid ... | High probability benign calcifications in the right lower inner breast. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at... |
Generate impression based on findings. | Pain, evaluate alignment Four views of the shoulder show slight inferior subluxation of the humeral head with respect to the glenoid. There is no fracture or dislocation. | Slight inferior subluxation of the humeral head. |
Generate impression based on findings. | 50 year-old female with history of cervical cancer. Patient with previous liver lesions who presents for characterization of these lesions. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: There are multiple hypoattenuating foci throughout the liver without enhancement which are not changed com... | 1.Numerous hepatic hypoattenuating lesions consistent with cysts.2.No evidence of local tumor recurrence or metastatic disease. |
Generate impression based on findings. | Right cheek squamous cell carcinoma status post resection and chemoradiation. There are post-treatment findings with right lateral cheek skin thickening and mild subcutaneous fat volume loss. There is no otherwise evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. The th... | Post-treatment findings with right lateral cheek skin thickening and mild subcutaneous fat volume loss. Otherwise, evidence of measurable locoregional mass lesions or significant cervical lymphadenopathy. |
Generate impression based on findings. | Esophageal atresia repair. Postoperative day 7. Extubated.VIEW: Chest AP (one view) 01/21/15, 1425 Endotracheal tube has been removed. Feeding tube tip is at level of gastric fundus and side port is at GE junction. Left-sided central line has its tip in left brachiocephalic vein. A right chest tube is present with side... | Persistent small right pneumothorax. |
Generate impression based on findings. | Ms. Carter is a 61 year old female with a recent benign right breast biopsy in December 2013. No current breast related complaints. 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 p... | 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: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | Stage IV Hodgkin lymphoma. There is no significant interval change in the cervical lymph nodes. For example, a right level 2A lymph node measures 8 mm in shift axis, previously 8 mm and a left level 2A lymph node measures 7 mm in short axis, previously 8 mm. There are unchanged left palatine tonsilloliths. The Waldeyer... | No significant interval change in the cervical lymph nodes. |
Generate impression based on findings. | 31-year-old female with daily headaches. 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 clear. The skull and extracranial soft tissues are unremarkable. | 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. | MVA, pain, swelling, recently diagnosed leg fracture Left tibia-fibula:There is a mildly comminuted but predominantly transverse fracture of the proximal fibular diaphysis in near anatomic alignment with overlying soft tissue swelling. No additional fractures are evident.Left elbow:No fracture, malalignment, or joint e... | 1. Fibular fracture as described above.2. Mild soft tissue swelling of the elbow without fracture. |
Generate impression based on findings. | Pain, status post fall onto shoulder Four views of the left shoulder show no acute fracture or malalignment. The glenohumeral joint alignment is preserved. | No fracture, malalignment, or other findings to account for the patient's pain. |
Generate impression based on findings. | 79-year-old male with adenocarcinoma right lung with concern for bone mets.RADIOPHARMACEUTICAL: 14.4 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 117 mg/dL. Today's CT portion grossly demonstrates innumerable bilateral pulmonary nodules compatible with metastases. Right lower lobe mass and consolidation w... | 1.Focus of moderate hypermetabolic tumor in the right lower lobe with surrounding mild diffuse FDG activity likely representing primary malignancy with associated atelectasis/consolidation. Innumerable bilateral pulmonary metastases, a few of which demonstrate increased FDG activity.2.Hypermetabolic mediastinal and bil... |
Generate impression based on findings. | Numbness in the upper extremities Two views of the cervical spine are provided. Again noted are morphologic abnormalities of C1 and C2. The C2 vertebral body is block shaped with a flat superior surface. The os odontoideum seen on CT is not evident on these radiographs. The anterior arch of C1 is unusually large and si... | Morphologic abnormalities of the upper cervical spine and degenerative disk disease of the lower cervical spine appearing similar to the prior exam. |
Generate impression based on findings. | Cough S.O.B. and process. Unspecified allergic alveolitis and pneumonitis. LUNGS AND PLEURA: Mosaic attenuation of the lung parenchyma, most pronounced at the bases, persists on the expiration sequence. No pleural fluid or pneumothorax. Subpleural reticulation and honeycombing is mild. Mild patchy groundglass opacity i... | Pulmonary fibrosis in a pattern most compatible with chronic hypersensitivity pneumonitis. Signs of pulmonary hypertension. Moderate coronary artery calcifications. |
Generate impression based on findings. | The right internal auditory canal is diminutive in size, although demonstrates normal signal intensity. There is lack of delineation of a right lateral semicircular canal, which appears as a common cavity with possibly mildly enlarged vestibule on the right. The inner ears are otherwise normal on MR, with normal T2 si... | 1. Semicircular canal-vestibule globular anomaly involving the right lateral semicircular canal. Significantly hypoplastic right internal auditory canal with inability to assess right seventh and eighth cranial nerves.2. Semicircular canal-vestibule globular anomaly involving the left lateral semicircular canal with le... |
Generate impression based on findings. | 66-year-old female with chronic calcific pancreatitis with recent onset of vomiting. Evaluate for duodenal obstruction. ABDOMEN:LUNG BASES: Severe cardiomegaly with moderate pericardial effusion.LIVER, BILIARY TRACT: Heterogenous appearance of the liver with dilated hepatic veins compatible with passive hepatic congest... | 1.No evidence of duodenal obstruction as clinically questioned. 2.Findings consistent with sequela of chronic pancreatitis.3.Severe cardiomegaly with moderate sized pericardial effusion, unchanged.4.Findings consistent with passive hepatic congestion. |
Generate impression based on findings. | Male, 59 years old.RFO NG tube tip overlies gastric antrum. IVC filter projects over the L2/3 vertebral bodies. Right upper quadrant postsurgical material was also expected. Surgical drains were expected. There is right sacral sponge, which was sutured to the ostomy site.No unexpected radiopaque foreign body. | No unexpected radiopaque foreign body. |
Generate impression based on findings. | Male 62 years old; newly diagnosed ampullary/pancreatic malignancy ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Accounting for differences in technique, stable 2.2 x 1.4 cm hepatic lesion located in segment 7 (timing of IV contrast bolus not optimal for assessment of hepatic lesions). Cho... | Outside exam read:1. Interval placement of biliary stent with improved biliary ductal dilatation. 2. Mild interval decrease in size of reference lymph node, remainder of exam without significant change including stable indeterminate hepatic segment 7 lesion as above. |
Generate impression based on findings. | 85 years, Male. Reason: check for ileus History: check for ileus Enteric tube tip overlies the gastric antrum. Partially visualized nonobstructive bowel gas pattern. Aortoiliac graft and brachytherapy seeds are noted. | Enteric tube tip overlies the gastric antrum. Partially visualized nonobstructive bowel gas pattern. |
Generate impression based on findings. | 57 year old female with history of recent partial small bowel obstruction in January. Evaluate. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Multiple bilateral hypoattenuating hepatic lesions, some of which are consistent with simple cysts and some of which are too small to characterize. No... | 1.Findings consistent with mild partial small bowel obstruction, possibly due to lesser sac internal hernia versus left paraduodenal internal hernia as detailed above. Finding relayed to Dr. Schwartz nurse, Mirthala Benavida, RN over the phone at approximately 4:27 p.m. |
Generate impression based on findings. | 85 years, Male. Reason: abdominal pain s/p AAA repair, check for free air History: abdominal pain Exam is limited by motion artifact. No definite evidence of free air. Enteric tube side port remains above the GE junction. | Exam is limited by motion artifact. No definite evidence of free air. Enteric tube side port remains above the GE junction. Partially visualized aortoiliac graft. |
Generate impression based on findings. | 50 years, Female. Reason: perforation? History: cardiac arrest Decubitus image is nondiagnostic due to artifact. Semierect view is also limited by motion artifact. NG tube tip overlies the gastric antrum. | NG tube tip overlies the gastric antrum. Exam limited by motion artifact. |
Generate impression based on findings. | Weakness and weight loss and former smoker, asbestos. Motion artifact limits exam quality, especially at the lung bases.LUNGS AND PLEURA: At the right lung base, there is a irregularly thin-walled cystic lesion measuring 13-mm near the right hemidiaphragm (4/90), indeterminate in appearance. On a prior abdominal CT dat... | 1. Indeterminate 13-mm cystic lesion in the right lower lobe with irregular walls measuring up to 4 mm in thickness, slightly larger, although increase in size may be due to enlargement of the central cystic component. Three-month CT follow-up recommended. 2. Additional subcentimeter noncalcified pulmonary nodules appe... |
Generate impression based on findings. | Fractures of the third and fourth metatarsals Three views of the left foot show fractures through the necks of the third and fourth metatarsals in near anatomic alignment. There is early callus formation suggestive of attempted early healing. There is a hallux valgus deformity with additional deformities of the proxima... | Third and fourth metatarsal fractures with early callus formation. |
Generate impression based on findings. | The paranasal sinuses and nasal cavity are clear. Unchanged mild nasal septal deviation and spur directed to the right. The lamina papyracea and ethmoid roofs are intact. The nasopharynx, orbits, and imaged intracranial structures appear to be unremarkable. | No evidence of sinusitis. |
Generate impression based on findings. | 65 years, Female. Reason: 65F s/p lung transplant with abdominal distention, epigastric pain History: abdominal distention/pain Nonobstructive bowel gas pattern. Vascular calcification noted. Overlying heart monitor limits exam. | Nonobstructive bowel gas pattern. Overlying heart monitor limits exam. |
Generate impression based on findings. | Pain There appears to be partial sacralization of the L5 vertebra, which likely accounts for apparent narrowing of the L5/S1 intervertebral disk space. Moderate degenerative disk disease affects L3/4, with a minimal anterolisthesis of L3. Mild facet joint osteoarthritis affects the lower lumbar levels. There is perhaps... | Degenerative disk disease and other findings as above. |
Generate impression based on findings. | Male; 67 years old. Reason: history of renal cancer, liver lesions. Evaluate for change History: renal cancer and sarcoid, sarcoidosis CHEST:LUNGS AND PLEURA: Scattered micronodules. Reference lesion in the right lung base measures 0.8 x 0.5 cm (series 5, image 67), stable. Stable thyroid nodules.MEDIASTINUM AND HILA: ... | Overall stable examination. Reference measurements are given above. |
Generate impression based on findings. | 72-year-old male with small cell cancer; please two scan and evaluate for abnormalities.RADIOPHARMACEUTICAL: 14.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 90 mg/dL. Today's CT portion grossly demonstrates scattered nonspecific bilateral pulmonary micronodules. Coronary artery and abdominal aortic athe... | 1.Markedly hypermetabolic conglomerate right inguinal lymph nodes and hypermetabolic right external iliac lymph node suspicious for malignancy.2.Mildly hypermetabolic normal sized left inguinal lymph nodes, nonspecific.3.Questionable increased FDG activity in the right temporal lobe, which could be further evaluated wi... |
Generate impression based on findings. | Reason: evaluation of lung / mediastinal mass History: evaluation of lung / mediastinal mass LUNGS AND PLEURA: Right upper lobe compressive atelectasis secondary to large anterior mediastinal mass.No suspicious pulmonary nodules. No pleural effusions.MEDIASTINUM AND HILA: Large anterior mediastinal mass demonstrates mi... | 1.Large right anterior mediastinal mass demonstrating mild interval increase in size from the prior outside exam dated 10/22/14.2.Enlarged anterior mediastinal lymph nodes demonstrating interval increase in size. |
Generate impression based on findings. | 4-year-old male with pneumonia. Question of aspiration.EXAMINATION: Oropharyngeal motility study 1/21/2015, 1330 hrs. Julie Ecclestone, speech and language therapist, supervised the examination.62 seconds of fluoroscopy was used.Thin liquids were administered via open cup and with a straw. Nectar fluid was administered... | Shallow penetration without aspiration.Please see the speech and language therapist's report for feeding recommendations. |
Generate impression based on findings. | 70 years, Male. Reason: eval Dobbhoff placement History: feeding tube DHT tip overlies gastric fundus. Partially visualized central lines overlies cavoatrial junction. Limited bowel gas evaluation. | DHT tip overlies gastric fundus. |
Generate impression based on findings. | Ms. Streeter is a 77 year old female with a personal history of left breast mastectomy in 1988 for cancer. Family history of breast cancer in sister and maternal aunt. No current breast related complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, right unilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Laceration, evaluate for foreign body Three views of the right foot show a large laceration along the plantar and lateral aspect of the mid/hindfoot. There are several shard-like radiopaque foreign bodies within this laceration measuring up to 2 cm in length. At least three smaller fragments are seen in the deeper soft... | 1.Right mid/hindfoot soft tissue laceration with multiple foreign bodies as described above.2.Left tibiotalar joint effusion. |
Generate impression based on findings. | 49 years old Female with malignant neoplasm of the Breast - unspecified site. This study was performed for staging. RADIOPHARMACEUTICAL: Please see report from outside hospital.BLOOD GLUCOSE (FASTING): Please see report from outside hospital. Today's CT portion grossly demonstrates a surgical clip is seen in the latera... | 1. Multiple conglomerate foci of increased activity in the left breast, consistent with the breast cancer.2.Hypermetabolic lymph nodes in the left axilla and left mediastinal internal mammary region as well as in the right lung hilum, suspicious for nodal metastases.3.No evidence of distant metastasis. |
Generate impression based on findings. | Eight year-old female with constipationVIEW: Abdomen AP (one view) 01/21/15 Amorphous stool is noted within the rectum and ascending colon. | Below-average stool burden. |
Generate impression based on findings. | 53-year-old male with history of end-stage renal disease. Pre-kidney transplant workup. ABDOMEN:LUNG BASES: Moderate pericardial effusion and cardiomegaly. No pleural effusions or focal areas of consolidation. LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No sig... | 1.Unchanged bilateral atrophic cystic kidneys, as above.2.Moderate atherosclerosis of the aorta and common iliac arteries, with mild atherosclerotic calcifications of the external iliac arteries. |
Generate impression based on findings. | Female, 74 years old.Multiple surgical teams, accounts are correct NG tube side-port just distal to GE junction. ET tube tip is at the carina. Circular sutures around the gastric cardia are expected. Bilateral abdominal drains are noted. Multiple surgical clips and skin staples are expected. Bilateral femoral fixation ... | No unexpected radiopaque foreign body. Findings discussed with Dr. Raphael Lee at 3:42 PM 1/21/2015. |
Generate impression based on findings. | A patient submitted outside study for review for a recent pea-sized palpable abnormality along the lateral margin of the scar along the inferior aspect of the left breast reported by the patient. Submitted for review are left breast mammograms and left breast ultrasound performed at South Bend Clinic. For comparison, m... | Findings compatible with scar tissue. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | Presyncope, gait instability No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. There is global parenchymal volume loss. Sulci and ventricles are within normal limits for age without evidence of hydro... | No evidence of acute 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. | Mesothelioma, chemotherapy follow-up. "Mesothelioma compare to last CT & measure 1) aortic arch 7 o'clock, 2) AP window 2 o'clock, 3) AP window 7 o'clock, 4) left atrium 4 o'clock, 5) left atrium 9 o'clock,, 6) left costophrenic angle mass." CHEST:LUNGS AND PLEURA: Interval removal of right-sided Pleurx catheter. Sever... | Thoracic and abdominal mesothelioma with reference measurements provided in the body of the report. |
Generate impression based on findings. | Postoperative changes are again seen from prior right suboccipital cranioplasty. Compared to 7/15/2014, interval decrease in size of heterogeneously enhancing lesion within the right cerebellopontine angle cistern is seen, measuring 8x12x10, previously 15x11x16 mm. Linear intracanalicular enhancement, which in part is... | Compared to 7/15/2014, there is interval decrease in size of the vestibular schwannoma involving the right cerebellopontine angle and internal auditory canal. |
Generate impression based on findings. | 52-year-old female with inability to ambulate, rule out intracranial hemorrhage. 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. Patchy bilateral opacification of the ethmoid air cells. Mastoid air cells are ... | 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. | Cerebral palsy and hip surgery.EXAMINATION: Pelvis AP/frog leg (two views) 01/21/15 Left femoral blade plate and screws device is in place. A healed left proximal femoral osteotomy is seen. The left femoral head is directed into the dysplastic acetabulum. The right femoral head is directed into the dysplastic acetabulu... | Bilateral femoral varus derotational osteotomy with femoral heads well directed into acetabula. |
Generate impression based on findings. | 24-year-old female with nausea, vomiting, and visual changes after recent head trauma. Redemonstration of a right frontal subgaleal hematoma that measures up to 8 mm in thickness, which appears more focal when compared to prior. There is beam hardening artifact in the frontal region. There is no evidence of intracrania... | Evolving right frontal subgaleal hematoma, but no evidence of skull fracture or acute intracranial hematoma. |
Generate impression based on findings. | Renal mass CHEST:LUNGS AND PLEURA: 4-mm right upper lobe micronodule as seen on image 28 of series 3.MEDIASTINUM AND HILA: Bilateral thoracic inlet adenopathy. Representative left thoracic inlet mass best seen on image 5 series 2 measures 3.5 x 2.9 cm.Mildly enlarged mediastinal lymph nodes. Representative left paratra... | Right renal mass as described. Associated with extensive bulky retrocrural, retroperitoneal, and proximal pelvic adenopathy. Bilateral thoracic inlet adenopathy suggestive for metastatic involvement. While the findings support the suspected diagnosis of metastatic renal cell carcinoma, other etiologies including lympho... |
Generate impression based on findings. | Pain, bunion There is a mild hallux valgus deformity with mild soft tissue prominence along the medial aspect of the first metatarsal head, similar to the prior exam. | Mild hallux valgus deformity appears similar to the prior exam. |
Generate impression based on findings. | Right shoulder pain with decreased range of motion; bilateral knee pain; ankle pain Right shoulder:Tiny glenohumeral osteophytes indicate mild osteoarthritis. The shoulder is otherwise within normal limits.Right knee:Severe osteoarthritis affects the medial compartment with near bone-on-bone apposition. There are small... | Osteoarthritis of the right shoulder, knees, and right ankle as described above. |
Generate impression based on findings. | Status post reduction of ankle fracture Evaluation of fine detail is limited by overlying cast material. Again noted is an oblique distal fibular fracture with 4 mm lateral displacement of the distal fracture fragment. There is persistent widening of the medial tibiotalar gutter measuring 8 mm, previously 10 mm. The pr... | Distal fibular fracture and medial gutter widening as described above. |
Generate impression based on findings. | 85 years, Male. Reason: NGT placement History: NGT placement Aortoiliac graft is noted. Side-port of the enteric tube is above the GE junction. | Aortoiliac graft is noted. Side-port of the enteric tube is above the GE junction |
Generate impression based on findings. | 72-year-old male with history of prostate cancer. Evaluate. CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: There is a bulky mediastinal lymphadenopathy which is stable. Reference subcarinal lymph node measures 3.1 cm in diameter (series 3, image 48), unchanged.Heart is normal in size with... | Stable lymphadenopathy in chest and abdomen. |
Generate impression based on findings. | RIGHT TEMPORAL BONE: The external auditory canal contains scattered opacifications likely representing debris/cerumen. The tympanic membrane is faintly visualized. The scutum remains sharp.The tympanic cavity and mastoid air cells are clear. The ossicular chain and tegmen tympani are intact, although the stapes is dim... | 1. Hypoplasia of the bony right internal auditory canal. Mildly dysplastic right cochlea with enlarged modiolus and cochlear aperture stenosis. Findings consistent with right lateral semicircular canal-vestibule globular anomaly. Probable associated right oval window stenosis with diminutive appearing stapes.2. Diminis... |
Generate impression based on findings. | Infertility Scout AP film of the pelvis was normal. Opacification of the uterine cavity revealed a normally oriented uterine cavity without mucosal irregularity or filling defects in the uterine cavity. Right tube opacified with contrast and had free spillage. There is a left hydrosalpinx with no spillage.TOTAL FLUOROS... | Normal uterine cavity and patent right fallopian tube. Left hydrosalpinx and blocked tube. |
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