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Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Personal history of skin cancer. Three standard digital views of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and distribution. Round marker... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Reason: Pleural mesothelioma please compare to prior exam per RECIST criteria. History: Pleural mesothelioma. LUNGS AND PLEURA: Pleural nodularity and right small pleural effusion compatible with history of mesothelioma have not significantly changed. Reference measurements on the right as follows:1.Level of the aortic... | 1.Interval increase in mediastinal and right hilar lymphadenopathy. 2.New right internal mammary chain lymphadenopathy.3.No significant change in right pleural reference lesions or intrapulmonary nodules. 4.Right diaphragm nonreference lesion has significantly decreased in size. |
Generate impression based on findings. | Severe osteoarthritis. Worsening knee pain. Two views of the left knee are provided. The bones appear demineralized, suggesting osteopenia/osteoporosis. Severe osteoarthritis affects the knee, with near bone on bone apposition of the medial tibiofemoral compartment. There are also tricompartmental osteophytes and a mil... | Severe osteoarthritis. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography.History of benign left breast biopsy. History of breast cancer in maternal and paternal cousins. Two standard digital views and tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously de... | No mammographic evidence of malignancy. Screening mammography is most sensitive when evaluating for interval changes. If patient submits outside mammogram, comparison will be made. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECO... |
Generate impression based on findings. | Pain. Bunion formation. The bones appear slightly demineralized, suggesting osteopenia. There is a severe hallux valgus deformity associated with moderate to severe osteoarthritis at the first metatarsophalangeal joint and first tarsometatarsal joint. There is also a pes planovalgus deformity with additional osteoarthr... | Hallux valgus deformity, pes planovalgus deformity and osteoarthritis as described above. |
Generate impression based on findings. | Mesothelioma ABDOMEN:LUNG BASES: Right basilar pleural abnormalities again seen. Please refer to separate chest CT report.LIVER, BILIARY TRACT: Stable perihepatic soft tissue thickening. SPLEEN: No significant abnormality notedPANCREAS: 0.6 cm cystic focus within the pancreatic neck seen on image 55 again noted and unc... | Interval decrease in size of reference right periaortic lymph node. |
Generate impression based on findings. | Subglottic stenosis due to post-traumatic intubation. There is focal narrowing of the subglottic airway by soft tissue. There is no evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. The thyroid and major salivary glands are unremarkable. There is a small amount of undes... | Findings compatible with subglottic stenosis related to intubation. |
Generate impression based on findings. | Persistent headache and neck pain, dizziness. History of gunshot wound with residual shrapnel to T4/T5. CervicalThe cervical vertebral bodies are appropriate height. Alignment is maintained. No fractures are identified in the cervical spine. No destructive osseous lesions are identified in the cervical spine. Nonspecif... | 1. Chronic fracture deformity involving the posterior inferior corner of the T4 vertebral body on the left. Sclerosis and osteophyte formation at the T4-T5 level also compatible with sequela of prior trauma. Deformity of right T4 transverse process and the right fourth and fifth ribs also compatible with prior trauma.2... |
Generate impression based on findings. | CT HEAD: There is expected contrast opacification of the CSF spaces of the brain including intraventricularly, right greater than left, secondary to patient postioning in the right lateral and Trendelenburg position prior to the exam. There are no masses, mass effect or midline shift. The ventricles and sulci are norm... | 1.CT cisternogram with expected contrast opacification of the CSF spaces of the brain including intraventricularly following intrathecal administration of 10 cc of Omnipaque 300 contrast.2.Opacification of the middle ear cavities and bilateral mastoid air cells, right greater than left.3.Bony defects involving the tegm... |
Generate impression based on findings. | 8 year-old female with cystic fibrosis and intermittent cough.VIEWS: Chest PA/lateral (two views) 1/28/2015 Persistent mild peribronchial thickening is seen. No significant bronchiectasis is evident. The cardiothymic silhouette is normal. No focal lung opacities are seen. Blunting of the right costophrenic may reflect ... | Persistent mild peribronchial thickening without focal opacity. Small right pleural effusion or mild pleural thickening. |
Generate impression based on findings. | 46 years old Female. Reason: presurgical evaluation for epilepsy surgery. History: right temporal epilepsy. The noncontrast brain CT portion of the study is not remarkable. The FDG PET imaging demonstrates mild decrease of metabolic activity in the left the right medial temporal lobes, more decrease in the right hippoc... | Decreased metabolic activity in the bilateral medial temporal lobes, right greater than left. Decreased metabolic activity in the right temporal pole and right supramarginal gyrus. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of left breast aspiration in 2000. Two standard digital views and tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is composed of scattered fibroglandular density, unchanged in pattern and ... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSB - Screening Mammogram. |
Generate impression based on findings. | Bilateral hip pain, worse on left. Rule-out any pathology. Two views of the left hip are provided. Mild osteoarthritis affects the hip joint. Mild chronic appearing enthesopathic changes are noted along the greater trochanter.Two views of the right hip are provided. Mild osteoarthritis affects the hip. Mild chronic app... | Osteoarthritis as described above. |
Generate impression based on findings. | Altered mental status. Evaluate for intracranial hemorrhage. There is loss of gray-white matter differentiation with sulcal effacement in the right frontal lobe and right insula, representing recent ischemia possibly from an embolic source. Given the bilaterality of the areas of occipital lobe hypoattenuation, posterio... | 1. Recent infarct in the right frontal lobe and right insula. Focal areas of hypoattenuation of the bilateral occipital lobes, may be attributable to PRES if clinically appropriate, versus additional embolic infarcts. No intracranial hemorrhage. Per Dr. Sharma's EPIC note, clinical team is aware of ischemic stroke.2. B... |
Generate impression based on findings. | Postop spinal stenosis, lumbar region, with neurogenic claudication. There is severe multilevel degenerative disk disease, most pronounced at L3/4, L4/5, and L5/S1. There is a slight rightward curvature of the lumbar spine. The bones appear demineralized, suggesting osteopenia. I see no findings to suggest an acute com... | Severe degenerative disk disease and other findings as above. |
Generate impression based on findings. | Male 59 years old; Reason: 59yo male with Diabetes and peripheral neuropathy and abdominal pain. Evaluate for gastroparesis Visually there was significant and progressive gastric emptying. Using anterior and posterior geometric means, residual gastric activity at the following postprandial intervals was calculated as f... | Gastric emptying within normal limits. |
Generate impression based on findings. | Six month old female with tachycardia and tachypnea.VIEWS: Chest AP/lateral (two views) 1/28/2015 Peribronchial thickening and streaky left basilar subsegmental atelectasis is seen. The cardiothymic silhouette is normal. No pleural effusion or pneumothorax is evident. | Bronchiolitis/reactive airways disease pattern, without superimposed pneumonia. |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. History of breast cancer in maternal second cousin. Two standard digital views and tomosynthesis of both breasts were performed and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which may obscure small masses, unchang... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Reason: Assess for recurrent head and neck cancer History: Previous tonsillar cancer CHEST:LUNGS AND PLEURA: Stable left intrapulmonary lymph node, without evidence of metastases. New patchy ground glass opacities are suggestive of aspiration.MEDIASTINUM AND HILA: There is no mediastinal or hilar lymphadenopathy.No cor... | No evidence of metastases, or other significant abnormality. |
Generate impression based on findings. | Lung cancer follow-up. Fatigue. CHEST:LUNGS AND PLEURA: Innumerable pulmonary micronodules. Given the presence of motion artifact it is difficult to localize the lesions several are endobronchial . Post-therapeutic changes in the right lung. No pleural fluid. MEDIASTINUM AND HILA: No significant change in soft tissue a... | 1. Innumerable pulmonary micronodules, most compatible with metastases given known brain lesions and absent clinical signs of atypical infection. 2. Several arterial aneurysms in the upper abdomen, two involving the left kidney and one involving the left gastric artery. The larger lesions appear to be peripherally calc... |
Generate impression based on findings. | 38 year old female with history of right breast cancer. CHEST:LUNGS AND PLEURA: Minimal dependent atelectasis, and a single right apical micronodule (3/34) that abuts the pleura and may represent scar. No consolidation or significant pleural effusion.MEDIASTINUM AND HILA: Heart size within normal limits, and there is n... | Right breast biopsy clips, and a mildly enlarged right axillary lymph node as above.Adnexal cysts |
Generate impression based on findings. | Asymptomatic female presents for routine screening mammography. Two standard digital views and tomosynthesis of both breasts were performed 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. Round marker was pla... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, routine screening mammogram is recommended annually.BIRADS: 1 - Negative.RECOMMENDATION: NSC - Screening Mammogram. |
Generate impression based on findings. | Reason: h/o HNC/CRT, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Several punctate micronodules are present, and there is mild upper lobe centrilobular emphysema.There is no evidence of pulmonary or pleural metastases.Scattered basilar basilar opacities likely related to aspiration, unlik... | 1. No evidence of metastases.2. Known left breast lesion, diagnosed in late 2011 as invasive ductal breast cancer, questionably larger. |
Generate impression based on findings. | 76-year-old female status post left mastectomy for breast cancer in 2013 presents for routine follow-up. History of right breast benign biopsy. No current breast complaints. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is heterogeneous... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, right unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 73-year-old female with leukemiaTECHNIQUE One Panorex view of the mandible Multiple missing teeth are noted. There is no gross bone destruction. The maxillary sinuses are clear. | Poor dentition without evidence of osteomyelitis. |
Generate impression based on findings. | Male 66 years old; malignant neoplasm of esophagusRADIOPHARMACEUTICAL: 12.8 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 120 mg/dL. Today's CT portion grossly demonstrates left paramediastinal pleural thickening with adjacent streaky opacities. There is a left lower neck and left upper chest wall soft tis... | 1. Increased activity in the mid esophagus consistent with patient's known esophageal cancer. 2. Mild activity in the small right paratracheal lymph node is nonspecific, cannot rule out metastatic disease.3. Mild bilateral hilar activity is likely inflammatory in nature. |
Generate impression based on findings. | 64-year-old female with pain There is no significant varus or valgus alignment of the knee relative to the neutral mechanical axis. Severe joint space narrowing, lateral, greater than medial, and small osteophytes affect the right knee. | Osteoarthritis, as described above. |
Generate impression based on findings. | Right shoulder pain. Assess for osteoarthritis versus fracture. I see no fracture or malalignment. I see no osteoarthritis. Spinal fixation hardware is incompletely imaged on this study. | No fracture, osteoarthritis, or other specific finding to account for the patient's right shoulder pain. |
Generate impression based on findings. | Male 43 years old Reason: eval for recurrence History: RCC s/p resection LUNGS AND PLEURA: No suspicious masses or nodules. No pleural effusions.MEDIASTINUM AND HILA: Heart size is normal without pericardial effusion. No hilar or mediastinal lymphadenopathy.CHEST WALL: No significant abnormality noted.UPPER ABDOMEN: Ab... | No evidence of metastasis. |
Generate impression based on findings. | Proximal humerus fracture. Left arm pain. Again seen is a comminuted fracture of the proximal humerus involving the surgical neck and greater tuberosity, with slight posterior angulation of the diaphyseal fracture fragment. Increasing callus indicates some interval healing. Mild osteoarthritis affects the acromioclavic... | Healing proximal humerus fracture. |
Generate impression based on findings. | 90 year-old male with history of prostate cancer, left lateral femur pain Mild osteoarthritis affects the knee. The proximal femur is intact. There is no evidence of osseous metastasis. Small ossicles are noted posteriorly about the knee joint, likely in a Baker's cyst. | Knee osteoarthritis without evidence of metastatic disease. |
Generate impression based on findings. | 68 years old Male. Reason: S/p Total Gastrectomy 12/27/10 for a stage 1b (T2NO MX0 adenocarcinoma). No adjuvant therapy. Recent EGD for dysphagia. Stricture in jejunum, biopsy positive recurrent adenocarcinoma with signet ring features. Need PET Scan for staging. History: Weight Loss, dysphagia. RADIOPHARMACEUTICAL: 13... | 1.Focus of increased activity in the upper abdomen either in the left lobe of liver or gastrohepatic ligament, which can be due to tumor or inflammatory change.2.Focal area of increased activity in the left upper abdomen located in the mesentery or hepatic flexure of the colon, which can be due to tumor or inflammatory... |
Generate impression based on findings. | 69-year-old male, evaluate left hip joint osteoarthritis There is prominence of the left femoral head-neck junction and marked joint space narrowing with subchondral sclerosis. No fracture is evident. A right total hip arthroplasty is noted on the frontal view. | Marked left hip osteoarthritis. |
Generate impression based on findings. | Left breast mass for which ultrasound guided biopsy is requested. Left ultrasound re-identified the target lesion for biopsy. The lesion to be targeted is a hypoechoic mass measuring 21 mm at the 7 o’clock position with increased vascularity, 5 cm from the nipple. The lesion was readily visible.PROCEDURE: The procedure... | Successful ultrasound-guided core biopsy of the left breast lesion and clip placement. Other benign morphology masses are not biopsied pending the results of this biopsy. Pathology is pending at this time.BIRADS: 2 - Benign finding.RECOMMENDATION: X - No Letter. |
Generate impression based on findings. | Palpable left breast mass. An outside ultrasound was performed for only the site of palpable concern, but a mammogram is requested now. Three standard views of both breasts and bilateral spot views were performed digitally and reviewed with the aid of R2 CAD 9.3. The breast parenchyma is heterogeneously dense, which ma... | Multiple left breast masses. The largest of these is palpable and will be biopsied under ultrasound guidance. The findings morphologically benign and are compatible with cysts and fibroadenomas. BIRADS: 2 - Benign finding.RECOMMENDATION: T - Take Appropriate Action - No Letter. |
Generate impression based on findings. | Clinical trial requirement. There is age-related global parenchymal volume loss. There is no evidence of intracranial hemorrhage, mass, or cerebral edema. The ventricles and basal cisterns are normal in size and configuration. There are scattered punctate foci and confluent areas of abnormal T2/FLAIR hyperintensity wit... | Global parenchymal volume loss. Moderate age-indeterminate small vessel ischemic changes. |
Generate impression based on findings. | Reason: renal cell carcinoma History: renal cell carcinoma ABDOMEN:LUNG BASES: Calcified pulmonary nodules and mediastinal lymph nodes consistent with prior granulomatous disease.LIVER, BILIARY TRACT: Hepatic granulomataSPLEEN: Splenic granulomataPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant ... | Multiple bilateral renal cysts of varying complexity, with some interval change in size and intrinsic attenuation of some of the lesions, but no new enhancement or other change that would specifically raise concern for malignancy. |
Generate impression based on findings. | Reason: h/o laryngeal ca, compare to previous, measurements pls History: none CHEST:LUNGS AND PLEURA: Scattered pulmonary micronodules, some of which are calcified, unchanged. No new or suspicious pulmonary nodules or masses. No pleural effusions. Minimal aspirate at the lung bases.MEDIASTINUM AND HILA: Tracheostomy tu... | 1. No suspicious pulmonary nodules.2. Interval tracheostomy tube placement. |
Generate impression based on findings. | Reason: Right sacroiliac lesion to be biopsed. increased uptake in the PET History: Right sacroiliac region pain, increased uptake in the PET. History of right sacroiliac metastastic squamous cell carcinoma, treated with radiotherapy in 2012. Normal PET post treatment. Question whether recurrence versus XRT changes.OPE... | Right sacral ala biopsy under CT guidance. A total of 8 biopsy specimens were delivered to pathology for analysis. |
Generate impression based on findings. | Female 77 years old Reason: elevated bilirubin, hepatic cysts, eval for biliary dilatation, biliary obstruction History: hyperbilirubinemia LIVER: The liver measures 17.2 cm in length and demonstrates mildly hyperechoic hepatic parenchyma suggestive of fatty infiltration. Multiple hypoechoic lesions in the liver sugges... | 1. No evidence of intra-or extrahepatic biliary duct dilatation.2. Fatty infiltration of the liver. Multiple hepatic cysts identified. No suspicious lesion is seen.3. Echogenic renal cortex bilaterally suggestive of medical renal disease.4. Bilateral pleural effusions. |
Generate impression based on findings. | Pleural mesothelioma ABDOMEN:LUNG BASES: Right pulmonary and pleural abnormalities again noted. Please refer to separate chest CT report.LIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: No significant abnormality notedADRENAL GLANDS: No significant abnormality note... | Stable negative examination. No evidence for intra-abdominal neoplastic, inflammatory, or acute finding. |
Generate impression based on findings. | Male 47 years old Reason: 46 yo with GB polyps please asses for growth History: none LIVER: The liver measures 14.2 cm in length and is mildly echogenic. No focal hepatic lesion. The portal vein demonstrates normal directional flow with peak velocity of 0.2 m/sec.GALLBLADDER, BILIARY TRACT: Multiple non-mobile, echogen... | 1. Echogenic hepatic parenchyma suggestive of fatty infiltration.2. Stable gallbladder polyps.3. Echogenic focus in the lower right kidney which is nonspecific. Angiomyolipoma is a differential consideration. Consider renal protocol CT for further evaluation.4. Nonobstructing left renal calculus. |
Generate impression based on findings. | Female 63 years old; Reason: pelvic mass on abdominal ultrasound History: as above ABDOMEN:LUNG BASES: Calcified right hilar lymph nodes. Mild left pleural thickening.LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS... | 1.Findings of a large right cystic ovarian mass with imaging features most compatible with a serous cystadenoma. However, given the nodularity along the cyst wall a malignant cystic neoplasm is also in the differential. |
Generate impression based on findings. | Reason: lung cancer compare to last CT \T\ measure 1) RLL mass, 2) RLL nodule, 3) inferior RLL nodule \T\ 4) LUL nodule History: post 2 cycles of chemo CHEST:LUNGS AND PLEURA: Previous reference right lower lobe mass abutting the mediastinum measures 5.2 x 5.1 x 7.6 cm (series 4 image 64) previously measuring 5.0 x 5.0... | 1.Right lower lobe mass with invasion of the mediastinum continues to increase in size in the craniocaudal dimension.2.Pulmonary metastases similar in size compared to prior.3.Reference mediastinal lymph node has not significantly changed. Non-reference mediastinal lymph nodes have slightly increased in size.4.Stable s... |
Generate impression based on findings. | Male 56 years old Reason: new elevated transaminitis, s/p cholecystectomy, eval biliary tree and liver - RUQ History: metastatic melanoma, transaminitis LIVER: The liver measures 18.0 cm in length. There is 3.8 x 3.6 x 2.4 cm solid mass in the gallbladder fossa corresponding to abnormality identified on recent PET stud... | 1. Solid mass in the gallbladder fossa corresponding to patient's known melanoma metastasis.2. Minimal intra-and extrahepatic biliary duct dilatation. |
Generate impression based on findings. | 2-year-old male for pneumonia/acute chestVIEWS: Chest AP/lateral (two views) 01/28/15 Cardiothymic silhouette is normal. No pleural effusion or pneumothorax. No focal pulmonary opacities. Mild to moderate bronchial wall thickening is suggestive of bronchiolitis/reactive airway disease. | Bronchiolitis/reactive airway disease. |
Generate impression based on findings. | Lung cancer. CHEST:LUNGS AND PLEURA: Postsurgical changes of a right thoracotomy and diaphragmatic patch. Right pleural and fissural nodularity has slightly increased compared to prior. Reference measurements as follows: 1.At the level of the great vessels origins (image 31): Three o'clock position measures 26 mm, prev... | Increasing right pleural reference measurements and chest wall tumor. Findings on the current study confirm pericardial/ mediastinal involvement.. : |
Generate impression based on findings. | The spine is in normal alignment. There is straightening of the normal cervical lordosis. There is mild disk narrowing and diffuse disk dessication at L5-S1. There is also disk desiccation at T8-T9 and throughout the cervical spine. There is central moderate vertebral body height loss of L1 with abnormal T1 hypointens... | 1. No evidence of acute cord compression or significant central spinal calcinosis. Questioned thickened and irregular appearance of the cauda equina nerve roots on sagittal STIR images, for which MRI lumbar spine with and without contrast is recommended in order to obtain at the time of this dictation, for further eval... |
Generate impression based on findings. | 29-year-old female with history of trauma. There is mild reticulation about the anterolateral soft tissues, but we see no acute fracture. | Mild soft tissue swelling without acute fracture. |
Generate impression based on findings. | 54-year-old male with history of knee pain. There is severe osteoarthritis affecting the patellofemoral joint with relatively mild osteoarthritis at the tibiofemoral articulation. We see no chondrocalcinosis. There is a moderate-sized joint effusion. Ossicles in the soft tissues surrounding the knee suggest loose bodie... | Osteoarthritis and joint effusion as above. |
Generate impression based on findings. | Malignant neoplasm of the kidney. Clinical trial. Baseline therapy. Metastatic RCC. CHEST:LUNGS AND PLEURA: Left lingular atelectasis. No definite pulmonary metastases.MEDIASTINUM AND HILA: No significant abnormality noted. Subcentimeter mediastinal lymph nodes.CHEST WALL: There is a 5.4 x 7.6 cm enhancing mass (image ... | Left complex renal mass compatible with renal cell carcinoma. Destructive metastasis involving the upper left thoracic spine with extension into the spinal canal; correlation with spine MRI is advised. Findings were discussed with the clinical service (pager number 7068) at the time of dictation. |
Generate impression based on findings. | 51-year-old female with history of medial ankle pain. There is mild soft tissue swelling about the ankle. There is a mild pes planus deformity. Mild osteoarthritis affects the ankle joint. | Mild soft tissue swelling, pes planus deformity, and osteoarthritis as above. |
Generate impression based on findings. | Bilateral shoulder pain for one year.VIEWS: Left shoulder internal rotation, external rotation, wide view and axillary view (4 views) right shoulder internal rotation, external rotation, wide view and axillary view (4 views) 1/28/2015 LEFT SHOULDER: Well-circumscribed cortically based lucency in the superolateral aspec... | Cystic changes in the bilateral proximal humeri are incompletely characterized and further evaluation with MRI can be considered as clinically indicated. |
Generate impression based on findings. | 76 year old female with history of newly diagnosed breast cancer and liver lesions. ABDOMEN:LIVER, BILIARY TRACT: Hepatic dome/segment 7 hypoattenuating lesion with brisk, peripheral nodular arterial enhancement (10/24) measuring approximately 1.7 x 1.5 cm, which follows the blood pool on delayed sequences.An additiona... | At least two arterial enhancing hepatic lesions, which follow the blood pool on delayed images, most consistent with hemangiomas but may represent focal nodular hyperplasia or adenoma. These lesions may be further evaluated with MRI liver protocol for additional specificity. |
Generate impression based on findings. | T3N0 laryngeal squamous cell carcinoma treated via chemoradiation completed 8/23/13. There are post-treatment findings with persistent extensive diffuse laryngeal mucosal edema. The thyroid, arytenoid, and cricoid cartilages appear to be intact. There are no enlarged neck lymph nodes by CT criteria. The thyroid and sal... | Post-treatment findings in the neck with persistent extensive laryngeal mucosal edema and tracheostomy tube in position, but no measurable residual laryngeal tumor or significant lymphadenopathy in the neck. |
Generate impression based on findings. | 16-month-old male with cystic fibrosis.VIEWS: Chest AP/lateral (two views) 1/28/2015 Mild peribronchial thickening is again evident. No focal lung opacity or bronchiectasis is seen.Cardiothymic silhouette is within normal limits. No pleural effusion or pneumothorax. | Persistent mild peribronchial thickening, without significant bronchiectasis or focal air space opacity evident. |
Generate impression based on findings. | Male 63 years old; Reason: pt with a history of prostate cancer, please assess for disease progression Interval resolution of activity in the T8 vertebral body. A focus in the right hemipelvis correlates with the sclerotic lesion seen in the right sacrum on same day CT as well as prior CT 8/29/2014, however this was no... | Interval resolution of activity in the T8 vertebral body. Focus of activity in the right sacrum not seen on prior bone scan however is identified on current and prior CT dated 8/29/2014 consistent with metastatic disease. |
Generate impression based on findings. | Right knee pain. Please evaluate. Four views of the right knee are provided. The bones appear slightly demineralized. Mild osteoarthritis affects the right knee, particularly the patellofemoral compartment. There is a moderate-sized joint effusion.Mild osteoarthritis also affects the left knee as seen on the frontal vi... | Mild osteoarthritis. |
Generate impression based on findings. | There is mild disk narrowing at L5-S1 with diffuse disk desiccation. There is moderate vertebral body height loss of L1 as well as moderate concavity of the superior endplate of L4. Less prominent superior endplate concavity is noted at L3 and L5, consistent with chronic compression deformities. There is mild enhancem... | 1. Thickening and redundancy of the cauda equina nerve roots secondary to a combination of underlying developmental narrowing of the mid to distal lumbar spinal canal and superimposed mild spondylotic changes, resulting in moderate central spinal canal stenosis at L4-L5 and L5-S1. This accounts for appearance on previo... |
Generate impression based on findings. | Large B cell NHL status post chemotherapy in presumed ongoing remission. There is no evidence of measurable mass lesions or significant cervical lymphadenopathy based on size criteria. The thyroid and major salivary glands are unremarkable. There is mild multilevel degenerative spondylosis. The airways are patent. The ... | No evidence of significant lymphadenopathy in the neck to suggest recurrent lymphoma. |
Generate impression based on findings. | Reason: Patient with previous radiation/chemotherapy, has h/o NSCLC History: f/u ct CHEST:LUNGS AND PLEURA: Paramediastinal fibrotic changes compatible was postradiation changes. Previously seen loculated intrafissural fluid collection has resolved or nearly resolved. There are few small subcentimeter fluid collections... | 1.Although mass and posttreatment changes are difficult to differentiate, right lower lobe cavitary mass and adjacent posttreatment changes have overall decreased in size compared to prior.2.Resolution or near resolution of previously seen right intrafissural fluid collection. A few small fluid density foci in in the r... |
Generate impression based on findings. | Pt is an 83 y/o male with met prostate cancer, evaluate for progression Interval solution of activity in the right humeral head. Uptake in the right acromioclavicular joint is consistent with degenerative changes. Increased activity in the left supraorbital region as well as midline upper face is unchanged and likely r... | Interval resolution of activity in the right humeral head. No new abnormal osseous foci are identified to indicate metastatic disease. |
Generate impression based on findings. | 70-year-old male with history of possible retained bullet fragment. Left tibia/fibula: Multiple metallic fragments are clustered along the posteromedial aspect of the tibial metadiaphysis compatible with a fragmented bullet. Focal sclerosis of the underlying tibia may reflect a healed fracture. There is mild diffuse so... | Bullet fragments adjacent to the proximal left tibia as described above. Findings relayed to the MRI technologist at 1500 on 1/28/15. |
Generate impression based on findings. | Again seen are postoperative changes of posterior spinal fusion from T7 to T12, T8-T10 laminectomy, and partial corpectomies at T9 and posterior superior aspect of T10. Right costo-transversectomy also seen at T9 and T10 levels. Irregularity involving the left T9 and T10 transverse process disease is also seen, presum... | 1. Periscrew lucencies suggestive of loosening involving the bilateral pedicle screws at T12 and and right pedicle screw at T11. 2. Mild anterior wedging involving the the T12 vertebral body stable to mildly worse compared to 9/4/2014. Apparent mild focal kyphosis at the T11-T12 level appears worse and can be correlate... |
Generate impression based on findings. | Female 42 years old Reason: RUQ pain, eval biliary tree and gallbladder History: abdominal pain LIVER: The liver measures 19.8 cm in length and demonstrates mildly hyperechoic parenchyma which is suggestive of fatty infiltration. There is no focal liver lesion.GALLBLADDER, BILIARY TRACT: Unremarkable appearance of the ... | 1. Mildly hyperechoic hepatic parenchyma suggestive of fatty infiltration. 2. No evidence of cholelithiasis or acute cholecystitis. |
Generate impression based on findings. | Lung mass, pleural effusion, dyspnea, longtime smoker evaluate for lung cancer. CHEST:LUNGS AND PLEURA: Moderate left pleural fluid collection. Assessment for pleural nodules limited given of intravenous contrast. Centrilobular and paraseptal emphysema with scattered cysts.Spiculated mass within the apical posterior le... | Left upper lobe masses and nodules with ipsilateral mediastinal, hilar and low cervical lymphadenopathy; highly suspicious for primary pulmonary neoplasm. Moderate left pleural effusion and a small pericardial effusion are present; metastases to these areas cannot be excluded. Diffuse septal thickening throughout the l... |
Generate impression based on findings. | Female 38 years old; Reason: chest pain, similar to previous PE in 2007; recent surgery and current immobility; Xarelto held for surgery; has Lupus nephritis with renal insufficiency so cannot get CT PE protocol The comparison chest radiograph performed on 10/30/2014 demonstrates stable blunting of the left costophreni... | Very low probability for pulmonary embolism. |
Generate impression based on findings. | 78 year old female with history of left mastectomy for breast cancer in March 2014, after remote history of left lumpectomy for breast cancer in 1995. No current breast complaints. Three standard views of the right breast were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is hetero... | No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, right unilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | There is carious disease of ADA 31 and a root canal of ADA 30 with carious disease of the posterior portion. There is enhancing soft tissue thickening measuring 14 x 6 mm at the medial aspect of the left maxillary alveolar process at ADA 16. ADA 16 is smaller in size than the contralateral tooth in the same position. ... | 1. Enhancing soft tissue thickening measuring up to 14 mm along the medial aspect of the left maxillary alveolar process at ADA 16. Recommend correlation with direct inspection. No discrete fluid collection.2. Right-sided dental caries. |
Generate impression based on findings. | There is premature fusion of the left coronal suture with asymmetric flattening of the left frontal calvarium. The metopic suture is partially fused. The sagittal suture, right coronal, and bilateral lambdoid sutures are patent. The anterior and posterior fontanelles are closed. The ventricles and sulci are within nor... | 1. Unilateral left coronal craniosynostosis with anterior plagiocephaly.2. Closure of the anterior and posterior fontanelles. |
Generate impression based on findings. | The ventricles and sulci are within normal limits. There is no midline shift or mass effect. There is no intracranial hemorrhage, within the limitations of only postcontrast imaging. There are no areas of abnormal attenuation or pathological enhancement. There is no extraaxial fluid collection. The visualized portions... | No CT evidence of intracranial metastases. If there is continued clinical concern and no contraindication to MR, MRI may be considered. |
Generate impression based on findings. | History of rheumatoid arthritis, limited range of motion of neck, paresthesias of left fourth and fifth fingers. Rule out instability. Evaluation of the cervical spine is limited due to inability to optimally position the patient. Evaluation of the lower cervical spine is further limited on the lateral views by overlyi... | Severe degenerative disk disease and facet joint osteoarthritis, with anterolistheses elicited on flexion as described above, suggesting instability. |
Generate impression based on findings. | Family history of breast cancer in her mother and grandmother. No current breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged in pattern and distribution. No suspiciou... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | 12-year-old male with abdominal pain, assess stool burden VIEW: Abdomen AP (one view) 01/28/15 Moderate amount of stool throughout the abdomen. No pneumatosis. Nonobstructive bowel gas pattern. | Moderate stool burden. |
Generate impression based on findings. | 59-year-old female with left breast asymmetry presents for short-term follow-up of left breast and annual mammogram for right breast. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglandular elements, unchanged ... | No mammographic or sonographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram. |
Generate impression based on findings. | 70 years, Male. Reason: evaluate for ileus History: no bm in days Pelvis is excluded from field of view. Nonobstructive bowel gas pattern. Partially visualized patchy airspace opacity and tenting of left diaphragm. | Pelvis is excluded from field of view. Nonobstructive bowel gas pattern. |
Generate impression based on findings. | 66 years, Male. Reason: Serial evaluation of stool burden in the setting of constipation/abdominal pain History: Abdominal pain Average stool burden. Distended bowel loops without significant change from prior study. Streaky bilateral lung base opacities compatible with atelectasis. | Average stool burden. Distended bowel loops without significant change from prior study. |
Generate impression based on findings. | 23 old female with history of JIA Left hand: There multiple erosions at the bases of the metacarpals as well as marked intercarpal joint space narrowing and small carpal erosions. The distal osseous structures appear within normal limits.Right hand: There may be mild periarticular osteopenia involving the bases of meta... | 1. Erosions and narrowing of the intercarpal joints involving the left hand, consistent with the history of JIA.2. Knee joint effusions. |
Generate impression based on findings. | The lumbar spine is in normal alignment, with straightening of the normal lumbar lordosis. There is mild to moderate disk narrowing at L2-L3, with mild disk desiccation at this level as well as at L3-L4. The vertebral body and disk heights are otherwise well-maintained. No worrisome focal marrow signal abnormality is ... | Minimal scattered spondylotic changes with mild developmental narrowing of the mid lumbar spinal canal. Findings most prominent at L2-L3 where there is a trace disk bulge which does abut the descending left L3 nerve root. Additional minimal encroachment upon the inferior aspect of the left L3-L4 foramen by a shallow le... |
Generate impression based on findings. | 59-year-old presents for annual mammogram. No new breast complaints. History of breast carcinoma in daughter diagnosed at the age of 33 and two maternal aunts. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is composed of scattered fibroglan... | No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Screening Mammogram. |
Generate impression based on findings. | 80 year-old female with pain and osteoarthritis Pelvis: The pelvis appears within normal limits for the patient's age.Left knee: There is a large joint effusion. Tibiofemoral joint compartment narrowing and small osteophytes are consistent with moderate osteoarthritis.Right hand: Marked osteoarthritis affects the basil... | Degenerative arthritic changes as described above. Large knee joint effusion. |
Generate impression based on findings. | 56 years, Female. Reason: evaluate stool burden History: abdominal pain, n/v, diarrhea, chronic narcotic use Nonobstructive bowel gas pattern. Less than average stool burden. Right periphery is excluded from the field-of-view. Multiple surgical clips overly the pelvis and abdomen. Central venous catheter tip overlies r... | Nonobstructive bowel gas pattern. Less than average stool burden. |
Generate impression based on findings. | History of superficially invasive keratinizing squamous cell carcinoma of the larynx, status post radiation therapy. Surveillance examination. There is unchanged mucosal thickening of the pharynx and larynx, but there is no evidence of distinct enhancing mass. There are secretions within the hypopharynx. There is no ev... | 1. No evidence of locoregional tumor recurrence or significant cervical lymphadenopathy. 2. The presence of secretions within the hypopharynx may indicate a risk for aspiration. 3. Extensive dental disease. |
Generate impression based on findings. | 7-year-old female status post falls now sleepy, AMSVIEWS: Shunt series: Skull AP/lateral (two views), chest AP/lateral (two views), abdomen AP/lateral (two views) 01/28/15 A left posterior transparietal approach ventriculostomy tube with tip at midline. The extracranial shunt tubing courses down the soft tissues of the... | No evidence of shunt discontinuity and kinking. |
Generate impression based on findings. | Reason: eval for tumor History: one month of abd pain with weight loss and palpable huge liver ABDOMEN:LUNG BASES: Small right pleural effusion with question of pleural nodularity, suspicious for neoplastic involvement. LIVER, BILIARY TRACT: Innumerable peripherally enhancing hepatic lesions and hepatomegaly consistent... | 1. Widespread metastatic disease in the liver, spleen, and throughout the visualized skeleton, consistent with metastatic disease of unknown primary origin. 2. Small right pleural effusion with question of nodularity, also suspicious for neoplastic involvement. |
Generate impression based on findings. | 83-year-old female with breast cancer. Restaging.RADIOPHARMACEUTICAL: 14.0 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 110 mg/dL. Today's CT portion grossly demonstrates new moderate left-sided pleural effusion, stable 6-mm right lower lobe nodule, new linear lingular density likely representing subsegme... | Mixed response to therapy, with decreased hypermetabolic activity associated with left pectoral muscle, left chest wall, left subpectoral lymph nodes, and most osseous lesions though also increased activity associated with the solitary liver and left iliac lesions. |
Generate impression based on findings. | Left shin pain. Evaluate for stress fracture. There is slight focal thickening of the cortex along the anterior aspect of the distal tibial diaphysis, as well as along the medial aspect of the proximal tibial diaphysis. These findings are nonspecific and do not necessarily represent stress fractures, but if there is st... | Foci of mild cortical thickening as described above are of uncertain clinical significance. If there is strong clinical concern for stress fracture, repeat radiographs may be obtained in 10 to 14 days. Alternatively, MRI may be considered. |
Generate impression based on findings. | 68-year-old female status post right TKA Hardware components of a total knee arthroplasty device are situated in near-anatomic alignment without evidence of complication. Foci of gas, drain and staples in the soft tissues reflect recent surgery. | Status post right TKA revision, as above. |
Generate impression based on findings. | 56 year old woman with angina referred to evaluate for coronary artery disease.CPT Code: 75574 Coronary arteries: LM: The left main coronary artery arises normally from the left sinus of Valsalva and bifurcates into the left anterior descending and left circumflex coronary arteries. There are no significant stenoses pr... | 1.There are no significant coronary artery stenoses noted; however, the distal vessels are not well seen due to limited image quality.This portion of the report pertains to the heart and great vessels only. The remaining soft tissues of the thorax and upper abdomen will be interpreted by the attending chest radiologist... |
Generate impression based on findings. | 74 year-old female, evaluate bunion formation There is severe hallux valgus deformity and mild osteoarthritis affecting the first MTP joint. The remainder of the foot appears unremarkable. | Severe hallux valgus deformity. |
Generate impression based on findings. | One year status post chelectomy first metatarsal head with residual pain and swelling. Evaluate first metatarsophalangeal joint for degenerative joint disease. Severe osteoarthritis affects the first metatarsophalangeal joint. Mild osteoarthritis affects the interphalangeal joints of the toes. There is a small plantar ... | Severe osteoarthritis of the first metatarsophalangeal joint and other findings as above. |
Generate impression based on findings. | 30-year-old male with history of ankle injury. There is a 4-mm ovoid density just distal to the tip of the fibula which may represent an avulsion fracture, but given its morphology, we suspect that it is chronic in etiology. There is a small tibiotalar joint effusion. Mild soft tissue swelling about the ankle. | Soft tissue swelling and tibiotalar joint effusion. Small ossicle distal to the tip of the fibula is thought to be chronic in etiology.Findings relayed to the ordering physician (pager 6137) on 1/28/15 at 1530. |
Generate impression based on findings. | 79-year-old male with history of metastatic lung cancer, initial staging exam. Multiple punctate enhancing foci are evident in the left frontal lobe (series 6, image 23; series 80424, image 39), left inferior parietal lobe (series 6, image 18), and left cerebellar hemisphere (series 6, image 11). The relatively largest... | 1. Multiple punctate enhancing foci within the left frontal lobe, left inferior parietal lobe, and the left cerebellar hemisphere are concerning for metastases. The relatively largest left frontal lesion measures up to 8 mm. No evidence of mass-effect or significant midline shift is present. Consider MRI brain for furt... |
Generate impression based on findings. | 54 years, Female. Reason: 54F s/p completion proctectomy, now with N/V History: Nausea, emesis There is dilatation of small bowel loops measuring up to 4.0 cm, caliber gradient noted with relatively collapsed distal loops seen in lower abdomen, suspicious for small bowel obstruction but postoperative ileus another diff... | Dilated small bowel, may be seen in setting of a small bowel obstruction, postoperative ileus another differential consideration, correlation with patient's clinical history/physical exam and continued followup recommended.Findings discussed with Dr. James Warnecke on 1/28/2015 3:04PM. |
Generate impression based on findings. | 63-year-old male with history of renal cell carcinoma, baseline exam for research study. There are no areas of abnormal attenuation or pathological enhancement. No intracranial hemorrhage is identified. No intracranial mass, evidence of mass-effect or significant midline shift is present. The gray-white differentiation... | 1. No CT evidence of intracranial metastatic disease. If clinically indicated MRI brain can be considered for more sensitive evaluation. 2. No evidence of intracranial hemorrhage or mass effect. |
Generate impression based on findings. | 25-year-old male with history of non-Hodgkin's lymphoma. Increasing lymph nodes, status post ASCT and radiation.RADIOPHARMACEUTICAL: 15.1 mCi F-18 fluorodeoxyglucose (FDG).BLOOD GLUCOSE (FASTING): 103 mg/dL. Today's CT portion grossly demonstrates increased right maxillary sinus opacification, increased size of left su... | New FDG activity associated with numerous lymph nodes in the left neck, chest, retroperitoneum, and pelvis as well as left paraspinal focus, compatible with recurrent lymphoma. |
Generate impression based on findings. | Malignant neoplasm of the prostate. Pain and elevated alkaline phosphatase. Please evaluate. The following observations are made given limitations of an unenhanced study.ABDOMEN:LUNG BASES: Calcified granulomata are stable.LIVER, BILIARY TRACT: Benign calcifications are again noted. No mass lesions are evident.SPLEEN: ... | Progressive adenopathy in the abdomen and pelvis. Diffuse bony metastases. |
Generate impression based on findings. | 45-year-old female with history of pain and fever. Additional history obtained via EPIC review: Vaginal hysterectomy on 1/5/15 and known postoperative abscess formation. Please note lack of IV and oral contrast limits evaluation of solid organ pathology, and also of the GI tract.CHEST:LUNGS AND PLEURA: No significant a... | Free fluid in the pelvis; without contrast it is impossible to determine the extent to which this is loculated. This is consistent with the patient's known history of pelvic abscess. |
Generate impression based on findings. | Reason: 61 yo m w cough, lung masses seen on abd ct, further eval History: cough LUNGS AND PLEURA: Moderate upper lobe predominant centrilobular emphysema. Partially necrotic right lower lobe mass with chest wall invasion that measured approximately 5.5 x 4.2 cm on recent CT abdomen and pelvis with contrast is again id... | 1.Large right lower lobe partially necrotic mass with chest wall invasion and large right hilar partially necrotic mass most compatible with primary lung malignancy with metastases. These masses are better assessed on recent CT abdomen and pelvis with contrast, which extended to the level of the hilum.2.Mediastinal lym... |
Generate impression based on findings. | Male 29 years old; Reason: eval for mass History: L testicular pain RIGHT TESTIS: Status post right orchidectomy.LEFT TESTIS: The left testis measures 5.2 x 2.4 x 3.5 cm and appears unremarkable demonstrating normal color Doppler flow.RIGHT EPIDIDYMIS: Surgically resected.LEFT EPIDIDYMIS: No significant abnormalities n... | Status post right orchidectomy. Unremarkable appearance of the left testis. |
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