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Generate impression based on findings. | Fracture healing. VIEWS: Right humerus AP/lateral (two views) 01/22/15 Healing transverse fracture through the mid humeral diaphysis with mild medial angulation measuring 13 degrees, previously 20 degrees. | Healing humerus fracture. |
Generate impression based on findings. | Reason: evaluate hips History: cerebral palsyVIEWS: Pelvis AP/frog leg, thoracolumbar spine supine AP (3 views) 01/22/15 Bilateral coxa valga with posterior dislocation of the right femoral head. The right acetabulum appears dysplastic. The left acetabulum appears well seated into the acetabulum. The left femur is abdu... | 1.Developmental dysplasia of the right hip with dislocation. Bilateral coxa valga.2.Dextroscoliosis of thoracolumbar spine. |
Generate impression based on findings. | Reason: eval liver lesions masses HCC History: HCC S/P TACE/RFA ABDOMEN:LIVER, BILIARY TRACT: Nodular cirrhosis with widening of the fissures. Hepatic steatosis and areas of fibrosis. Patent hepatic vasculature. No biliary dilatation.2.8 x 2.1 cm lesion in segment 1 (101:35) demonstrates post-therapeutic changes withou... | 1.No significant change in reference hepatic lesions. |
Generate impression based on findings. | 90 year-old male with lateral ankle pain and swelling Mild soft tissue swelling about the ankle. No fracture is evident. Alignment is anatomic. | No fracture or dislocation. |
Generate impression based on findings. | Male; 53 years old. Reason: rule out PE History: chest pain, LLE tenderness PULMONARY ARTERIES: No acute pulmonary embolus. Normal caliber of the main pulmonary artery. No evidence of right heart strain.LUNGS AND PLEURA: Minimal bibasilar dependent subsegmental atelectasis. No suspicious pulmonary nodules or masses. No... | No acute pulmonary embolus or other significant cardiopulmonary abnormality.PULMONARY EMBOLISM: PE: Negative.Chronicity: Not applicable.Multiplicity: Not applicable.Most Proximal: Not applicable.RV Strain: Not applicable. |
Generate impression based on findings. | Male; 76 years old. Reason: Pt with smooth muscle neoplasm of the distal esophagus. Need to evaluate for change in lesion. History: Mild abdominal pain CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: No significant interval change in distal esophageal biopsy-proven leiomyoma. The mass is ... | 1. No significant interval change in distal esophageal biopsy-proven leiomyoma.2. Stable infrarenal abdominal aortic aneurysm. |
Generate impression based on findings. | 49-year-old male with history of type 2 diabetes, nausea, vomiting. Question of gastroparesis. Visually there was a significant delay in gastric emptying. Using anterior and posterior geometric means, residual gastric activity at the following postprandial intervals was calculated as follows:30 mins: 84.1 % of peak act... | Significantly delayed gastric emptying. |
Generate impression based on findings. | 57 years, Female. Reason: ng tube placement given tube dysfxn History: tube dysfxn Enteric tube tip in gastric body, unchanged from prior study. Improvement in the mild gaseous distention of the small bowel. Nonobstructive bowel gas pattern. Bilateral pleural effusions noted. Partially visualized two central venous cat... | Enteric tube tip in gastric body, unchanged from prior study. Nonobstructive bowel gas pattern. |
Generate impression based on findings. | Male 71 years old; Reason: Pancreas cancer with CT imaging indicative of left iliac bone mets and new onset thoracic and upper back pain please assess History: As above There is a markedly large osteoblastic lesion in the right posterolateral 9th rib which corresponds to a large sclerotic lesion present on CT consisten... | Multiple lytic and sclerotic osseous metastases. |
Generate impression based on findings. | Patella fx? Inferior pole patella tender to palpation.... pain w/ extended periods of running over anterior knee... hx of fall w/ swelling 4wk priorVIEWS: Left knee AP/lateral (two views) 01/22/15 No acute fracture or malalignment. Long secondary apophysis of the anterior and inferior aspect of the patella, normal vari... | No acute fracture or malalignment. |
Generate impression based on findings. | 67 year-old female breast cancer. Follow-up after treatment.RADIOPHARMACEUTICAL: 14.5 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 94 mg/dL. Today's CT portion grossly demonstrates postsurgical changes in the right anterior chest wall. There is a thin, circumscribed fluid collection in the surgical bed, l... | 1.Complete interval resolution of all previous extensive hypermetabolic tumor involving right breast, right axilla, and lungs, indicating a significant metabolic response to therapy.2.However, a single new significantly hypermetabolic 1-cm pleural-based nodule in the left apex is suspicious for tumor progression in thi... |
Generate impression based on findings. | Time average mean velocities: Right middle cerebral artery: 104 cm/sec.Right internal carotid artery: 83 cm/sec.Left middle cerebral artery: 120 cm/sec.Left internal carotid artery: 93 cm/sec. | Normal time average mean velocities of intracranial blood vessels as described above (<180 cm/sec). |
Generate impression based on findings. | 69-year-old female with history of right breast cancer and lymphadenopathy in the right neck. There are multiple necrotic-appearing lymph nodes in the right supraclavicular and right level 5B regions. For example, a right level 5B node, measures 15 x 13 mm and a right supraclavicular lymph node measures 12 x 11 mm. The... | 1. Multiple necrotic appearing right supraclavicular and level 5 lymph nodes are highly suspicious for metastatic involvement. 2. Nonspecific 3-mm nodule in the right lung apex. A dedicated baseline chest CT may be useful for further evaluation.3. Extensive degenerative spondylosis of the cervical spine. I personally r... |
Generate impression based on findings. | Male 33 years old Reason: s/p ACL History: s/p ACL recon Postsurgical changes from an ACL graft. Joint alignment is anatomic. There is a small joint effusion. No acute fracture or dislocation.Mild osteoarthritis affects the left knee. | Postsurgical changes from ACL graft placementt. |
Generate impression based on findings. | 79 year-old female with left hip pain Severe osteoarthritis affects the left hip with extensive subchondral cyst formation, osteophytes, and severe superior joint space narrowing.Severe degenerative disk disease with vacuum phenomena affects the visualized lower lumbar spine. Mild arthritic changes affect the left SI j... | Severe osteoarthritis as described above. |
Generate impression based on findings. | Female 75 years old Reason: evaluate for OA History: Pain and stiffness Right hip: There is mild joint space loss. There are small superolateral osteophytes. No acute fracture or dislocation.Osteoarthritis affects the right sacral iliac joint.Left hip: There is mild joint space loss. There are superolateral osteophytes... | Bilateral mild osteoarthritis. |
Generate impression based on findings. | 53-year-old female status post THA Hardware components of a total right hip arthroplasty device are situated in near-anatomic alignment without evidence of hardware complication. Drains and foci of gas in the soft tissues reflect recent surgery. | THA in near-anatomic alignment. |
Generate impression based on findings. | 59 year-old female with recurrent hyperparathyroidism. Please assess for parathyroid adenomas. No thyroid gland uptake, compatible with history of thyroidectomy. There is otherwise physiologic distribution of the radiopharmaceutical. No abnormal focus of activity consistent with an enlarged parathyroid gland is seen. | No scintigraphic evidence for parathyroid adenoma. |
Generate impression based on findings. | 22 year old female, evaluate ankle fracture Interval removal of cast. Small ossicle distal to the fibular tip likely represents an avulsion fracture fragment. There is adjacent soft tissue swelling. No additional fracture is noted. | Interval removal of cast with fibular tip avulsion fracture and adjacent soft tissue swelling as described above. |
Generate impression based on findings. | 66 year old female with history of polymyositis and intermittent dysphagia with solid foods. Scout radiograph of the chest was unremarkable.Double contrast evaluation of the esophagus and gastric cardia/fundus demonstrated an outpouching measuring 18 x 15 mm that filled with and retained contrast, extending from the le... | 1.Left-sided anterolateral cervical esophageal outpouching measuring up to 18 mm, appearance compatible with a Killian-Jameson diverticulum. 2.No evidence of spontaneous or provoked gastroesophageal reflux.3.Findings compatible with minor esophageal motility disorder as described above, of questionable clinical signifi... |
Generate impression based on findings. | 22 year-old female with left ankle pain Fine osseous detail is obscured by overlying cast material. An ossicle distal to the fibular tip likely represents an avulsion fracture fragment. | Casted fibular avulsion fracture as described above. |
Generate impression based on findings. | Reason: where is pcvc/how is gas pattern History: new pcvcVIEWS: Chest and abdomen AP (two views) 01/22/15, 1324 NG tube tip is in the stomach. Left lower extremity PICC with tip in the right atrium.Cardiothymic silhouette is normal. Minimal bilateral atelectasis.Gas distended stomach and multiple loops of bowel. Persi... | Gas distended loops of small bowel with a persistent bubbly appearance suggestive of pneumatosis. Left lower extremity PICC tip is in the right atrium. |
Generate impression based on findings. | Female 69 years old; Reason: 69 y/o f with UCTD, APS, and DVTs with chronic dyspnea, please eval for chronic thromboembolic disease. History: see above The comparison chest radiograph performed on 1/22/2015 demonstrates no focal pulmonary opacities or pleural fluid. The ventilation images show a uniform distribution of... | Very low probability for pulmonary embolism. |
Generate impression based on findings. | 72-year-old male with hematuria. Evaluate for stone. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Hepatic granulomata. Status post cholecystectomy.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETE... | 1.Punctate nascent non-obstructing stone formation bilaterally. No hydroureteronephrosis.2.Postsurgical changes of partial gastrectomy with the previously noted probable pseudotumor which is not well evaluated on this noncontrast examination; attention on subsequent imaging is recommended. |
Generate impression based on findings. | 56 year-old female with left hip osteoarthritis Pelvis: Two side plates with screws affix the right acetabulum without evidence of hardware complication, appearing similar to the prior exam. Left hip: Moderate osteoarthritis affects the left hip with superior joint space narrowing.Left knee: There is mild medial tibiof... | Postoperative and arthritic changes as described above without evidence of complication. |
Generate impression based on findings. | Female 78 years old; Reason: 78 y.o with Right breast cancer lesion , now 3 cm vague density after chemo, need lymph for SLBX sched 1-23-15 History: Right breast cancerRADIOPHARMACEUTICAL: The right breast was prepared in a sterile manner. A total of 1.0 mCi Tc-99m filtered sulfur colloid was injected in four periareol... | Sentinel node identified in the right axilla. |
Generate impression based on findings. | Male 61 years old; Reason: HCV, HCC, eval possible mets History: HCV HCC, cirrhosis No abnormal osseous foci are identified to indicate metastatic disease. Uptake involving the bilateral knees consistent with degenerative changes. Several foci of mild activity in the left hemipelvis seen only on anterior view likely ar... | No evidence of bone metastases. |
Generate impression based on findings. | Reason: assess for colon cancer recurrence History: N/A ABDOMEN:LUNG BASES: Stable small cardiophrenic lymph nodes.LIVER, BILIARY TRACT: No suspicious hepatic lesions. Patent hepatic vasculature. No ductal dilatation. Cholelithiasis.SPLEEN: Granulomas with associated blooming artifact.PANCREAS: No significant abnormali... | 1.Interval increase in infrarenal abdominal aortic aneurysm, now measuring up to 4.2 cm, further detailed above. Otherwise, essentially unchanged exam without definite metastatic disease. |
Generate impression based on findings. | 64-year-old male with prostate cancer with rising PSA. History of T12 compression fracture. ABDOMEN:LUNG BASES: No lung nodules or effusions seen. However, scans through the lung bases did not go high as on prior examination there is mild micronodular was visualized. This is an incomplete evaluation lungs and if concer... | 1. Scattered sclerotic skeletal abnormalities suggestive of metastatic disease technical medicine bone scintigraphy is a more accurate indicator of extent of skeletal metastatic disease. 2. No evidence of abdominal/pelvic lymphadenopathy. 3. Cholelithiasis. |
Generate impression based on findings. | 65-year-old male with LVAD and sepsis. Evaluate for source of infection. Evaluation of solid organs and for abscess is limited given noncontrast examinationCHEST: Motion artifact and streak artifact from LVAD limits evaluation.LUNGS AND PLEURA: There has been interval worsening of left upper lobe ground glass opacities... | Limited examination given lack of contrast enhancement, motion artifact, and streak artifact from hardware.1.Interval worsening of left upper lobe opacities highly suspicious for infectious etiology.2.Interval development of large left and small right pleural effusion with overlying atelectasis/consolidation.3.Interval... |
Generate impression based on findings. | Ms. Levine is a 43 year old female with a personal history of recent left breast excisional biopsy in April 2014 for a complex sclerosing lesion. She has no current breast related complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is ... | Expected postsurgical changes in the left breast. 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 - Screen... |
Generate impression based on findings. | Mandibular distraction.VIEWS: Mandible AP/right lateral/left lateral (3 views) 01/22/15 A marker was placed on the left device.Nasoenteric and nasotracheal tubes are present.The mandibular distractor devices are intact. Several millimeters of distraction are present bilaterally at the osteotomy sites.. | Postoperative changes. |
Generate impression based on findings. | Male 25 years old Reason: hx of testicular cancer, evaluate for metastatic disease. CHEST:LUNGS AND PLEURA: Stable right middle lobe nodule series 5 image 54, 0.5 x 0.3 cm.No new nodules. No effusions.MEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIAR... | Slight increase size of retrocaval fluid collection. It may represent a lymphocele given history of lymph node dissection although timing is somewhat unusual.Stable solitary lung nodule. |
Generate impression based on findings. | 70 year-old male with history of liver transplant. Evaluate vasculature does appear to kidney transplant. Within the limits of a non-IV contrast enhanced examination which limits the ability to the other solid parenchymal organs and vascular structures, following observations can be made:ABDOMEN:LUNG BASES: Small right... | 1. Minimal calcification seen in the iliac arteries bilaterally as delineated above. 2. Status post liver transplantation with stable appearance. 3. Small right pleural effusion. 4. Left inguinal hernia containing only mesenteric fat. |
Generate impression based on findings. | 22 year-old female with Crohn's disease and fever. Evaluate for abscess or free air. ABDOMEN:LUNG BASES: Small bilateral pleural effusions with mild overlying atelectasis.LIVER, BILIARY TRACT: Liver measures 26 cm in the craniocaudal dimension without focal hepatic lesions. Mild periportal edema. Marked gallbladder wal... | 1.Findings suggestive of active Crohn's colitis as above without evidence of abscess or fistulous disease.2.Findings suspicious for a small splenic infarct.3.Marked gallbladder wall thickening likely related to periportal edema and ascites.4.New small bilateral pleural effusions with mild overlying atelectasis.5.Hepato... |
Generate impression based on findings. | Male 70 years old Reason: s/p reverse TSA History: s/p reverse TSA Components of a reverse total left shoulder arthroplasty are in near anatomic alignment without radiographic evidence of hardware complication. The left humeral head has been resected. A joint drain is in place. Osteoarthritis affects the left AC joint. | Status post reverse left total shoulder arthroplasty without radiographic evidence of hardware complication |
Generate impression based on findings. | Female; 61 years old. Reason: worsening opacity 9/16; completed chemo 8/2014, ILD protocol History: dyspnea LUNGS AND PLEURA: Interval decreased diffuse patchy groundglass opacities in the upper lobes. Bilateral lower lobe mild reticular opacities, traction bronchiectasis, and groundglass are similar to prior study on ... | Findings most consistent with an NSIP pattern and similar to prior study on 7/2/14. Findings on CT chest from 9/16/14 were likely due to under inflation rather than worsening of disease. |
Generate impression based on findings. | 63 year old female with history of endometrial carcinoma (stage IA), status post hysterectomy/BSO. Stable lymph nodes on prior exams. CHEST:LUNGS AND PLEURA: No new suspicious pulmonary nodules or masses. Unchanged calcified left lower lobe granuloma.MEDIASTINUM AND HILA: Reference upper right paratracheal/R1 lymph nod... | 1.Postoperative findings of hysterectomy/BSO without findings of local recurrence or metastases.2.No significant interval change in reference lymph nodes. |
Generate impression based on findings. | Ms. Fox is a 76 year old female with a personal history of unilateral spontaneous clear nipple discharge for the past one year. Per patient, she has not had any discharge for the past one month. Family history of breast cancer in sister and maternal aunt. Three standard views of both breasts were performed digitally an... | 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 - Diagnostic Mammogram. |
Generate impression based on findings. | Male 64 years old; Reason: Prostate Cancer with rising PSA History: History of T12 compression fracture Focus of increased activity in the left skull is unchanged. Intense activity involving the left acetabulum and extending to the left inferior ischial tuberosity is increased compared to prior study and corresponds to... | Interval progression of osseous metastatic disease in the left hemipelvis as described above. Stable focus of activity in the left skull suggestive of stable additional metastatic disease or a benign lesion. No new suspicious osseous foci. |
Generate impression based on findings. | 77-year-old female with back pain and right lower extremity radiculopathy There is multilevel degenerative disk disease with loss of disk height and vacuum phenomenon at its T1-L1, L1-L2, L4-L5, and L5-S1. Multiple anterior osteophytes. Grade 1 anterolisthesis of L4 relative to L5. Small Schmorl's node along the superi... | Multilevel cervical spondylosis with severe spinal canal stenosis at L4-L5 is not significantly changed from the recent MRI. |
Generate impression based on findings. | Reason: 28 yo female with epigastric abdominal pain and elevated fecal fat. Please assess for signs of pancreatic inflammation or signs of chronic inflammatory change History: Epigastric abdominal pain, elevated stool fat ABDOMEN:LIVER, BILIARY TRACT: No focal hepatic lesions or ductal dilatation.SPLEEN: No significant... | 1.Unremarkable pancreas and M.R.C.P. |
Generate impression based on findings. | Female; 80 years old. Reason: evaluate ILD History: cough soboe fibrosis LUNGS AND PLEURA: Mild scattered streaky subsegmental atelectasis and/or scarring in both lungs. Scattered pulmonary micronodules, some of which are calcified. No suspicious pulmonary nodules or masses. Although there is some subtle subpleural ret... | No specific evidence of chronic interstitial lung disease other than mild air trapping. |
Generate impression based on findings. | Female 79 years old; Reason: look for recurrence History: abn CT scans with lung ca s/p XRT X 2RADIOPHARMACEUTICAL: 13.7 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 107 mg/dL. Today's CT portion grossly demonstrates a pleural-based 1 cm nodule in the posterior right lung apex new from prior study. There ... | 1.New markedly hypermetabolic right apical nodule is highly suspicious for tumor progression. No additional suspicious hypermetabolic activity is noted in the lungs. Additional activity elsewhere in the right lung as described above is likely inflammatory in nature. 2.Several additional significantly hypermetabolic sub... |
Generate impression based on findings. | 76 year old female s/p Dobbhoff placement. Exam mildly limited by patient motion artifact. Lower pelvis excluded from field of view. Dobbhoff tube tip in the gastric antrum. Nonobstructive bowel gas pattern. Incompletely visualized orthopedic hardware in the left pelvis. | Dobbhoff tip in gastric antrum. Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 69-year-old male with history of mesenteric plasmacytoma and rising paraprotein. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Post cholecystectomy findings.SPLEEN: Splenomegaly, unchanged.PANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, URET... | 1.Stable size of soft tissue mass adjacent to the descending colon, and lymphadenopathy, as above.2.Increased size of T12 vertebral lucency, which in the setting of known multiple myeloma could represent progression of disease. PET imaging or other follow-up would add diagnostic specificity. |
Generate impression based on findings. | Unilateral sensorineural hearing loss and speech delay. Also mild conductive hearing loss. There is nonspecific opacification scattered throughout the middle ears bilaterally. Specifically, in the right middle ear, there is opacification posterosuperior to the malleus, along the crura of the stapes, adjacent to the ten... | 1.Scattered nonspecific opacities in the middle ears bilaterally which could represent effusions, without osseous erosion. Slightly more rounded appearance of opacification just anterior to the left cochlear promontory. If there is concern for a mass lesion, MRI may provide further information.2.The inner ear structure... |
Generate impression based on findings. | Reason: 62 year-old female with large hiatal hernia noted on CT chest 11/2014. History of severe asthma, multiple intubations (last in 2005). Evaluate hiatal hernia. Scout radiograph of the chest unremarkable.There was large sliding type hiatal hernia with approximately 60% of the stomach situated above the hemidiaphra... | 1.Large sliding type hernia without functional obstruction.2.No evidence of gastroesophageal reflux. |
Generate impression based on findings. | 57-year-old male with history of abdominal pain. Evaluate for renal stone. ABDOMEN:Please note lack of IV and oral contrast limits evaluation of solid organ pathology, and also of the GI tract.LUNG BASES: Mild atelectasis/scarring at the basesLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: Several calcifi... | No nephrolithiasis, hydronephrosis or other findings to explain the patient's pain. |
Generate impression based on findings. | Evaluate healing torus fractures of the radius and ulna.VIEWS: Right wrist AP lateral (two views) 1/22/2015 Cast material obscures fine bone detail. Increasing sclerosis and periosteal reaction is noted along the distal radial and ulnar buckle fracture lines, consistent with healing. The bones of the wrist are in near-... | Healing distal radial and ulnar buckle fractures. |
Generate impression based on findings. | There is asymmetric enlargement of the lateral ventricles, left greater than right, increased since the prior US exam. There is also enlargement of the third and fourth ventricles. No abnormal T2 signal or diffusion restriction. The aqueduct appears patent with a flow-void which may suggest hyperdynamic flow. CSF flow... | 1.Posthemorrhagic ventricular enlargement, increased since the prior exam, with findings suggestive of hyperdynamic flow within the aqueduct.2.Susceptibility along the ventricuar margins likely represents chronic hemosiderin staining from prior hemorrhage. No acute hemorrhage.3.There appears to be generalized diffuse l... |
Generate impression based on findings. | Patient with acute kidney failure and hypertension, rule out renal vein thrombosis. BLADDER Wall Thickness: Normal Contents: The bladder is distended and a small amount of dependent debris is present. Distal Ureter -- SFU Grade** Right: 0 Left: 0 Ureteral Jets Right: Observed Left: ObservedKIDNEYS Cortical Echo... | 1.No evidence of renal vein thrombosis2.Medical renal disease.*SFU grading system: Grade 0: No hydronephrosis. Grade 1: The renal pelvis is visualized. Grade 2: A few but not all of the calices are identified in addition to the renal pelvis. Grade 3: Virtually all the calices are seen. Grade 4: Grade 3 and parenchymal ... |
Generate impression based on findings. | History of enlarging right groin mass / nodule s/p arterial catheterization on 1/12/15. Evaluate for pseudoaneurysm. ANGIOGRAPHY: Mild atherosclerotic calcification affects a normally sized distal abdominal aorta and iliac arteries. Within the right groin at the site of recent arteriotomy, there is induration of the so... | No evidence of pseudoaneurysm or significant hematoma. |
Generate impression based on findings. | 55-year-old male with left hip pain Mild degenerative changes affect the left hip without fracture evident. Alignment is within normal limits. Note is made of a calcified left testis, present on prior exams. Surgical clips project over the pelvis. | No fracture or dislocation. |
Generate impression based on findings. | CT head:There is a large enhancing lesion within the soft tissues overlying the left parietal calvarium measuring approximately 5.9 x 1.6 x 6.0 cm (80897/67 and 80854/33) which is new from the prior exam and likely correlates with patient's known squamous cell carcinoma. The lesion extends to the calvarial surface wit... | 1.Enhancing mass overlying the left parietal calvarium likely represents patient's known squamous cell carcinoma and is described above. This lesion abuts the calvarium, however there is no definite calvarial destruction. An MRI may be considered to evaluate for subtle infiltration of the marrow space, as it would be m... |
Generate impression based on findings. | 53-year-old female with pain, assess for arthritis or nonunion Orthopedic screws transverse the medial cuneiform, middle cuneiform and base of the first metatarsal. An additional horizontal screw affixes the base of the first and second metatarsals. We see no evidence of hardware complication. There has been fusion of ... | Orthopedic fixation as described above with fusion of the medial cuneiform and first metatarsal. No evidence of nonunion or hardware complication. |
Generate impression based on findings. | Male 65 years old Reason: pt with hx of small cell of the prostate; needs imaging to evaluate for possible biopsy of liver mets History: none LIVER: 14.3 cm in length. Gallbladder is surgically absent. No biliary dilatation. Common bile duct .3 cm in diameterNormal background echotexture and contour, with several discr... | At least two of the liver lesions are visible by ultrasound.Right renal stent. Gallbladder surgically absent. |
Generate impression based on findings. | 20 year-old male status post traumatic injury with back pain There is mild kyphosis of the thoracic spine. Vertebral body heights and disk spaces are preserved. No fracture is evident. | Mild kyphosis of the thoracic spine without evidence of fracture. |
Generate impression based on findings. | 58-year-old female with left lower extremity radiculopathy Lumbar spine: Note is made of an IVC filter. Vertebral body heights and disk spaces are preserved.Left hip: Alignment is anatomic. No fractures evident. Deformity of the superior and inferior pubic rami likely represent old fracture.Pelvis: There is deformity o... | Chronic appearing pubic rami fractures without other specific findings to account for the patient's symptoms. |
Generate impression based on findings. | 59-year-old female status post right total hip arthroplasty Hardware components of a total hip arthroplasty device are situated in near-anatomic alignment without evidence of complication. Drain and gas in the soft tissues reflect recent surgery. Severe osteoarthritis affects the left hip as seen on the frontal view. | THA without evidence of complication. |
Generate impression based on findings. | Time average mean velocities: Right middle cerebral artery: 166 cm/sec.Right internal carotid artery: 140 cm/sec.Left middle cerebral artery: 164 cm/sec.Left internal carotid artery: 117 cm/sec. | Normal time average mean velocities of intracranial blood vessels as described above (<180 cm/sec). |
Generate impression based on findings. | Female 73 years old Reason: RA History: large effusions Left knee: Bone mineralization is normal. Alignment is near-anatomic. There are tricompartmental osteophytes and joint space narrowing resulting in moderate to severe osteoarthritis. No significant joint effusion. No acute fracture or malalignment.Right knee: Bone... | Moderate to severe bilaterally osteoarthritis. |
Generate impression based on findings. | 59-year-old female with history of neoplasm of the esophagus (pathology reviewed and patient with invasive adenocarcinoma of the esophagus) who presents for evaluation. CHEST:LUNGS AND PLEURA: Scattered pulmonary micronodules with reference left upper lobe nodule measuring 0.8 x 0.7 cm (series 5, image 26). No pleural ... | 1.Diffuse marked distal esophageal wall thickening most likely patient's esophageal carcinoma results in severe narrowing of distal esophageal lumen. 2.Diffuse hepatic metastatic disease. 3.Left upper lobe 8mm pulmonary nodule is nonspecific but metastatic disease not entirely excluded. |
Generate impression based on findings. | For the purposes of numbering, there are 5 lumbar type vertebral bodies. Vertebral body heights are maintained. There is mild loss of lumbar lordosis. No spondylolisthesis. There is mild lumbar dextrocurvature as seen on prior radiographs. There are postsurgical changes of laminectomy from L3 to L5.Multilevel degenera... | Postsurgical changes of prior laminectomies from L3 to L5. Multilevel degenerative changes are seen throughout the lumbar spine. No high-grade spinal canal stenosis is seen. There is moderate to severe neural foraminal stenosis at multiple levels as detailed above and can be further assessed with MRI if clinically indi... |
Generate impression based on findings. | Ms. Lee is a 45 year old female with a personal history of left breast lumpectomy in 2010 for malignant Phyllodes tumor followed by radiation therapy. Family history of ovarian cancer in two maternal aunts. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast... | Stable postsurgical changes of the left breast. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram is recommended annually. Results and recommendation were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnos... |
Generate impression based on findings. | Female 52 years old; Reason: r/o PE History: chronic dyspnea The comparison chest radiograph performed on 1/22/2015 demonstrates no focal pulmonary opacities or pleural fluid. There is moderate matched ventilation perfusion defect in the superior lingular segment of the left lung. Otherwise the remaining segments of th... | Low probability for pulmonary embolism. |
Generate impression based on findings. | Female 57 years old Reason: ra History: oa Left foot: Bone mineralization is normal. Alignment is anatomic. There is mild joint space loss at the first metatarsal phalangeal joint. Mild arthritis affects the midfoot. There is a small calcaneal heel spur. No focal erosive change.Right foot: Bone mineralization is normal... | No radiographic evidence of rheumatoid arthritis. |
Generate impression based on findings. | 65 real female with right knee pain. Three weight-bearing views of the right knee are provided. Moderate osteoarthritis with joint space narrowing and osteophyte formation greatest in the medial tibiofemoral compartment. No acute fracture or malalignment.Moderate osteoarthritis is also noted in the left knee on the fro... | Moderate osteoarthritis. |
Generate impression based on findings. | Female 67 years old; Reason: 67y/o female with right breast cancer; surgery 1/23/15 right breast wire loc lumpectomy and R SNBx in DCAM History: 67y/o female with right breast cancer; surgery 1/23/15 right breast wire loc lumpectomy and R SNBx in DCAMRADIOPHARMACEUTICAL: The right breast was prepared in a sterile manne... | Sentinel node identified in the right axilla. |
Generate impression based on findings. | 53 year old female with cough, lung mass. LUNGS AND PLEURA: Thick walled cavitary mass with consolidation in the right upper lobe, with mild bronchiectasis within the cavity. There is associated right lung volume loss and retraction. Moderate centrilobular emphysema. Scattered micronodules measuring less than 4 mm, wit... | 1. Thick walled right upper lobe cavitary mass, for which differential considerations include necrotizing infection secondary to pyogenic infection or mycobacteria including tuberculosis, or less likely malignancy. 2. Borderline enlarged nonspecific mediastinal lymph nodes may be reactive in etiology. 3. Moderate centr... |
Generate impression based on findings. | 78-year-old female with pain, evaluate for fracture There is a cortical step off along the iliopubic line with minimal displacement. The proximal femur appears intact. | Minimally displaced pelvic/acetabular fracture, CT is recommended for further evaluation. |
Generate impression based on findings. | Reason: patient with history of endometrial stromal sarcoma and now with an anterior vaginal wall lesion, possibly a urethral diverticulum History: vaginal bleeding PELVIS:UTERUS, ADNEXA: Status post hysterectomy. Within the vaginal cuff, centered more on the left, there is a lobulated, gray T2, low T1 mass, measuring ... | 1.Approximately 3 cm lobulated mass within the vaginal cuff as described above is suspicious for recurrence in light of given history of endometrial stromal sarcoma. |
Generate impression based on findings. | Ms. Fox is a 76 year old female with a history of unilateral spontaneous left nipple discharge. On physical exam by Dr. Chhablani today, she had nipple discharge that was slightly blood tinged. The discharge has been sent for cytology. Upon physical exam. Upper left breast, no nipple discharge was able to be expressed.... | Ductal ectasia with no abnormal intraductal mass or vascularity. The patient will follow-up with Dr. Chhablani regarding the nipple discharge and resultant cytology. All results and recommendations were relayed to the patient and Dr. Chhablani.BIRADS: 2 - Benign finding.RECOMMENDATION: T - Take Appropriate Action - No ... |
Generate impression based on findings. | Male; 77 years old. Reason: Decreased diffusion capacity on PFTs, please examine for parenchymal process History: Shortness of breath LUNGS AND PLEURA: Mild upper lobe predominant paraseptal and centrilobular emphysema. Mild bibasilar bronchiectasis and bronchial wall thickening. Minimal streaky bibasilar subsegmental ... | Emphysema, but no evidence of chronic interstitial lung disease. |
Generate impression based on findings. | 84-year-old male with nonhealing partial distal phalanx amputation Marked soft tissue swelling and irregularity about the distal aspect of the first toe. There is cortical erosion and irregularity of the distal aspect of the residual distal phalanx of the first toe. | Findings concerning for osteomyelitis of the distal phalanx of the first toe as described above. |
Generate impression based on findings. | Reason: eval for mediastinal mass History: 15yo F with eye swelling, parotitis, want to r/o mediastinal massVIEWS: Chest PA/lateral (two views) 01/22/15 Aortic arch, cardiac apex, and stomach are left sided. Cardiothymic silhouette is normal. No pleural effusion or pneumothorax. No focal pulmonary opacities. Mild to mo... | Bronchiolitis/reactive airway disease pattern. No mediastinal mass as clinically questioned. |
Generate impression based on findings. | Reason: evaluate healing after posterior spinal fusion History: scoliosisVIEWS: Thoracolumbar spine PA/lateral (two views) 01/22/15 Spinal fusion instrumentation extends from T3 to L2. Rods, hooks, and pedicle screws are intact without evidence of hardware complication. Minimal rightward curvature of the lower thoracic... | Spinal instrumentation without evidence of hardware complication. |
Generate impression based on findings. | Severe headache No intracranial hemorrhage is identified. No intracranial mass or evidence of mass-effect. No midline shift or uncal herniation. Gray-white differentiation is maintained. No extra-axial collections. Ventricles are within normal limits without evidence of hydrocephalus.Small left maxillary mucous retenti... | No evidence of acute intracranial hemorrhage or mass effect. If there is continued suspicion for an intracranial structural abnormality, consider MRI for further evaluation. |
Generate impression based on findings. | 50-year-old female with history of benign biopsy of the left breast in 2008 presents for annual mammogram. No current breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. Tomosynthesis images are also obtained. The breast parenchyma is extremely dens... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Tomosynthesis is useful for dense breasts. Results and recommendations were discussed with the patient.BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Ma... |
Generate impression based on findings. | Reason: 2 right middle lobe nodules seen on previous Chest CT, smoker History: SOB, Cough, known lung nodules LUNGS AND PLEURA: Two elliptically shaped right middle lobe nodules seen previously are unchanged measuring 6 mm (series 5, images 49, 50). There is increased lower lobe bronchial wall thickening now with impac... | 1. The two elliptically shaped right middle lobe nodules seen previously are unchanged and likely are intrapulmonary lymph nodes. Two new right middle lobe nodular opacities, along with increased lower lobe bronchial wall thickening/impaction, collectively suggest bronchiolitis possibly secondary to recurrent aspiratio... |
Generate impression based on findings. | 67 year old female status post OGT placement. Pelvis excluded from field of view. OG tube sidehole at the GE junction and may be advanced at least 8 cm. Nonobstructive bowel gas pattern. Levoscoliosis, spinal degenerative disease and changes from prior laminectomies again noted. Minimal right basilar atelectasis/scarri... | OG tube sidehole at the GE junction, may be advanced at least 8 cm. |
Generate impression based on findings. | Male 59 years old; Reason: h/o HNC and CRT History: problems with ORN; has mandibular lesion; see CT neck 11/4/14RADIOPHARMACEUTICAL: 15.4 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 91 mg/dL. Today's CT portion grossly demonstrates posttherapy changes in the neck, as well as a lytic process in the left ... | 1.New mild to moderate hypermetabolic activity corresponding to the lytic process in the left mandible on CT may represent infectious/inflammatory osseous process or tumor. No additional suspicious FDG avid lesion to otherwise suggest metastatic disease.2.New hypermetabolic colonic (likely sigmoid) lesion may represent... |
Generate impression based on findings. | Reason: evaluate healing of fracture History: left humerus x-rayVIEWS: Left humerus AP/lateral (two views) 01/22/15 Overlying cast material obscures fine bone detail. Again seen is a comminuted fracture through the mid diaphysis in near anatomic alignment with mild periosteal reaction and callus formation suggestive of... | Healing left humeral diaphysis fracture. |
Generate impression based on findings. | Reason: r/o pna History: sobVIEW: Chest AP (one view) 01/22/15 Aortic arch, cardiac apex, and stomach are left-sided. Cardiothymic silhouette is normal. No pleural effusion or pneumothorax. No focal pulmonary opacities. Minimal peribronchial cuffing suggestive of bronchiolitis/reactive airway disease. | Bronchiolitis/reactive airway disease pattern. |
Generate impression based on findings. | Reason: eval for metatarsal fracture History: foot pain sports in volleyball and basketball for 2 weeksVIEWS: Right foot AP/oblique/lateral (3 views) 01/22/15 No acute fracture or malalignment is evident. | Normal examination. |
Generate impression based on findings. | 2 to 3 months of breast tenderness. Family history of breast cancer in mother and sister. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchanged in pattern and distribution. No domin... | No mammographic evidence of malignancy. Clinical correlation is recommended regarding the patient's breast tenderness. 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.RECO... |
Generate impression based on findings. | Reason: evaluate healing 6 weeks after posterior spinal fusion History: scoliosisVIEWS: Thoracolumbar spine PA/lateral (two views) 01/22/15 Spinal fusion instrumentation extends from T3 to L2. Rods, hooks, and pedicle screws appear intact without evidence of hardware complication. Minimal residual rightward thoracic cu... | Spinal fusion instrumentation without evidence of hardware complication. |
Generate impression based on findings. | Reason: L Hip Arthritis in Pt w/ CP who quit walking 3mo prior History: L hip painVIEWS: Left hip AP/frog leg (two views) 01/22/15 No acute fracture or malalignment is evident. No findings to account for patient's pain. | Normal examination. |
Generate impression based on findings. | 87-year-old female with new diagnosis of esophageal cancer. Initial staging.RADIOPHARMACEUTICAL: 14.2 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 97 mg/dL. Today's CT portion grossly demonstrates mass-like thickening of the mid to distal esophagus, compatible with known esophageal malignancy. Enlarged ga... | 1.Markedly hypermetabolic mid to distal esophageal mass compatible with known primary esophageal carcinoma. Markedly hypermetabolic, enlarged gastrohepatic lymph nodes are compatible with regional lymph node metastases.2.Numerous smaller, more mildly but still abnormal hypermetabolic lymph nodes in the chest and abdome... |
Generate impression based on findings. | 54-year-old male with first MTP joint pain and swelling Prominent posterior calcaneal heel spur. The Achilles tendon is not well visualized. There is diffuse soft tissue swelling about the foot. No fracture is evident. | Diffuse soft tissue swelling without fracture evident. |
Generate impression based on findings. | 57-year-old male with neutropenia and dental pain, rule out abscess Several missing molars are noted. There is no gross bone destruction or other evidence of osteomyelitis. The maxillary sinuses are well-aerated. | No evidence of osteomyelitis. |
Generate impression based on findings. | Mild proptosis and concern for thyroid disease. Orbit: There is mild proptosis, with the distance from the infrazygomatic line to the anterior surface of the globe measuring 28 mm bilaterally. There is mild thickening of the inferior, medial, and superior rectus muscles bilaterally. In addition, there is central hypoat... | 1. Findings compatible with thyroid eye disease with proptosis and mild crowding of the structures in the orbital apex, but otherwise no definite evidence of optic nerve compression.2. No evidence of intracranial hemorrhage or mass.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree wit... |
Generate impression based on findings. | Female 63 years old; Reason: other cause of RUQ pain History: RUQ pain, pos murphy's, neg RUQ ultrasound ABDOMEN:LUNG BASES: Hazy reticular opacities at the lung bases, likely atelectasis.LIVER, BILIARY TRACT: Subcentimeter hypodensity in the right hepatic lobe (4:29) is too small accurate characterize.SPLEEN: No signi... | 1.No acute abdominal or pelvic pathology.2.Interval increase in size of cystic lesion in the right adnexa. Follow up ultrasound is suggested to better assess the lesion. |
Generate impression based on findings. | 60 year-old female with history of metastatic breast cancer CHEST:LUNGS AND PLEURA: Multiple bilateral pulmonary nodules are again seen, with the reference right lower lobe pulmonary nodule (6/73) measuring 14 x 12 mm, previously 10 x 7 mm.Several small new pulmonary nodules are appreciated.MEDIASTINUM AND HILA: Heart ... | Multiple pulmonary nodules, some of which have increased in size, in addition to a new left hepatic dome hypoattenuating focus. Bilateral axillary lymphadenopathy as described above. Findings suggestive of progression of disease. |
Generate impression based on findings. | Female; 57 years old. Reason: PE History: L sided chest pain PULMONARY ARTERIES: Extensive bilateral acute pulmonary emboli with clot seen in the right and left main pulmonary arteries extending into all of the lobar branches. Normal caliber of the main pulmonary artery. Increased caliber of the right ventricle with fl... | Extensive bilateral acute pulmonary emboli with right ventricular strain as described above.PULMONARY EMBOLISM: PE: Positive.Chronicity: Acute.Multiplicity: Multiple.Most Proximal: Main.RV Strain: Positive. |
Generate impression based on findings. | 52 year male stem cell transplant patient needing an MRI of sinus. Need x-ray to rule out metal jaw implants from previous procedure. Wire-like device projects over the angle of the mandible bilaterally. Multiple dental amalgam. | Wire-like device projects over the angle of the mandible bilaterally. MRI compatibility cannot be determined from this radiograph. |
Generate impression based on findings. | 14 year old female with thyroid left wrist pain.VIEWS: Left wrist AP lateral and oblique (3 views) 1/22/2015 A minimally displaced transverse fracture through the distal pole of the scaphoid is evident. Moderate soft tissue swelling is evident about the wrist. No additional fracture is seen. | Minimally displaced transverse fracture of the distal scaphoid. |
Generate impression based on findings. | 48-year-old female status post explant TSA, Abx spacer placement. Hardware components of a reverse left total shoulder arthroplasty device are situated in near anatomic alignment with no radiographic evidence of hardware complication. New placement of cerclage wire. Metal fragments again noted projecting over the left ... | Postsurgical changes with new placement of cerclage wire. No radiographic evidence of hardware complication. |
Generate impression based on findings. | Female, 63 years old, with new lethargy and left-sided weakness. Loss of gray-white distinction is seen involving the right insula, perhaps the right putamen, and perhaps within the right temporal lobe. Areas of hypoattenuation are also seen within the right corona radiata. The right MCA is hyperdense at the level of t... | Findings concerning for acute right MCA distribution ischemia.(Discussed with Dr. Greenberg at 5:00 PM on 1/22/15.) |
Generate impression based on findings. | Female 63 years old Reason: OA, eval interval change History: knee pain, crepitus Right knee: Bone mineralization is normal. There is genu varus due to severe medial compartment joint space loss where there is bone-on-bone apposition. There is moderate to severe extensor compartment joint space loss. There are tricompa... | Severe bilateral knee osteoarthritis. |
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