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Generate impression based on findings. | 39 year old female. Evaluate for fluid collection, abscess, evolution of the abdominal wall collections noted previously. History of chronic enterocutaneous fistula.Additional history: Post operative day #8 s/p ex lap, enterocutaneous fistula takedown, small bowel resection, ventral hernia repair. ABDOMEN:Lack of intra... | 1.Inflammatory changes in multiple foci of gas about the abdominal incision and is suspicious for abscess. Fluid collection within the anterolateral abdominal wall containing gas, also suspicious for abscess.2.Hyperattenuating fluid collection in the anterior abdominal wall, most likely representing intramuscular hemat... |
Generate impression based on findings. | Reason: 82 yo F with h/o SCC of esophagus, TE fistula s/p tracheal/esop stenting now with difficulty swallowing 2/2 possible swelling of arytenoids, ?vocal cord dysfunction History: as above LUNGS AND PLEURA: Spiculated nodular opacity in the right upper lobe with the solid component measuring approximately 7 x 8 mm (i... | 1. Right upper lobe scar-like spiculated opacity, unchanged.2. Several small lung nodules, stable.3. New left upper lobe small focus of consolidation.4. Tracheal and esophageal stents with soft tissue density prolapsing over the proximal portion of esophageal stent. |
Generate impression based on findings. | 15 year-old female status post MVA with cervical neck tenderness, unable to clear C-spine with plain film and clinical exam. Straightening of the cervical spine, likely due to positioning or muscle spasm. The cervical vertebral bodies are appropriate in overall alignment and height. Asymmetry of the distance between th... | Asymmetry of the distance between the lateral masses of C1 and the odontoid likely due to rotation with no fractures identified in the cervical spine. If there is clinical concern for ligamentous injury, then MRI should be considered. |
Generate impression based on findings. | 54-year-old female with left lower quadrant pain, history diverticulitis. Evaluate for abscess. ABDOMEN:LUNG BASES: Small left pleural effusion. Right basilar atelectasis.LIVER, BILIARY TRACT: No significant abnormality noted in the liver. Status post cholecystectomy.SPLEEN: No significant abnormality notedPANCREAS: No... | 1. Small left pleural effusion. 2. No GI tract abnormality identified. |
Generate impression based on findings. | 73-year-old female with abdominal pain/vomiting.? Obstruction. Within the limits of a non-IV contrast enhanced examination limiting the ability. Evaluate subpectoral organs and vessels, structures to following observations can be made:ABDOMEN:LUNG BASES: No change benign calcifications in the liver. No other abnormalit... | 1. Prior cystectomy with right ileal loop conduit bladder with expected appearance -- resolution of prior noted bilateral hydronephrosis. 2. Disproportionate dilatation of proximal small bowel with collapsed distal small bowel indicative of small bowel obstruction -- most likely due to adhesions is no significant mass ... |
Generate impression based on findings. | 25 year-old female with right lower quadrant pain. Rule out appendicitis. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality notedKIDNEYS, U... | Dilated, thick-walled enhancing appendix with peri-appendiceal inflammatory changes suggestive of appendicitis. |
Generate impression based on findings. | 67-year-old male. Evaluate free air and evaluate integrity of abdominal hernia repair. Abdominal pain status post ventral hernia repair 8/3/13. ABDOMEN:LUNG BASES: Moderate left and small right pleural effusion with associated compressive atelectasis.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No sign... | 1.Large amount of free intraperitoneal air. We cannot exclude bowel injury, however there is no evidence of focal bowel inflammation -- see above discussion. 2.Loculated fluid collection in the left upper quadrant containing mottled air, likely postsurgical in etiology.3.Moderate left and small right pleural effusion. |
Generate impression based on findings. | 67-year-old male with vomiting and abdominal distention -- evaluate for small bowel obstruction. History of metastatic lung cancer. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Hypoattenuating lesion in segment 7, presumably representing liver metastasis. No new lesions identified. No evide... | 1. Presumed liver metastasis, unchanged. 2. No evidence for bowel obstruction and no bowel or mesenteric abnormalities seen. |
Generate impression based on findings. | 68-year-old female with abdominal pain, vomiting. Evaluate for stent migration, obstruction. ABDOMEN:LUNG BASES: Bibasilar bronchiectasis/fibrosis. LIVER, BILIARY TRACT: Cholecystectomy clips. The biliary stent has been replaced with a large bore stent which contains air and appears in place. There is expected pneumobi... | The biliary stent is in the appropriate position with biliary air supporting patency. No acute change compared to prior exam. |
Generate impression based on findings. | Reason: Pt with HNC s/p CRT 3/8/13. Please re-eval as above History: as above CHEST:LUNGS AND PLEURA: Punctate micronodules and calcified granuloma.No evidence of pulmonary pleural metastases.MEDIASTINUM AND HILA: A Dobbhoff tube traverses the esophagus.Right jugular central line tip at SVC/RA junction level.No mediast... | No change, and no evidence of metastases. |
Generate impression based on findings. | Colon carcinoma CHEST:LUNGS AND PLEURA: Interval increase in size of left lower lobe nodule best seen on image 54 of series 5, now measuring 5 mm in diameter; in retrospect, the micronodule was present on the prior study, but measured less than 3 mm..Stable left apical micronoduleMEDIASTINUM AND HILA: No significant ab... | Interval increase in size and number of bilobar hepatic metastatic lesions. Interval increase in size of left lower lobe lung nodule consistent with progression of metastatic focus. |
Generate impression based on findings. | 36-year-old female is febrile, tachycardic, and has left lower quadrant pain/tenderness. Status post appendectomy in the distant past. Possible history of pancreatic tumor. Evaluate for intra-abdominal process. ABDOMEN:LUNG BASES: There is a focal area of atelectasis along the pleura of the left lower lobe(image 9, ser... | Striated nephrogram appearance of the left kidney with mild peri-nephric fat stranding. This finding is non-specific but in the clinical setting of an elevated white count and with the observed inflammatory changes is most consistent with pyelonephritis. |
Generate impression based on findings. | Reason: Pt with hx of cancer of palate. s/p CRT 1 year ago. Please re-eval for recurrence History: as above CHEST:LUNGS AND PLEURA: Azygos pseudo-lobe noted.No sign of pulmonary or pleural metastases.Dependent atelectasis noted bilaterally.MEDIASTINUM AND HILA: No mediastinal or hilar lymphadenopathy noted.CHEST WALL: ... | No evidence of metastases. |
Generate impression based on findings. | Reason: lung CA, s/p chemo and RT followup History: cough CHEST:LUNGS AND PLEURA: Spiculated right upper lobe nodule (series 4, image 85) measures 11 x 7 mm, unchanged. Additional nodular density peripheral to the index lesion is not discretely measurable, but appears smaller. New focus of consolidation with air bronch... | 1.No significant interval change in spiculated right upper lobe nodule. 2.Decrease in size of right upper lobe satellite nodule. 3.New focus of consolidation in the superior segment of the right lower lobe compatible with post radiation change, less likely infection. |
Generate impression based on findings. | Reason: hx H\T\N ca, s/p CRT, evaluate dx and compare measurements to previous scans History: as above CHEST:LUNGS AND PLEURA: Scattered stable nonspecific micronodules.No suspicious pulmonary nodules or masses.Mild left basilar scarring/discoid atelectasis.Mild upper lobe predominant emphysema.MEDIASTINUM AND HILA: St... | No evidence of metastatic disease. |
Generate impression based on findings. | Reason: follow up 8 mm LLL nodule History: none LUNGS AND PLEURA: Scattered pulmonary micronodules all have a benign appearance and are unchanged since the prior study. The 8-mm nodule previously measured in the left lower lobe has not significantly changed and has an inflammatory appearance or may be an intrapulmonary... | Benign appearing postinflammatory micronodules. The largest 8mm nodule is stable, likely benign, but further 9 to 12 month follow up is recommended. |
Generate impression based on findings. | 53-year-old male with history of cancer of palate. Status post CRT one year ago. Please re-evaluate for recurrence. HEAD:The ventricles, sulci, and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass, mass effect, edema, midline shift, intra- or extra-axial fluid c... | 1.No evidence of intracranial metastases. 2.Postsurgical changes of the right hard palate and alveolar ridge with no evidence of recurrence. 3.Stable cervical lymph nodes with no new or enlarging lymph nodes. 4.Please see separate dictation for CT Chest also performed on the same day. |
Generate impression based on findings. | Reason: rule out SDH after fall in patient on warfarin History: headache There is a left frontal scalp hematoma present relatively stable when compared to the prior exam.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracr... | Examination is stable. There is a left frontal scalp hematoma without underlying calvarial abnormality or intracranial hemorrhage. |
Generate impression based on findings. | Reason: Pt with Larynx Ca s/p 7 cycles of FHX. Plese re-eval and compare to prior scans History: as above CHEST:LUNGS AND PLEURA: Pleural thickening with calcified pleural plaques, compatible with previous asbestos exposure.Bronchial wall thickening and posterior subpleural opacities in the right hemithorax compatible ... | 1.Stable increased enhancing soft tissue in the right paratracheal and right superior mediastinal region may represent residual tumor.2.Slight interval decrease in the right hilar and subcarinal lymphadenopathy.3.Bronchial wall thickening and increasing areas of subpleural atelectasis in the right lung compatible with ... |
Generate impression based on findings. | Reason: 69 yo F hx of amyloid, COPD with lung nodule - pls evaluate for progression History: baseline SOB from COPD LUNGS AND PLEURA: Scattered benign appearing micronodules had been present and stable since at least 10/7/2010.Stable linear basilar scarring. Left lower lobe bronchial wall thickening has diminished.MEDI... | Post inflammatory appearing pulmonary abnormalities, but no suspicious nodules requiring follow-up. No new findings. |
Generate impression based on findings. | 85 year-old female with history of small cell lung cancer status post CRT LUNGS AND PLEURA: Ground-glass opacities, bronchial wall thickening, and volume loss in the right upper lobe, unchanged.Occasional calcified granulomata.No new or suspicious nodules, masses, or pleural effusion.MEDIASTINUM AND HILA: Heart size is... | 1. Unchanged inflammatory abnormalities in the right upper lobe.2. No evidence or disease recurrence or metastasis.3. Scattered granulomata of the lungs, liver, spleen and calcified hilar and subcarinal lymph nodes compatible with old granulomatous disease.4. Marked atherosclerosis and calcification of the aorta and ma... |
Generate impression based on findings. | 51-year-old female with cervical esophageal cancer status post CRT, reevaluate and compare to prior. BRAIN: The cerebral and cerebellar hemispheres and the brain stem are normal in morphology and attenuation. Ventricular size is within normal limits. No CT evidence of acute territorial infarction or large bleed. No abn... | 1. Stable post treatment change of the neck without evidence of new mass or lymphadenopathy.2. No acute intracranial abnormality or evidence of metastatic disease. |
Generate impression based on findings. | Reason: pt with lung ca s/p chemo x 6 weeks and daily RT History: doing well now needs disease evaluation compare to previous sans and comment LUNGS AND PLEURA: Right middle lobe mass (series 4, image 165) measures 25 x 15 mm, previously 38 x 29 mm. Additional scattered micronodules are noted. No new suspicious pulmona... | 1.Interval decrease in size of right middle lobe mass. 2.Decreasing mediastinal and hilar lymphadenopathy.3.No new sites of disease. |
Generate impression based on findings. | 34-year-old male preop planning for biopsy. Limited examination for preoperative planning. Streak artifact from halo limits evaluation. Vague hypoattenuating mass in the right frontal subcortical white matter is grossly unchanged. No significant associated mass effect or midline shift. The ventricles, sulci, and cister... | Grossly stable right frontal lobe mass for preoperative planning. |
Generate impression based on findings. | Reason: Pt with hx of HNC s/p CRT; please re-eval and compare History: as above CHEST:LUNGS AND PLEURA: Left lower lobe 4-mm benign-appearing nodule stable since it least 8/13/2011.No significant pulmonary or pleural abnormality.MEDIASTINUM AND HILA: No significant abnormality noted.CHEST WALL: No significant abnormali... | No evidence of metastases or change. |
Generate impression based on findings. | 78 year old female. Clostridium difficile, worsening abdominal pain. No bowel movement in two days, evaluate for worsening colonic process. Vaginal bleeding, negative pelvic ultrasound, evaluate for etiology of bleeding. Abdominal pain. ABDOMEN:LUNG BASES: Changes of left pneumonectomy with shift of the mediastinum to ... | 1.No evidence of obstruction or inflammatory process in the colon.2.No findings to account for patient's vaginal bleeding.3.Diffuse fatty infiltration of the liver. |
Generate impression based on findings. | 83-year-old female with abdominal pain. Rule-out diverticulitis. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Punctate calcification, presumably from prior granulomatous disease. No focal, solid masses are seen in the liver. Gallbladder shows gallstone without other complication. There is d... | 1. Gallstones identified in gallbladder. Mild dilatation of intrahepatic. Next hepatic bile ducts, but without other signs to suggest, biliary obstruction -- clinical correlation with liver function tests and clinical signs for biliary obstruction could clarify significance of these findings. 2. Small anterior pelvic w... |
Generate impression based on findings. | 46 year old female. Evaluate for progression of metastatic disease. History of malignant melanoma. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: Mediastinal lymphadenopathy. Reference precarinal lymph node measures 1.5 x 1.1 cm (image 36, series 3) previously 1.5 x 1.3 cm.CHEST... | 1.No significant change in mediastinal lymphadenopathy. 2.Progression of disease in the abdomen and pelvis.3.Left hydroureter, likely due to adenopathy surrounding ureter. |
Generate impression based on findings. | 56-year-old female with history of tongue cancer status post CRT. BRAIN: No evidence of abnormal intracranial enhancement or mass-effect to suggest intracranial metastases. The gray white matter differentiation is preserved. There is no evidence of mass effect or midline shift. The ventricles and sulci are unremarkable... | 1. Stable postoperative/treatment changes of the neck without evidence of new mass or lymphadenopathy.2. No evidence of intracranial metastases. |
Generate impression based on findings. | 59-year-old female with esophageal candidiasis of unclear etiology. Screen for occult malignancy. CHEST:LUNGS AND PLEURA: Scattered punctate micronodules, some of which are dense, most likely calcified, presumably scarring from prior inflammatory changes. No significant nodules, masses, or infiltrates identified. No pl... | 1. No evidence of thoracic, abdominal or pelvic malignancy. 2. No source of etiology for candidiasis identified. |
Generate impression based on findings. | 29 year old female. Metastatic adenocarcinoma, unknown primary. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: Cardiac size is normal. No pericardial effusion. No mediastinal or hilar lymphadenopathy.CHEST WALL: Right breast mass measuring 2.0 x 1.8 cm (image 40, series 3). Bulk... | 1.Right breast mass, with associated right axillary lymphadenopathy and diffuse lytic osseous lesions compatible with metastatic breast cancer.2.Large lytic lesion in the right femoral neck which is concerning for possible impending pathologic fracture.Findings discussed with Dr. Dickens (pager 3676) via phone at 1:45 ... |
Generate impression based on findings. | 59-year-old male with stage IV metastatic melanoma. Reevaluate disease status following additional systemic therapy. CHEST:LUNGS AND PLEURA: Several scattered pulmonary micronodules, mostly subpleural and all unchanged. No significant size nodules, no masses or acute infiltrates identified. MEDIASTINUM AND HILA: No ade... | 1. No new evidence for metastatic disease or enlarging foci. 2. Small residual abnormalities remain stable in areas in left anterior chest wall and gallbladder wall that in remote past showed larger lesions.These may represent scarring. |
Generate impression based on findings. | One year old female with metopic synostosis. Evaluate sutures and fontanelle. History of frontal ridging status post anterior vault cranioplasty. Interval postsurgical changes of frontal calvarial cranioplasty including bilateral supraorbital craniotomies that extend laterally and along the coronal sutures. Areas of lu... | Interval postsurgical changes of frontal cranioplasty with decreased trigonocephaly. |
Generate impression based on findings. | Reason: please evaluate for bronchiectasis History: productive cough in a nonsmoker LUNGS AND PLEURA: No significant bronchial wall thickening or bronchiectasis. No focal consolidation or pleural effusion. Mild dependent atelectasis.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. No mediastinal or ... | No significant abnormality. |
Generate impression based on findings. | Male 65 years old; Reason: pancreas cancer please compare to previous scan and provide index lesion measurements History: As above CHEST:LUNGS AND PLEURA: No new pulmonary lesions. Micronodule in the right lower lobe (image 63/series 5) is unchanged.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. N... | 1.Stable to slight decrease in the size of the reference lesions. |
Generate impression based on findings. | Reason: h/o sinus cancer History: r/o lung mets LUNGS AND PLEURA: Small punctate calcified micronodules, unchanged.No evidence of pulmonary or pleural metastases. MEDIASTINUM AND HILA: Dual chamber pacemaker leads and coronary artery calcifications are unchanged.Scattered mediastinal lymph nodes are all within normal s... | No evidence of metastases. |
Generate impression based on findings. | 62 year old male. Oncocytoma, and prostate cancer. Evaluate for change in oncocytoma. AABDOMEN:LUNG BASES: Right lower lobe pulmonary nodule measures 11 mm (image 19, series 4), unchanged from prior exam.LIVER, BILIARY TRACT: Cholecystectomy. No focal hepatic lesion. Portal and hepatic veins are patent.SPLEEN: No signi... | 1.Solid, enhancing mass arising from the left inferior renal pole, increased in size from prior exam.2.Pulmonary nodule, unchanged in size.3.Diffuse sclerotic osseous metastases. |
Generate impression based on findings. | Reason: mediastinal adenopathy History: mediastinal adenopathy LUNGS AND PLEURA: Minimal lower lobe bronchiectasis, unchanged.Small calcified granuloma right lung base.No suspicious pulmonary nodules or masses.No pleural effusions.MEDIASTINUM AND HILA: Multiple enlarged mediastinal lymph nodes are stable to minimally d... | Stable anterior mediastinal lymphadenopathy unchanged since 11/29/12 would support the diagnosis of benign lymphoid hyperplasia. |
Generate impression based on findings. | Reason: r/o ICH History: syncope The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Atherosclerotic calcifications are present along the d... | 1.No evidence for acute intracranial hemorrhage mass effect or edema.2.Opacification of the interim nasal cavity as nonspecific. Please correlate with clinical symptoms and clinical evaluation |
Generate impression based on findings. | Male 61 years old; Reason: hx localized urothelial cancer History: hx localized urothelial cancer CHEST:LUNGS AND PLEURA: Severe upper lobe and moderate to severe lower lobe emphysema. Postoperative changes from wedge resections in the left lower lobe.The left upper pulmonary lesion measures 0.7 x 0.7 cm (image 14/seri... | 1.Decrease in the size of the reference lesions. |
Generate impression based on findings. | 58 year-old female with right upper quadrant pain and elevated alkaline phosphatase -- normal Ultrasound examination. Question of hepatobiliary pathology. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Liver shows less than expected density throughout and most likely relates to diffuse fatty ... | 1. Probable diffuse fatty infiltration of the liver. 2. Multiple benign-appearing hepatic cysts throughout liver parenchyma. 3. Hiatal hernia. 4. No other abnormalities seen. |
Generate impression based on findings. | Male 73 years old; Reason: rule out metastatic disease History: history of bladder cancer s/p cystectomy ABDOMEN:LUNGS BASES: No significant abnormality notedLIVER, BILIARY TRACT: Liver is normal in morphology. The hepatic and portal veins are patent. Subcentimeter right hepatic lobe hypodense lesion is unchanged. No n... | 1.Status post cystoprostatectomy and ileal conduit. No evident metastatic disease in the abdomen or pelvis. 2.Stable appearance of the hepatic artery thrombosed aneurysm. |
Generate impression based on findings. | Reason: evaluate for progression. History: Metastatic osteosarcoma. Status post RT to left hilar mass LUNGS AND PLEURA: Stable postoperative changes in the left upper lobe.Persistent narrowing of the left upper lobe bronchus and associated peribronchial soft tissue density (image 37, series 3) is decreased in size now ... | Interval decrease in size of known left hilar mass. |
Generate impression based on findings. | 64 year old female with syncope. Please evaluate for intracranial hemorrhage. VENTRICLES/CSF SPACES:No midline shift. CSF spaces appropriate for patient age.BRAIN PARENCHYMA:No abnormal mass lesions, edema, or hemorrhage. There is minimal periventricular hypodensity which may represent chronic small vessel disease.FLUI... | 1. NO EVIDENCE OF INTRACRANIAL HEMORRHAGE AS CLINICALLY QUERIED. |
Generate impression based on findings. | Male 80 years old; Reason: bladder cancer r/o mets History: bladder cancer r/o mets ABDOMEN:LUNGS BASES: Reference right lower lobe pulmonary nodule measures 4-mm on image 16 / series 6. This is unchanged.LIVER, BILIARY TRACT: Liver is normal in morphology. 7-Mm right hepatic lobe hypodensity is too small to characteri... | 1.Stable exam without evident metastatic disease. |
Generate impression based on findings. | Male 55 years old; Reason: Rectal cancer completed therapy 2010 evaluate for disease recurrence history: Rectal cancer CHEST:LUNGS AND PLEURA: Stable left lower lobe cyst. No suspicious pulmonary lesions.Calcific granulomata in the right upper lobe with ipsilateral calcified hilar lymph nodes.MEDIASTINUM AND HILA: Hear... | 1.Stable exam without evident metastatic disease in the chest, abdomen or pelvis. |
Generate impression based on findings. | Female 74 years old; Reason: assess for fascial dehiscence History: excessive wound drainage ABDOMEN:LUNGS BASES: Trace bilateral pleural effusion and atelectasis.LIVER, BILIARY TRACT: Liver is unremarkable for unenhanced technique. Mild perihepatic ascites. Mild gallbladder distention.SPLEEN: No significant abnormalit... | 1.No discrete body wall fluid collection to account for the patient's wound drainage.2.Multiple air-fluid levels within mildly distended small bowel loops without a discrete transition point most likely indicating ileus. Follow up is suggested.3.Small amount of abdominal and pelvic ascites.4.Mildly distended gallbladde... |
Generate impression based on findings. | 64-year-old with dizziness. VENTRICLES/CSF SPACES:No midline shift. CSF spaces appropriate for patient age.BRAIN PARENCHYMA:No abnormal mass lesions, edema, or hemorrhage. Periventricular and subcortical low attenuation white matter likely represents prior small vessel disease. Mild supratentorial and multiple bilatera... | 1.NO CT FINDINGS TO SUGGEST ACUTE INFARCT. CT IS NOT AS SENSITIVE AS MRI IN THE DETECTION OF ACUTE INFARCT, IF CLINICALLY INDICATED AN MRI EXAMINATION COULD PROVIDE ADDITIONAL DETAIL.2.PRIOR ISCHEMIC DISEASE AS DETAILED ABOVE BETTER RESOLVED ON PRIOR MRI EXAMINATION FROM 2007. |
Generate impression based on findings. | Female, 51 years old, status post posterior fossa craniotomy for meningioma. Evaluate for edema and hydrocephalus. Redemonstrated is surgical change consistent with a suboccipital/retromastoid craniotomy on the right. The orientation and morphology the craniotomy flap are grossly unchanged.Since the prior examination, ... | 1. Resolution of postsurgical pneumocephalus with no evidence of any new or acute intracranial abnormality. This includes no evidence of mass effect, midline shift, acute hemorrhage or hydrocephalus.2. Soft tissue thickening and possibly mild tracking fluid have become more prominent in the scalp overlying and adjacent... |
Generate impression based on findings. | Pneumonia in with history of urothelial cancer -- restaging status post cystoprostatectomy CHEST:LUNGS AND PLEURA: Scattered subpleural micronodules some of which are high density -- these most likely relate to prior inflammation. No suspicious nodules, masses, infiltrates or effusions seen.MEDIASTINUM: Calcification i... | 1. Status post cystoprostatectomy without evidence of recurrent or metastatic disease. 2. Cortical scarring in left kidney greater than right kidney without other renal abnormality seen. 3. No significant abnormality seen in the chest. |
Generate impression based on findings. | Female 71 years old; Reason: carcinoid surveillance History: none CHEST:LUNGS AND PLEURA: No suspicious pulmonary lesion. The pleural spaces are clear.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. Multiple nodules adjacent to the right dome of the diaphragm.CHEST WALL: No significant abnormality ... | 1.Stable appearance of the hepatic lesion and the multiple nodular implants along the hepatic surface. MRI is recommended for further characterization of the hepatic lesion.2.Thickened loops of ileum in the pelvis |
Generate impression based on findings. | Male 85 years old; Reason: assess for metastatic cancer History: assess for metastatic cancer CHEST:LUNGS AND PLEURA: Spiculated right upper lobe in the posterior subsegment pulmonary lesion measures 1.4 x 1.1 cm (image 25/series 5). The pleural spaces are clear.MEDIASTINUM AND HILA: No mediastinal lymphadenopathy. Hea... | 1. ABDOMEN:LUNGS BASES: No significant abnormality notedLIVER, BILIARY TRACT: Liver is normal in morphology. There are least two categories of hepatic lesions. There are well marginated fluid in lesions without evident enhancement compatible with cysts. A second category of lesions are hypodense lesions with peripheral... |
Generate impression based on findings. | Male 74 years old; Reason: please evaluate recurrence of prostate cancer History: patient s/p prostatectomy for Gleason 9 and previously undetectable PSA, now with rapidly rising PSA ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: Liver is diffusely hypoattenuating compatible with severe fat... | 1.Findings suspicious for a 1.9-cm right renal mass. The mass is incompletely evaluated due to the single phase examination and follow-up is suggested.2.No measurable metastatic disease in the abdomen or pelvis following prostatectomy. Please refer to concurrent bone scan for osseous findings. |
Generate impression based on findings. | 73-year-old female with a history of renal cell carcinoma -- evaluate for renal recurrence ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Right hepatic lobe benign cysts and punctate calcification, consistent with granulomatous changes, unchanged. Left lobe avascular lesion is slightly higher... | 1. Expected postoperative appearance of the right kidney following partial right nephrectomy. No evidence of recurrent or residual tumor. 2. No evidence of metastatic disease. 3. No other significant abnormalities seen. |
Generate impression based on findings. | Male 57 years old; Reason: Resected small bowel gist. Evaluate for disease recurrence. Also with slightly enlarged mediastinal ln on previous scan. Evaluate for interval growth history: Gist CHEST:LUNGS AND PLEURA: Stable left upper lobe cyst.New right upper peribronchial airspace opacities (image 33 series 9) are new.... | 1.Status post small bowel resection without evident metastatic disease.2.New airspace opacities in the right upper lobe, likely infectious/inflammatory. |
Generate impression based on findings. | Reason: lung cancer s/p chemo/RT previously and s/p 6 months since last scan. Please evaluate for recurrent disease and compare with previous scans History: lung cancer CHEST:LUNGS AND PLEURA: Traction bronchiectasis and consolidation predominantly in the right lower lobe compatible with radiation fibrosis, unchanged. ... | 1.No significant change in right lung radiation fibrosis. 2.No discrete measurable pulmonary nodules or masses. 3.Stable lymphadenopathy. |
Generate impression based on findings. | 66 year old female. History of bladder cancer. Status post cystectomy with ileal conduit. Evaluate for recurrent or metastatic disease. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Cholelithiasis. Small areas of focal calcification in the right hepatic lobe adjacent to the gallbladder fossa... | 1.Changes status post cystectomy and ileal conduit.2.No evidence of recurrent or metastatic disease.3.Cholelithiasis. |
Generate impression based on findings. | Reason: Left submandibular adenoid cystic cancer cancer status post CRT and surgery (2001) with worsening dysphagia over last several years. Had pulmonary nodules on last CT History: Pulmonary nodules. Please assess and compare LUNGS AND PLEURA: Multiple small pulmonary nodules, micronodules, and scattered ground-glass... | 1. No evidence of metastatic disease.2. Multiple small pulmonary nodules and scattered ground glass opacities, unchanged, could be due to aspiration or infection. |
Generate impression based on findings. | Male 81 years old; Reason: Assess for infectious focus, anastomotic leak. Non-contrast study please. History: Post cystectomy, post prostatectomy with respiratory failure minimally responsive to diuresis. TTP on exam CHEST:LUNGS AND PLEURA: Bilateral consolidative and patchy ground glass opacities representing edema an... | 1.Pulmonary edema with probable superimposed pneumonia. Bilateral effusions, left greater than right.2.Status post cystoprostatectomy without evident fluid collection in the abdomen or pelvis.3.Small amounts of pelvic hematoma. |
Generate impression based on findings. | Reason: Pt with multiple hx of recurrence. Please re-eval and compare to prior scan History: as above CHEST:LUNGS AND PLEURA: No pulmonary or pleural metastases, or other significant abnormality. MEDIASTINUM AND HILA: Severe coronary artery and other vascular calcifications.No mediastinal or hilar lymphadenopathy.Left ... | No evidence of metastases, or significant change. |
Generate impression based on findings. | Reason: pt w/ nasopharyngeal scc s/p 2 cycles of induction. please re-eval and compare with prior History: as above CHEST:LUNGS AND PLEURA: Interval appearance of a diffuse centrilobular nodules with associated tree in bud pattern. Diffuse bronchial wall thickening, lower lobe bronchiectasis and pleural based foci of c... | 1.Interval appearance of a diffuse centrilobular nodules with tree in bud pattern. Associated scattered bronchial wall thickening, lower lobe bronchiectasis and pleural foci of consolidation. Small bilateral pleural effusions and dependent subsegmental atelectasis. The constellation of findings is consistent with bronc... |
Generate impression based on findings. | 66-year-old male with metastatic pancreatic cancer. Evaluate progression. CHEST:LUNGS AND PLEURA: Right middle lobe and lingular nodular opacities seen are stable in appearance compared to prior exam. Calcified left lower lobe granuloma.MEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant ab... | 1. Interval slight decrease in size of pancreatic mass compared to the prior exam. Soft tissue encasement of arterial and venous vasculature.2. Interval decrease in size of reference hepatic lesion compared to the prior exam.3. Mild intrahepatic biliary ductal dilatation with continued severe dilatation of the common b... |
Generate impression based on findings. | 56-year-old male with acute hemoglobin dropped on heparin -- rule-out bleeding. CHEST:LUNGS AND PLEURA: Right intrafissural nodular subcentimeter density most likely lymph node (series 5, image 50). No pulmonary, parenchymal nodules, masses, infiltrates. Left basilar atelectasis. No significant pleural effusion seen.ME... | 1. No evidence of hematoma. 2. Punctate left renal calcifications, most consistent with small, nonobstructing calculus. 3. No other significant abnormality seen. |
Generate impression based on findings. | 67 year old male status post fall, evaluate for hematoma, CVA. Patient has past medical history of multiple myeloma and seizures secondary to an arachnoid cyst, status post drainage catheter placement in 1998. VENTRICLES/CSF SPACES:Stable in size and appearance to the 2005 exam, is a prominent arachnoid cyst within the... | 1.No evidence for acute intracranial hemorrhage, hematoma, or stroke. Evaluation of stroke on CT exam is limited, an MRI examination could provide additional information as clinically indicated.2.Scattered ill-defined, poorly characterized lucent lesions within the skull which may be consistent with the clinical histor... |
Generate impression based on findings. | Reason: metastatic breast CA to lung, liver, mediastinum, on chemo. Follow up History: cough CHEST:LUNGS AND PLEURA: Near complete resolution of previously described lingular soft tissue mass, which is no longer discretely measurable. Mild interlobular septal thickening and ground lass opacity in the right lung compati... | 1.Near resolution of lingular soft tissue mass.2.Decreasing mediastinal lymphadenopathy.3.Decreasing hepatic metastases.4.Decreasing gastrohepatic lymph node.5.Stable osseous metastases. |
Generate impression based on findings. | Reason: Rule out lymphadenopathy, extramedullary myeloma involvement History: dysphagia, shortness of breath CHEST:LUNGS AND PLEURA: 3-mm micronodule noted in the right lower lobe.Scattered calcified granulomas.No suspicious pulmonary nodules or masses. No pleural effusions.MEDIASTINUM AND HILA: Scattered minimally pro... | 1.No significant pulmonary or pleural abnormalities.2.Multiple vertebral osteolytic foci, compatible with known diagnosis of multiple myeloma. This can be confirmed with MRI of the thoracic and lumbar spine. |
Generate impression based on findings. | 57 year old female one year status post lumbar fusion For the purposes of this dictation the lowest well formed disk space will be designated as L5/S1. Posterior lumbar fusion of L4/L5 with bilateral pedicle screws and paraspinal rods at each level is again noted. Intervening diskectomy with disk spacer appears unchang... | 1. Stable posterior lumbar fusion hardware and disk spacer without evidence of fracture or complication. The right L4 and L5 pedicle screws have a lateral position within the pedicle and have tips that extend perivertebral, not significantly changed2. Interval progression of degenerative changes affecting the L4 and L5... |
Generate impression based on findings. | 76-year-old male. History of urothelial carcinoma, right upper tract. Status post nephrectomy and bladder cancer. ABDOMEN:Evaluation of the visceral abdominal organs is limited due to lack of intravenous contrast.LUNG BASES: Moderate right and small left pleural effusion.LIVER, BILIARY TRACT: No significant abnormality... | No evidence of recurrent or residual disease. Moderate right and small left pleural effusion. |
Generate impression based on findings. | 69-year-old female with history of right carotid artery stenosis. Neck CTA: There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is conventional branching of the great vessels. There are atherosclerotic calcifications of the aortic arch and the... | 1.Over 75% stenosis at the bifurcation of the right common carotid artery.2.50 to 60% stenosis of the supraclinoid segment of the right internal carotid artery. Less severe disease of the left ICA is seen.3.Area of outpouching adjacent to the right vertebral artery at the foramen magnum is contiguous with the adjacent ... |
Generate impression based on findings. | 57 year old female. Stage IV pancreatic cancer, compare to previous scan. CHEST:LUNGS AND PLEURA: No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: Multiple thyroid nodules, unchanged. Cardiac size is normal. No pericardial effusion. No mediastinal or hilar lymphadenopathy.CHEST WALL: Bilateral breast imp... | Interval decrease in size of pancreatic mass, and hepatic metastases. No new metastatic lesions identified in the chest, abdomen or pelvis. |
Generate impression based on findings. | Male 62 years old; Reason: Assess for resolution of pelvic fluid collection and urine leak History: h/o pelvic fluid collection ABDOMEN:LUNGS BASES: No significant abnormality noted.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: The spleen is enlarged measuring 13 cm.PANCREAS: No significant abnormality... | 1.Massive distention of the neobladder with displacement of the drainage catheter. Replacement/repositioning of the percutaneous catheter is recommended. |
Generate impression based on findings. | 79-year-old male with cancer retromolar area and multiple history of recurrence. Please reevaluate and compare to prior scan. HEAD:The ventricles, sulci, and cisterns are symmetric and unremarkable for patient's stated age. The gray-white matter differentiation is normal. There is no mass, mass effect, edema, midline s... | 1.No acute interval change. Postsurgical and posttreatment changes with stable enhancing soft tissue at the right mandibular resection cavity, likely representing scarring. 2.Skin retraction along the mandibular osteotomy site with overlying soft tissue defect. The osteotomy site appears sharp. 3.No pathologically enla... |
Generate impression based on findings. | 50 year old female. Abdominal pain and bloating. Evaluation of unresectable pancreatic cancer. CHEST:LUNGS AND PLEURA: No significant abnormality noted.MEDIASTINUM AND HILA: Calcified right thyroid nodules. No mediastinal or hilar lymphadenopathy. Cardiac size is normal. No pericardial effusion.CHEST WALL: No significa... | Pancreatic mass with associated hepatic and ovarian metastases as well as peritoneal carcinomatosis. |
Generate impression based on findings. | Male 54 years old; Reason: Pt is a 54 y/o male with met RCC, on pazopanib, evaluate for response History: met rcc, pazopanib CHEST:LUNGS AND PLEURA: Multiple bilateral pulmonary lesions. Reference left upper lobe pulmonary lesion measures 1.2 x 1.0 cm (image 37/series 5) previously, 1.3 x 0.7 cm.The remainder of the pu... | 1.Near stable measurements of the reference lesions. |
Generate impression based on findings. | 70-year-old female with 2-cm pancreatic neuroendocrine tumor in the body of the pancreas. Please evaluate for changes and/or abnormalities. ABDOMEN:LUNG BASES: A focal area of consolidation within the right lower lobe along the minor fissure is unchanged from prior exam (image 11, series 8).LIVER, BILIARY TRACT: There ... | 1. No significant change of pancreatic mass.2. No significant change of small retroperitoneal lymph nodes.3. Right adrenal adenoma unchanged from prior exam.4. The cervix appears prominent, correlate with pelvic exam. |
Generate impression based on findings. | 66-year-old female with urothelial cancer currently receiving treatment -- assess for disease progression. CHEST:LUNGS AND PLEURA: Continued decrease in size in the reference left lower lobe nodule (series 4, image 61), which now measures 0.9 x 0.9 cm, compared to previous 1.1 x 1.1 cm.. Left upper lobe nodule (series ... | 1. Decrease in size of pulmonary lung nodules compatible with metastases. 2. No evidence for metastatic disease in the abdomen. |
Generate impression based on findings. | 32-year-old male with history of right testicular cancer. Assess for recurrence. CHEST:LUNGS AND PLEURA: Previously noted subcentimeter nodular density in the right lobe of the lung is unchanged prior exam (image 72, series 5).MEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormality ... | 1. No significant change from the prior exam.2. Stable subcentimeter pulmonary nodular density.3. Stable index left paraortic lymph node. |
Generate impression based on findings. | : New diagnosis of HCC. Hx of sheet metal exposure. Evaluate lumng parenchyma and ? mets. History: NA LUNGS AND PLEURA: Focal pleural calcification anteriorly in the right hemithorax may be posttraumatic in origin. No suspicious pulmonary nodules or masses.MEDIASTINUM AND HILA: No hilar or mediastinal lymphadenopathy.M... | No evidence of metastatic disease. |
Generate impression based on findings. | Reason: Hx of osteosarcoma. Evaluate for metastases History: Hx of osteosarcoma. Evaluate for metastases LUNGS AND PLEURA: Stable pulmonary micronodule in the right middle lobe (series 5 image 157) measuring approximally 4 mm. This is compared to the baseline chest CT from this institution on 4/20/12.No new suspicious ... | 1.Stable right middle lobe pulmonary micronodule measuring 4 mm when compared to one year earlier. No suspicious pulmonary nodules.2.The left breast demonstrates asymmetric nodularity of the parenchyma, slightly more pronounced on this examination. Correlation to physical examination and possibly mammogram is recommend... |
Generate impression based on findings. | Reason: recurrent head and neck ca, on therapy, eval for dz History: as above CHEST:LUNGS AND PLEURA: Redemonstration of debris within the bronchus intermedius with extension into the right middle lobe and right lower lobe bronchi.Right middle lobe atelectasis unchanged.Stable micronodule and intrapulmonary lymph node ... | 1.No interval change in the right middle lobe collapse and redemonstration of extensive debris within the bronchus intermedius.2.No evidence of metastatic disease. |
Generate impression based on findings. | 42-year-old with blunt trauma to left eye. Evaluate for orbital fracture. BONE:There is no evidence for displaced orbital fracture. There is no evidence of herniation of orbital fat into the maxillary sinus. There is a linear lucency with smooth margins within the left sphenoid wing (image 13, series 7) that represents... | 1.No evidence for displaced orbital fracture. |
Generate impression based on findings. | Male 72 years old; elevated PSA status post salvage prostatectomy. CHEST:LUNGS AND PLEURA: Multiple pulmonary nodules in the upper lobes. There is centrilobular pattern. The pleural spaces are clear. Scattered areas of atelectasis.MEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: Extensive osseous metas... | 1.Extensive osseous metastatic disease.2.Multiple pulmonary upper lobe micronodules with a pattern suggesting infectious/inflammatory etiology. |
Generate impression based on findings. | Male 72 years old; Reason: 71 year old man with low-grade NHL. Compare to prior scan. Also, compare aortic aneurysm with prior scan. History: None CHEST:LUNGS AND PLEURA: No dominant lung lesions. The pleural spaces are clear.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. There are small mediastin... | 1.Decrease in the size of the right axillary lymphadenopathy. Near stable size measurements of the left axillary lymph nodes.2.Dilated ascending thoracic aorta; follow up is suggested |
Generate impression based on findings. | 58-year-old female with insulinoma -- evaluate for interval change. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Multiple nodular enhancing masses seen on arterial phase imaging, becoming isodense on portal venous phase imaging are seen with a pattern and distribution unchanged. Many of the... | 1. Numerous enhancing foci in the liver, consistent with metastases -- all are unchanged in appearance and their relationship to prior ablation zones. 2. Fluid-filled endometrial cavity again identified unchanged. |
Generate impression based on findings. | Reason: eval for metastatic disease History: wt loss CHEST:LUNGS AND PLEURA: Multiple pulmonary nodules of varying size are now identified bilaterally with the largest noted anteriorly in the right upper lobe (image 26, series 5, measuring 2.8 cm by 3 cm.New right pleural effusion.Moderate upper lobe predominant centri... | 1.Multiple new pulmonary nodules compatible with metastatic disease.2.New moderate-sized pericardial and right pleural effusions probably malignant in origin. |
Generate impression based on findings. | Colon carcinoma CHEST:LUNGS AND PLEURA: No significant abnormality notedMEDIASTINUM AND HILA: No significant abnormality notedCHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: Interval resection of segment 7 right lobe liver lesion. 4.3 x 5.8 cm fluid collection in region of resection site. No w... | Interval resection of segment 7 liver metastatic focus. Loculated fluid collection arising from resection site; favor post operative change. However, special attention to this area on future surveillance scans recommended.No evidence for new metastatic focus. |
Generate impression based on findings. | 80 year old female. Abdominal pain. Evaluate for abdominal process. ABDOMEN:LUNG BASES: Right basilar atelectasis. Calcified mediastinal lymph nodes, compatible with prior granulomatous disease. Calcification of the aorta and coronary arteries. Elevated right hemidiaphragm.LIVER, BILIARY TRACT: No significant abnormali... | No findings to account for patient's symptoms. |
Generate impression based on findings. | Reason: 70 yr old female with h/o AML; pre allo SCT evaluation History: Evaluate LUNGS AND PLEURA: Mild apical scarring. No focal pulmonary consolidation or pleural effusion. Bilateral basilar predominant cysts.MEDIASTINUM AND HILA: Right chest wall Port-A-Cath tip at the cavoatrial junction. Heart size is normal. No p... | No acute abnormality or evidence of infection. |
Generate impression based on findings. | Bladder carcinoma CHEST:LUNGS AND PLEURA: Stable right micronodules. Stable calcified plaques.MEDIASTINUM AND HILA: No change in coronary artery calcifications.CHEST WALL: No significant abnormality notedABDOMEN:LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No s... | Progression of metastatic disease manifest by interval increase in size of retrocrural and retroperitoneal adenopathy as well as interval appearance of extensive pelvic metastatic adenopathy. Increase in size of left adrenal metastatic focus.Slight interval increase in the mild left hydronephrosis |
Generate impression based on findings. | 65-year-old male. Abdominal pain, anemia. Assess for small bowel abnormality, mass lesion, stricture ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: Cholelithiasis.SPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality noted... | Well-defined, round, hyperdensity within small bowel lumen in the right lower quadrant. This could be a polypoid mass, or residual oral material. |
Generate impression based on findings. | Male 57 years old; Reason: eval for mets History: L thalamic lesion CHEST:LUNGS AND PLEURA: Biapical scarring and subpleural emphysematous changes. The pleural spaces are clear. No dominant lung lesion.MEDIASTINUM AND HILA: Heart size is normal. No pericardial effusion. No mediastinal lymphadenopathy.CHEST WALL: No sig... | 1.Small hepatic lesion too small to fully characterize but is suspicious for a small metastatic focus given the patient's history.2.Please note the CT is suboptimal to evaluate for mucosal lesions. Given the lack of a definite primary lesion, etiology such as melanoma, lymphoma should be considered3.Further clinical su... |
Generate impression based on findings. | Reason: evaluate shunt History: HA, retroorbital, neck pain, gait disturbance There is a marked encephalomalacia along the right hemisphere of the brain. The septum pellucidum is shifted well across to the right side the midline . Overall there is no change in this appearance since the prior exam. The third ventricle i... | 1.There is extensive right-sided hemisphere encephalomalacia. The left hemisphere has shifted across the midline towards the right and the brainstem is deviated towards the right.2.There are bilateral shunt catheters present extending into the right and left lateral ventricles. The ventricles are smaller on the current... |
Generate impression based on findings. | 4/1/1980 (33 yrs.) - F. Reason: Please assess both temporal bones for otosclerosis History: Bilateral conductive hearing loss. The external and internal auditory canals are symmetric in diameter and intact. The middle ear structures are intact. The courses of the facial nerves were followed and appear intact. The masto... | Findings are suspicious for stage I otosclerosis. |
Generate impression based on findings. | Reason: intracranial or cervical arterial stenosis History: transient left arm paralysis . 40-year old female Neck CTA: There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On... | 1.No evidence for aneurysm.2.No evidence for cervicocerebral occlusive disease |
Generate impression based on findings. | Reason: recurrent head and neck ca, on therapy, eval for dz History: as above CT neck:There is a redemonstration of a status post surgery for the floor of the mouth. The submandibular glands have been removed. There is fatty replacement of the tongue the sternocleidomastoid muscles and trapezius muscles are atrophic. T... | 1.No evidence for local recurrence or neck lymphadenopathy on the basis of CT size criteria for lymphadenopathy. There appears to be an ulceration at the angle of the right mandible where there is previous large lesion. Stability would suggest that soft tissue thickening at this location it represents posttreatment cha... |
Generate impression based on findings. | Reason: 23 y/o with back pain MRI c/w abnormal signal and enhancement of the L5 spinous process, recommended CT History: 23 y/o with back pain MRI c/w abnormal signal and enhancement of the L5 spinous process, recommended CT Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall a... | 1.There is no compromise lumber spinal canal or exiting nerve roots.2.Spondylo-lysis at L5 with minimal if any listhesis3.A couple punctate lytic foci in the L5 spinous process. This is nonspecific and suspected to be degenerative in nature . It is conceivable that this represents an early manifestation of Baastrup's d... |
Generate impression based on findings. | Clinical question: Subarachnoid hemorrhage from a leak. Signs and symptoms: Headache. Nonenhanced head CT:No detectable acute intracranial process. CT however is insensitive for detection of acute non-hemorrhagic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF cisterns and gray -- white ma... | Negative nonenhanced head CT. |
Generate impression based on findings. | Clinical question: Evaluate for intracranial hemorrhage. Signs and symptoms: On Coumadin, fall and head injury. Nonenhanced head CT:No detectable acute posttraumatic intracranial, calvarial or soft tissues of the scalp findings.CT however is insensitive for detection of acute nonhemorrhagic ischemic strokes.Revisualiza... | 1.Ectopia of cerebellar tonsils with resultant complete effacement of subarachnoid space at the level of foramen magnum. Unchanged since prior exam. Recommend follow-up with dedicated MRI and CSF flow studies.2.Unremarkable nonenhanced head CT otherwise. |
Generate impression based on findings. | Clinical question: Evaluate for intracranial hemorrhage. Signs and symptoms: Fall, loss of consciousness. Nonenhanced head CT:No detectable acute posttraumatic intracranial or calvarial findings. There is however evidence of hemorrhage and edema of the subgaleal region. The combination of findings measures approximatel... | 1.No evidence of intracranial abnormalities.2.Midline subgaleal hemorrhage and edema as detailed in high convexity posterior parietal.3.Unremarkable calvarium. |
Generate impression based on findings. | Clinical question: New right hemispheric CVA, assess interval change. Signs and symptoms: Left-sided weakness. Nonenhanced head CT:Previously known acute large right MCA territory ischemic stroke is again identified. There is no convincing evidence of any interval change in particular no evidence of hemorrhagic transfo... | 1.No convincing evidence of any acute intracranial process. 2.Stable large right hemispheric nonhemorrhagic subacute ischemic stroke and its associated mass effect and midline shift as detailed. |
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