Instruction: Generate impression based on findings.

Input: Diagnosis: Fracture of neck, unspecified, subsequent encounterClinical question: pre op planning for C1-2 fractureSigns and Symptoms: C1 C2 fracture The cervical vertebral bodies are appropriate in overall height. The cervical spinal cord has normal signal characteristics and overall morphology. There is anterior subluxation of C3 on C4.At C1-2 there is some hypertrophy of the tissues at the cruciate ligaments which is associated with narrowing of the spinal canal. The odontoid appears to be chronically fractured. There are signal changes within the odontoid process . These findings are stable when compared to the prior exam. There is mild posterior subluxation of C1 relative to C2.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is loss of disk space height associated with endplate reactive changes and bilateral facet hypertrophy. There is anterior subluxation of C3 on C4 with resultant narrowing of the spinal canal and bilateral neural foramina. There is encroachment of the exiting nerve roots. The spinal cord is surrounded by spinal fluid at this level. There is no significant change in this appearance when compared to the prior exam.At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is loss of disk space height at this level with near obliteration of the disk space and osseous bridging. There is associated bilateral facet hypertrophy at this level associated with fusion across the left facet joint. Findings were also present on the prior exam.At C5-6 there is no significant compromise to the spinal canal. There is loss of disk space height and disc desiccation. There is a also diffuse disk bulge and bilateral uncovertebral and endplate osteophytes with narrowing of the neural foramina bilaterally and encroachment of the exiting nerve roots.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is loss of disk space height and disk desiccation as well as bilateral uncovertebral osteophytes and some posterior ligamentous hypertrophy at this level. There is bilateral neural frontal narrowing with encroachment of exiting nerve roots at this level. This appears stable compared to prior exam.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact. The left vertebral artery is smaller than the right vertebral arterySome scattered opacities are present in the right mastoid air cells.MRA neck: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 the basis of NASCET criteria there is no significant stenosis at the carotid bifurcations. There is no significant stenosis along the course of the vertebral arteries. The right lobe of the thyroid gland appears heterogeneous within a 2 cm region. This appears stable and compared to an MRI of the cervical spine from 3/29/2013.

Output: 1.There are multilevel degenerative changes present in the cervical spine. These findings are stable compared to the previous exam. 2.There is pannus formation along the cruciate ligaments at the C1 C2level which narrows the spinal canal mildly but does not compress the spinal cord or brainstem. There is a chronic odontoid fracture present. There is stable posterior subluxation of C1 relative to C2. These findings are stable compared to the previous exam.3. There is anterior-subluxation of C3 on C4 associated degenerative changes and mild spinal stenosis associated with encroachment of exiting nerve roots. These findings are stable compared to the previous exam.4.There degenerative changes present at C5-6 and C6-7 with bilateral neural foramen encroachment encroachment of exiting nerve roots. These findings are stable compared to the previous exam.5.No evidence for carotid or vertebral stenosis in the neck.6.There is heterogeneity and enlargement of the right thyroid gland lobe. This is a nonspecific finding. It is stable compared to the prior exam.


Instruction: Generate impression based on findings.

Input: 61-year-old status post left lumpectomy for DCIS intermediate grade, close surgical margins. There is scattered fibroglandular tissue in both breasts.Mild parenchymal enhancement is noted bilaterally.There is a post-surgical seroma, measuring 76 x 54 x 42 mm at upper inner quadrant in the left breast. No suspicious enhancement is seen near the seroma or elsewhere in the left breast. No abnormal enhancement is seen in right breast. No abnormal lymph nodes are identified in either axillary region.

Output: Status post left lumpectomy. No MRI evidence for malignancy. BIRADS: 2 - Benign finding.RECOMMENDATION: X - No Letter.


Instruction: Generate impression based on findings.

Input: History of a GBM. Difficulty ambulating, weakness and vomiting. Since prior CT, there has been increased edema in the right posterior parietal with more mass effect on the right lateral ventricle, which has been completely effaced and the left lateral ventricle has been dilated. Also, there is a 16.4 mm leftward midline shift. The calcification within the edema is again noted. In addition, there are a hypodensity in the genu of corpus callosum and hyperdensity in the head of the left caudate, which are new findings since prior CT, however, are visualized on prior MRI dated 2/12/08 and now appear more pronounced. The left frontal encephalomalacia remains unchanged. No intracranial hemorrhage or abnormal extraaxial fluid collection is detected.

Output: 1. Interval increased right posterior parietal edema with increased mass effect causing effacement of the right lateral ventricle, hydrocephalus and a leftward midline shift, suggesting tumor progression. 2. Interval new abnormal densities in the genu of corpus callosum and in the head of the left caudate. These may represent tumor spreading. A brain MRI is recommended for further evaluation. 3. Stable left frontal encephalomalacia.


Instruction: Generate impression based on findings.

Input: 33-year-old female presents with left shoulder pain, evaluate for labral tear. ROTATOR CUFF: The tendons and muscles of the rotator cuff are normal in appearance.SUPRASPINATUS OUTLET: No significant abnormality noted.GLENOHUMERAL JOINT AND GLENOID LABRUM: There is tearing of the posterior and posterosuperior labrum with associated paralabral cysts. There is also decentering of the humeral head which overlies the posterior labrum.BICEPS TENDON: No significant abnormality noted. ADDITIONAL

Output: 1. Posterior and posterosuperior labral tear with associated paralabral cysts.2. Decentering of the humeral head which overlies the posterior labrum.


Instruction: Generate impression based on findings.

Input: Left sided asymmetric sensorineural hearing loss. There is an enlarged left vestibular aqueduct. There also appears to be deficient bone overlying the superior semicircular canal. There is a somewhat prominent venous flow void in the cerebellopontine angle cistern, but the cranial nerve 7 and 8 complexes are intact. There is no evidence of mass lesions. The mastoid air cells and middle ears also appear unremarkable.Right: The cranial nerve 7 and 8 complexes are intact. There is no evidence of mass lesions. The inner ear structures, including the cochlea, vestibule, endolymphatic duct, and semicircular canals, appear unremarkable. The mastoid air cells and middle ears also appear unremarkable.

Output: Enlarged left vestibular aqueduct and apparent deficient bone overlying the superior semicircular canal, which may represent dehiscence, but no evidence of retrocochlear or inner ear lesions. A temporal bone CT may be useful for further evaluation.


Instruction: Generate impression based on findings.

Input: Sciatica. The vertebral column alignment is within normal limits, aside from trace anterolisthesis of L4 on L5. The vertebral body and disc space heights are preserved. The vertebral bone marrow signal is unremarkable, including mild scattered areas of focal fat or hemangiomas. There are trace disc bulges and mild facet hypertrophy in the lower lumbar spine, but no significant spinal canal or neural foraminal stenosis. The spinal cord displays normal signal and morphology. There is diffuse paravertebral muscle atrophy. There is edema in the posterior lower back subcutaneous tissues.

Output: Trace disc bulges and mild facet hypertrophy in the lower lumbar spine, but no significant spinal canal or neural foraminal stenosis. The spinal cord displays normal signal and morphology.


Instruction: Generate impression based on findings.

Input: Female 58 years old Reason: rectal cancer staging please History: rectal bleedingPer pathology report:Descending colon polyp - Invasive moderately differentiated colonic adenocarcinoma arising in tubulovillous adenoma.Rectal mass- Invasive moderately differentiated rectal adenocarcinoma. PELVIS:UTERUS, ADNEXA: No significant abnormality noted. BLADDER: No significant abnormality noted. LYMPH NODES: Lymph nodes in the perirectal space, within the mesorectal fascia: Scattered prominent mesorectal lymph nodes with a subcentimeter lymph node less than 1 cm from the circumferential resection margin (series 401, image 52)Lymph nodes outside the mesorectal fascia: Mildly prominent pelvic sidewall lymph nodes with reference left-sided lymph node measuring 1.0 x 0.8 cm (series 901, image 53). Reference presacral lymph node measures 1.2 x 1.0 cm (series 901, image 55), unchanged.BOWEL, MESENTERY: Rectal Tumor:Size: 1.7 x 2.6 x 1.5 cm (image 26/series501; image 35, series 901)Tumor appearance on T2-weighted images: Isointense. Immediately proximal to the aforementioned lesion, there is a region of asymmetric T2 gray signal measuring approximately 1 cm without evidence of enhancement (series 501, image 24).Tumor location: Rectosigmoid(For lower rectal tumors):Distance of the lower edge of the tumor to the anal verge (lower edge of the anal canal): 3.7 cmDistance of the lower edge of the tumor to the pelvic floor (relationship of the tumor to the anal sphincter complex): 1.6 cmCircumference of the rectum involved: 25%Relationship and proximity of the tumor to adjacent structures (uterus, cervix, vagina): Not involvedOther: There is possible infiltration of the tumor beyond the serosal margin (series 801, image 27). BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: 1.Rectal lesion consistent with history of carcinoma as detailed above.2.Prominent mesorectal, presacral, and pelvic sidewall lymph nodes.


Instruction: Generate impression based on findings.

Input: Female 76 years old with vaginal bleeding and discharge new diagnosis of cervical cancer, evaluation of extent of disease. PELVIS:UTERUS, ADNEXA: Enlarged, lobular uterine contour containing multiple T2 hypointense intramural lesions compatible with fibroids the largest of which measures 3.2 x 3.1 x 3.8 cm. There is distortion of the endometrial cavity likely due to mass effect from the fibroids. No evidence of adenomyosis. The adnexa appear unremarkable.A T2 hypointense, enhancing mass compatible with the patient's known cervical cancer is centered primarily along the left cervix and measures up to 2.7 cm in craniocaudal dimension (series 3, image 22) and 2.6 x 3.9 cm transverse by AP (series 5, image 23). The mass touches the posterior aspect of the urinary bladder. The intervening fat between the cervix and the rectum is obliterated, serosal invasion of the rectum is not excluded (series 5, image 25). Hazy T2 hypointensity in the fat adjacent to the cervix on the left indicates parametrial invasion (series 5, image 24).BLADDER: The cervical mass touches the posterior aspect of the urinary bladder.LYMPH NODES: No pelvic lymphadenopathy.BOWEL, MESENTERY: The intervening fat between the cervix and the rectum is obliterated and serosal invasion of the rectum is not excluded. Colonic diverticulosis.BONES, SOFT TISSUES: Degenerative changes affect the pubic symphysis.OTHER: There is a small amount of pelvic free fluid. No hydroureter.

Output: 1.Left cervical mass described above is compatible with the patient's history of cervical cancer. There is evidence of parametrial invasion on the left.2.Cervical mass touches the urinary bladder. Intervening fat between the cervix and rectum is obliterated and serosal invasion of the rectum is not excluded.3.No pelvic lymphadenopathy.4.Fibroid uterus.


Instruction: Generate impression based on findings.

Input: 55 year old female with metastatic breast cancer who presents with left-sided blurry vision. Rule out metastases disease to the eye or brain. Expansile lytic destructive changes of calvarium consistent with metastatic lesions are again identified. There is significant interval increase in the size of lesions since prior study. There is no apparent epidural spread of tumor into the spinal canal. This can be significantly better visualized on MRI exam. The brain parenchyma remains normal in density and demonstrates no abnormal enhancement of the right parenchymal or the meninges. There is also suggestion of new additional metastatic lesions to the calvarium.Expansile mixed density left frontal bone lesion with significant extension into the right orbit is consistent with fibrous dysplasia is again identified with no interval change.CT of maxillofacial. Significant expansion of right frontal bone in all of its segments and in particular along the floor of the right anterior cranial fossa is noted. The changes extends medially and involves the fovea ethmoidalis and the left frontal bone and is contiguous with fibrous dysplasia changes of sphenoid bone. Significant expansion of the right frontal bone causes elevation of right frontal lobe. Expansile changes of right frontal bone reduces the carinal cephalad axis of the right orbit and applies mass effect on the external ocular musculature and globe. Coronal reformatted images demonstrate these findings with better advantage. There is fibrous dysplasia of left frontal bone along the floor of the anterior cranial fossa. There is mild compromise of the left optic nerve canal and likely the right optic nerve canal secondary to fibrous dysplasia changes at the level of planum sphenoidale. The retro-orbital fat, extraocular musculature and globe remains normal on the left.

Output: 1.Increase in the size of lytic destructive metastatic lesions of the calvarium with no apparent extension into the intracranial space.2.No evidence of edema brain parenchyma or abnormal enhancement of the brain or leptomeninges.3.Large fibrous dysplasia of right and to a lesser degree left frontal bones with associated changes of the orbit as detailed above.


Instruction: Generate impression based on findings.

Input: 33-year-old female with draining wounds evaluate for osteomyelitis. There is soft tissue irregularity along the distal aspect of the great toe consistent with the stated history of ulceration. Note is made of foci of deep subcutaneous gas density adjacent to the distal tuft of the distal phalanx of the great toe. There is perhaps mild cortical indistinctness along the distal tuft of the distal phalanx of the great toe consistent with the findings on recent MRI of osteomyelitis. No acute fracture or malalignment. There is soft tissue swelling about the ankle. Vascular calcifications are identified in the overlying soft tissues.

Output: Findings consistent with osteomyelitis of the distal phalanx of the great toe as described above.


Instruction: Generate impression based on findings.

Input: History of arterial enhancing hepatic lesion. History of carcinoid symptoms with no clear primary. ABDOMEN:LIVER, BILIARY TRACT: The liver is normal in morphology, signal intensity and enhancement. Several subcentimeter hepatic cysts. No focal suspicious lesion is identified. No biliary ductal dilatation. The portal vein, hepatic veins and hepatic artery are patent. Normally distended gallbladder without gallstones.SPLEEN: The spleen is normal morphology size and signal intensity. There are 2 splenules along the inferior anterior aspect of the spleen.PANCREAS: The pancreas is moderately atrophic without pancreatic ductal dilatation or focal lesion. This is out of proportion to what would be expected for the patient's age.ADRENAL GLANDS: Normal in size and morphology.KIDNEYS, URETERS: Several subcentimeter renal cysts are noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: 1. No suspicious liver lesion or other finding to account for the patient's carcinoid symptoms.2. The pancreas is diffusely moderately atrophic without pancreatic ductal dilatation or a focal lesion.


Instruction: Generate impression based on findings.

Input: Progressive bilateral hearing loss. History of T2DM, coronary artery disease and hypertension. Status post renal and heart transplant in 2009. The bilateral cranial nerve 7 and 8 complexes are intact and show no abnormal contrast enhancement or mass lesion. Other than for apparent asymmetric thinning of the bony coverage over the apex of the left superior semicircular canal which likely remains within normal limits, the inner ear structures, including the cochlea, vestibule, endolymphatic duct, and semicircular canals, appear unremarkable. The bilateral mastoid air cells and middle ears also appear unremarkable.Included brain is notable for chronic left thalamic lacunar infarcts in addition to multiple of T2-hyperintensity in the brain and brainstem which are nonspecific but likely represent small vessel ischemia. There is also mild-to-moderate cerebellar volume loss. There is mild mucosal thickening in the paranasal sinuses.

Output: No evidence of retrocochlear or inner ear lesions to account for sensorineural hearing loss.


Instruction: Generate impression based on findings.

Input: Reason: r/o ligamentous/meniscal injury History: pain MENISCI: There is increased signal intensity within the posterior horn of the medial meniscus at its root, likely representing insertional degeneration with a small cyst anterior to the PCL. The medial meniscus appears intact. The lateral meniscus appears intact.ARTICULAR CARTILAGE AND BONE: There is focal degeneration of the articular cartilage of the far medial facet of the patella with linear increased signal intensity likely representing a full-thickness or near full-thickness cleft. The medial and lateral compartment cartilage appears intact. LIGAMENTS: The cruciate and collateral ligaments appear intact. EXTENSOR MECHANISM: The extensor mechanism appears intact. There is a prominent enthesophyte at the insertion of the patellar tendon on the tibia. There is mild edema of the enthesophyte as well as within the underlying tibia. There is mild degeneration of the adjacent patellar tendon as well as mild inflammation within the adjacent soft tissues.ADDITIONAL

Output: 1. Prominent enthesophyte along the anterior tibia at the insertion of the patellar tendon with mild degeneration of the adjacent patellar tendon and inflammation of the adjacent soft tissues.2. Focal degeneration and tearing of the articular cartilage of the medial facet of the patella.3. Degeneration of the root of the posterior horn of the medial meniscus with a small adjacent cyst.


Instruction: Generate impression based on findings.

Input: Again seen are postsurgical changes including suboccipital craniectomy and resection of the posterior arch of C1. The CSF space remains well expanded at this level and the cerebellar tonsils are neither crowded nor peglike. CSF flow is seen through both the anterior and posterior aspects of the foramen magnum, similar to prior. Minimal scarring is again evident involving the posterior inferior aspect of the cerebellar surface. No evidence of tumor recurrence at the site of prior tumor dorsal to the medulla.No evidence of parenchymal edema, mass, or mass effect is seen. No evidence of ischemia or hemorrhage. The ventricular system is normal in caliber and morphology. No abnormal parenchymal or meningeal enhancement is seen.CERVICAL SPINE

Output: 1. Postoperative changes related to resection of exophytic tumor along the posterior aspect of the medulla. No evidence of tumor recurrence.2. Postoperative changes related to lipomyelomeningocele repair and prior cord untetherings. No significant change in appearance of the conus which appears to adhere to the dorsal dural surface and demonstrates no ventral motion with prone imaging. Extensive adhesions within the distal thecal sac are also evident and unchanged. Re-tethering is again not excluded and can be correlated with clinical findings. No new cord signal abnormality or syrinx.


Instruction: Generate impression based on findings.

Input: Possible hypopituitarism hypoglycemia. Pituitary: There is a punctate focus of T1 hyperintensity along the superior tuber cinereum with absence of the pituitary stalk otherwise. The posterior pituitary bright spot in not present in the sella. The pituitary gland is not enlarged. The optic apparatus and cavernous sinuses are intact. Brain: There is no evidence of intracranial hemorrhage, mass, or acute infarct. The brain parenchyma appear unremarkable, with a normal degree of myelination. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.

Output: Ectopic pituitary with interruption of the pituitary stalk.


Instruction: Generate impression based on findings.

Input: 50 year-old female with history of multiple myeloma presents with headachesIMAGE ACQUISITIONS: Noncontrast head CT There is a large high-density extra-axial mass centered in the left frontal bone with a large intracranial component causing significant mass-effect on the left cerebral hemisphere. There is extension through the anterior aspect of the falx cerebri and into the right anterior medial frontal lobe. There is also a smaller extracranial component.Although there is no other obvious tumor or lytic calvarial lesion, there does appear to be some additional mass-effect in the posterior fossa causing rightward shift of the fourth ventricle. We recommend a brain MRI with contrast to further evaluate these findings.Findings were discussed with Dr. Mattingly at 2:30 p.m.

Output: Large left frontal extra-axial mass with destruction of the left frontal bone and significant extra- and intra-cranial components. We recommend a brain MRI with contrast.


Instruction: Generate impression based on findings.

Input: Reason: evaluate etiology of headache History: daily frontal headaches for 7 weeks 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.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.

Output: MRI of the brain is within normal limits.


Instruction: Generate impression based on findings.

Input: Cerebral infarction, unspecified [I63.9], Reason for Study: ^Reason: stroke workup History: left sided weakness, dysphagia, slurred speech The examination is limited secondary to extensive motion artifact. There is a confluent area of encephalomalacia and gliosis in the right paramedian parietal lobe, cingulate gyrus, medial temporal lobe, and occipital lobe. There is associated ex vacuo dilatation of the right lateral ventricle. There are also small areas of encephalomalacia in the left basal ganglia and corona radiata with ex vacuo dilatation of the frontal horn. There is a background of scattered cerebral white matter T2 hyperintensity. There is a new area of T2/FLAIR hyperintensity involving the right thalamus and paramedian right midbrain. There is no evidence of acute ischemia. There are no masses, mass effect or midline shift. The skull, paranasal sinuses, and mastoid air cells are unremarkable.

Output: 1. No evidence for acute ischemia.2. Right PCA territory encephalomalacia with chronic infarcts in the left basal ganglia and corona radiata superimposed upon a background of small vessel ischemic disease, similar to prior examination.3. A focus of T2/FLAIR hyperintensity involving the right thalamus and right paramedian midbrain appears new since prior examination and may relate to interval area of now subacute ischemia since prior MRI from 7/5/2016.3. MRA and MRV could not be obtained due to patient's inability to tolerate the examination.


Instruction: Generate impression based on findings.

Input: Previous fusion with neck pain. Low back pain, previous L2-L5 laminectomies. CERVICAL SPINE: There is mild anterolisthesis of C7 on T1 of 3 mm. There is anterior spinal fusion at C6-C7 with intervertebral disc spacer and wide decompressive laminectomies at C3-C7. There are endplate degenerative changes at C4-C5 with severe loss of disc space. There is mild loss of disc height at C3-C4, moderate loss of disc height at C5-C6 and severe loss of disc height at C7-T1. There is mild multilevel facet arthropathy. The vertebral body heights are preserved. The spinal cord displays normal signal and morphology. The vertebral bone marrow signal is unremarkable. The paravertebral soft tissues are unremarkable. There is a 10 mm nodule in the left thyroid lobe.C2-C3: Small disc osteophyte complex. No significant spinal canal or foraminal stenosis.C3-C4: Status post laminectomy. Disc osteophyte complex with large left paracentral osteophyte, contributing to mild flattening of the left ventral cord. No significant foraminal stenosis.C4-C5: Status post laminectomy. Disc osteophyte complex with left uncinate spur, contributing to mild left foraminal stenosis. No significant right foraminal stenosis.C5-C6: Status post laminectomy. Small disc osteophyte complex. No significant foraminal stenosis.C6-C7: Status post laminectomy. Disc osteophyte complex with large central bridging osteophyte, contributing to mild left foraminal stenosis and mild flattening of the ventral cord. C7-T1: Status post laminectomy. Small disc osteophyte complex. No significant foraminal stenosis.LUMBAR SPINE: For the purposes of numbering, there are 5 lumbar type vertebral bodies. The vertebral column alignment is within normal limits. The vertebral body heights are preserved. There is mild to moderate multilevel loss of disc height and disc desiccation. The vertebral bone marrow signal is unremarkable. The distal spinal cord and conus are within normal limits with the conus terminating at the L1 level. There is posterior soft tissue edema at the L3-L5 levels. There is a 39 mm left renal cyst.T12-L1: Small central disc protrusion. No significant spinal canal or foraminal stenosis.L1-L2: No significant disc bulge, spinal canal or foraminal stenosis.L2-L3: There is central and paracentral disk extrusion with mild inferior migration of approximately 10 mm and bilateral facet degeneration, contributing to mild spinal canal stenosis and mild bilateral foraminal stenosis. L3-L4: Status post laminectomy. Disc bulge with and bilateral facet degeneration, contributing to mild spinal canal narrowing in the transverse dimension and mild to moderate bilateral foraminal stenosis. L4-L5: Status post laminectomy. Disc bulge with and bilateral facet degeneration, contributing to mild to moderate bilateral foraminal stenosis. L5-S1: Disc bulge with and bilateral facet degeneration, contributing to moderate right and mild left foraminal stenosis.

Output: 1. Status post anterior spinal fusion with decompressive laminectomies from C3 to C7. 2. Degenerative changes of the cervical spine with large posterior bridging osteophytes at C3-C4 and C6-C7. There is mild impression on the ventral cord at the left C3-4 and bilateral C6-C7 levels. No high-grade spinal canal stenosis. Foraminal narrowing as detailed above.3. Post-operative changes of the lumbar spine without residual high-grade spinal canal stenosis. There is expected enhancement involving the paraspinous and dorsal epidural soft tissues.4. Degenerative changes of the lumbar spine including disc extrusion at L2-L3, contributing to mild spinal canal stenosis and mild bilateral foraminal stenosis. Additional levels as above.5. 10 mm nodule in the left thyroid lobe, which may be further evaluated with ultrasound as clinically warranted.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: 70-year-old female with history of pancreatitis and pancreatic IPMN ABDOMEN:LIVER, BILIARY TRACT: Status post cholecystectomy. Mild intrahepatic biliary ductal dilatation.SPLEEN: T2 hyperintense lesions in the liver.PANCREAS: Resolution of pancreatitis. Focal enlargement of the pancreatic tail is not significantly changed.Appropriate response to secretin. No main pancreatic duct dilatation. There is a 3 mm focal cystic lesion with communication to the main pancreatic duct compatible with an IPMN, decreased in size when compared to the prior examination. ADRENAL GLANDS: Nodular left adrenal gland. KIDNEYS, URETERS: Renal cyst in the right kidney.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Small gastric diverticulum is present. BONES, SOFT TISSUES: Leftward curvature of the lumbar spine. Right T10 perineural cyst.OTHER: No significant abnormality noted.

Output: 1.Interval decrease in size of a cystic lesion with identifiable communication with the main pancreatic duct compatible with a sidebranch IPMN.2.Resolution of pancreatitis. No evidence of complication.


Instruction: Generate impression based on findings.

Input: Behavioral/memory change. There is no evidence of intracranial hemorrhage, mass, or acute infarct. There is mild scattered cerebral white matter T2 hyperintensity. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The skull, mastoid air cells, and scalp soft tissues are grossly unremarkable. There is a right lens implant. There is cosmetic filler material within the bilateral nasolabial fold regions and cheeks. There is mucosal thickening and secretions in the left maxillary sinus. There is a small pannus posterior to the dens.

Output: Mild scattered cerebral white matter T2 hyperintensity is nonspecific but may represent chronic small vessel ischemic disease. Otherwise, no evidence of acute intracranial hemorrhage, mass, or acute infarct.


Instruction: Generate impression based on findings.

Input: Pain and cellulitis There is diffuse subcutaneous edema and skin thickening of the lower extremities, right greater than left. There is no evidence of osteomyelitis. Mild enhancement of the subcutaneous tissues represents soft tissue inflammation but there is no focal fluid collection. There is mild atrophy of the lower extremity musculature.

Output: Diffuse subcutaneous edema without evidence of osteomyelitis or focal fluid collection.


Instruction: Generate impression based on findings.

Input: MS, bladder dysfunction The thoracic vertebral bodies are appropriate in the overall alignment and height. The thoracic spinal cord has normal signal characteristics and overall morphology. There is no compromise of thoracic spinal canal or exiting nerve roots. No abnormal enhancing lesions are identified in the thoracic spine.There is a high signal focus within the left posterolateral aspect of the T4 vertebral body identified on T2-weighted imaging. This is isointense to the rest vertebral body on T1 displays contrast enhancement following contrast administration. It measures 14 x 8 mm axial dimensions. There is a similar-appearing lesion present at C7 which can be identified on c-spine MRI from 2013.

Output: 1.There is a lesion within the T4 vertebral body which is suspected to represent an atypical hemangioma in the absence of known primary tumor. A similar lesion is present at C7 which has been previously identified on MRIs dating back to 2013. A follow-up exam would help confirm this. Alternatively a CT scan may help further assess this.2.No thoracic spinal cord lesion is appreciated to suggest demyelinating lesion in the thoracic spinal cord.


Instruction: Generate impression based on findings.

Input: 59 year old female with a BRCA 1 mutation presents for screening MRI. Family history of breast cancer in her paternal grandmother at age 55, aunt at age 36 and cousin at age 48 There is scattered fibroglandular tissue in both breasts.Minimal parenchymal enhancement is noted bilaterally.No abnormal enhancement is seen in either breast. No abnormal lymph nodes are identified in either axillary region.

Output: No MRI evidence for malignancy. BIRADS: 1 - Negative.RECOMMENDATION: NS - Routine Screening Mammogram.


Instruction: Generate impression based on findings.

Input: A patient submitted outside study for review. Submitted for review are:1. Bilateral diagnostic mammogram dated 7/1/2016 and ultrasound dated 7/1/2016 performed at . For comparison,12/17/2015 incomplete tomo images are available. Bilateral diagnostic mammogram and ultrasound dated 7/1/2016:Heterogeneously dense breast parenchyma noted bilaterally. Surgical clips identified in the left breast 12:00 position posterior depth with area of postsurgical distortion. Benign calcifications seen in both breasts.Ultrasound demonstrated an indeterminate hypoechoic area slightly taller than wide with spiculated margins in the left breast 12:00 position 7 cm from the nipple that measures 6 x 4 x 7 mm. A second lesion is identified in the left breast 12:00 position 3 cm from the nipple that measures 7 x 5 x 4 mm in the anterior depth.No abnormal axillary lymph nodes identified in the axillary region. No suspicious masses, or calcifications identified in both breasts.Subsequent MRI guided biopsy of 2 sites in the left breast performed. Diagnostic MRI is not submitted.

Output: Mammographically occult, sonographically detected 2 indeterminate masses in the left breast 12:00 position. These lesions were subsequently biopsied under MRI guidance. Diagnostic MRI has not been submitted.BIRADS: 6 - Known cancer.RECOMMENDATION: T - Take Appropriate Action - No Letter.


Instruction: Generate impression based on findings.

Input: 31-year-old man with seizure yesterday. Known seizure history. Fell with trauma and contusion to left eye. There is no evidence of intracranial hemorrhage, mass or edema. Right temporal encephalomalacia is present with ex vacuo dilatation of the trigone of the right lateral ventricle -- this finding has been previously evaluated with MRI and is stable. The ventricles and basal cisterns are otherwise normal in size and configuration.Findings of left orbit trauma are partially visualized including blowout fracture of the lamina papyracea with herniation of orbital fat into the left ethmoid air cells, thickening of the medial rectus muscle, and orbital emphysema. The visualized paranasal sinuses and mastoid air cells are otherwise normally pneumatized.

Output: 1. Partially visualized findings of the left orbit trauma including medial wall fracture. If clinically appropriate, consider dedicated orbital CT.2. No CT findings of intracranial traumatic injury.


Instruction: Generate impression based on findings.

Input: MRI findings: There is no diffusion abnormality to suggest acute ischemia. No evidence of intracranial hemorrhage. There is no abnormal enhancement in the bilateral cavernous sinuses. Bilateral orbits and chiasm are grossly unremarkable. There is mild global parenchymal volume loss. There is no midline shift or mass effect. There are scattered punctate foci and confluent areas of abnormal T2/FLAIR hyperintensity within the periventricular and subcortical white matter as well as the pons, consistent with moderate chronic small vessel ischemic changes. Incidentally noted is partially empty sella, normal variant. No extra-axial fluid collection is identified. There is a tiny maxillary mucous retention cyst, otherwise paranasal sinuses are clear. The visualized portions of the orbit is unremarkable.MRA findings: The intracranial internal carotid arteries demonstrate no significant stenosis. The middle and anterior cerebral arteries also demonstrate no significant stenosis.There is mild irregularity of the basilar artery, likely related to mild atherosclerotic changes. Otherwise, the basilar artery is patent without evidence of high-grade stenosis or aneurysm. P1 segment of right posterior cerebral artery is hypoplastic with the right PCA predominantly fetal in origin. The left PCA is unremarkable. The right vertebral artery is normal in course and caliber. The V4 segment of the left vertebral artery is small with the partially visualized V3 segment of the left vertebral artery appearing larger indicating that there is likely moderate stenosis involving the left V4 segment rather than hypoplasia.

Output: 1. No intracranial mass or mass effect. Moderate small vessel ischemic changes including involvement of pons. No findings to suggest acute ischemia.2. No significant stenosis involving the basilar artery. There is moderate stenosis suspected involving the left V4 segment. Otherwise no significant stenosis in the anterior or posterior circulations.


Instruction: Generate impression based on findings.

Input: 64-year-old male with altered mental status and weakness Redemonstrated are multiple small foci of hyperintensity on diffusion weighted images in the anterior right paramedian medulla, right middle cerebellar peduncle, left mid and posterior temporal white matter, right cerebral peduncle, midline splenium of corpus callosum, splenium of corpus callosum and several larger lesions in bilateral subcortical and periventricular white matter of the cerebral hemispheres, unchanged in appearance. Several demonstrate tiny internal signal void suggestive of vasculature. As before, a tiny right anterior medullary lesion demonstrates restricted diffusion and consistent with acute ischemia. The remaining lesions lesions are well visualized on FLAIR and T2-weighted images as well-demarcated foci of hyperintensity. Several also demonstrate T1 hypointensity. Also redemonstrated are multiple ill-defined foci of FLAIR hyperintensity in bilateral middle cerebral peduncles, diffusely in the pons and a focus of hemorrhagic encephalomalacia in the right cerebellum. Many of these lesions are highly suggestive of chronic ischemic changes however possibility of overlapping chronic demyelinating disease cannot be entirely excluded. None demonstrate abnormal contrast enhancement.As before there is slight prominence of cortical sulci and supratentorial ventricular system for patient's stated age. No evidence of midline shift.Flow voids within bilateral internal carotid arteries , bilateral anterior and middle cerebral arteries are identified. Small caliber bilateral vertebrals and basilar artery is noted. As noted before, there is abnormal signal intensity of the left intracranial vertebral artery which could be artifactual or as a result of vascular lumen compromise.Unremarkable barium and orbits. Left maxillary sinusitis is unchanged and unremarkable other paranasal sinuses are noted.

Output: 1.Diffusion-weighted images demonstrate a single tiny focus of restricted diffusion in the right anterior paramedian medulla of acute ischemia, unchanged. As noted before, there is abnormal signal intensity of the left intracranial vertebral artery which could be artifactual or as a result of vascular lumen compromise.2.None of the many additional supratentorial and infratentorial foci of diffusion/T2 hyperintensity, without restricted diffusion, demonstrate abnormal contrast enhancement. These findings remain concerning for demyelinating disease given lesional morphology and locations. Other differential considerations remain possible, but are more rare and less likely, such as ADEM, Susac syndrome, vasculitides, or other etiologies if the patient is HIV positive.3.Additionally patchy foci of FLAIR hyperintensity is noted in the periventricular and sub-cortical white matter, pons, bilateral middle cerebellar peduncles, corpus callosum and right cerebellum as detailed above which may represent superimposed chronic small vessel ischemic disease, although findings of the aforementioned processes mentioned in number two may also represent a primary source for these findings.


Instruction: Generate impression based on findings.

Input: History of concussions with migraines without aura. There is a small nodular thickening at the right ventricular atrium which follows the signal of cortex with an associated radial migration line extending peripherally. There is no evidence of intracranial hemorrhage, mass effect, or acute infarct. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The skull and extracranial soft tissues are unremarkable.

Output: Small cortical heterotopia suspected at the right ventricular atrium. The relevance of this finding to patient's complaint is uncertain. No other findings to account for her symptoms.


Instruction: Generate impression based on findings.

Input: 80 yo female with neurogenic claudication, back pain and leg pain. Five lumbar type vertebral bodies are presumed to be present. Vertebral body heights are within normal limits. There is mild retrolisthesis of L4 and L5. Alignment is otherwise maintained. Bone marrow signal is benign with prominent type I Modic/edematous bone marrow signal changes involving the inferior L4 and superior L5 endplates. The conus medullaris is normal in position.Multilevel degenerative changes are seen, as described below:L1-L2: No significant disc disease. No spinal canal or neural foraminal stenosis.L2-L3: Mild disk desiccation and bulge and ligamentum flavum thickening. Minimal spinal canal stenosis. Minimal bilateral neural foraminal narrowing.L3-L4: There is loss of disk height with mild T2 hyperintensity likely on a degenerative basis. There is severe spinal canal stenosis related to disk bulge, bilateral ligamentum flavum thickening, and facet arthropathy. There is moderate right and moderate to severe left neural foraminal stenosis.L4-L5: There is loss of disk height with minimal T2 hyperintensity likely on a degenerative basis. There is marked spinal canal stenosis related to right central and foraminal disk extrusion, facet arthropathy, and ligamentum flavum thickening. There is severe right neural foraminal stenosis and mild left neural foramina narrowing.L5-S1: Minimal disk bulge, eccentric to the right with minimal right neural foraminal narrowing. Otherwise no significant spinal canal or left neural foramina narrowing. Multiple facet arthropathy with mild distention of the facet joints. Small bilateral renal cysts. Paraspinous soft tissues are within normal limits.

Output: 1. Multilevel degenerative changes which are advanced at L3-L4 and L4-L5. There is severe spinal canal stenosis at L3-L4 and L4-L5.2. Severe right L4-L5 neural foraminal stenosis and at least moderate bilaterally at L3-L4 , as detailed above.3. Mild retrolisthesis of L4 and L5.


Instruction: Generate impression based on findings.

Input: History of rectal cancer status post chemoradiation therapy. PELVIS:UTERUS, ADNEXA: The uterus is lobular in contour and enlarged secondary to numerous well-defined hypointense masses compatible with numerous fibroids. The endometrium is not significantly thickened. The adnexa are unremarkable.BLADDER: The bladder is normally distended without a focal abnormality.There is abnormal marked circumferential T2 weighted mildly hyperintense thickening of the urethra extending from the bladder base for 2.4 cm with the ureter measuring up to 1.8 x 1.6 cm (series 401/16), suspicious for malignancy. LYMPH NODES: Interval near complete resolution of the mesorectal lymphadenopathy with small lymph nodes measuring less than 1 to 2 mm in short axis. (Series 401/27).BOWEL, MESENTERY: There is asymmetric wall thickening of the lower anterior rectum measuring up to 2.6 x 0.9 x 2.9 cm (series 401/15 and series 501/33), significantly decreased in size from the prior study. The asymmetric thickening is intermediate and markedly low signal intensity on T2-weighted imaging compatible with residual tumor and/or postradiation therapeutic changes. There is no restricted diffusion associated with the mass or definite postcontrast enhancement. There is mild irregularity of the adjacent serosal surface but no definite invasion into the adjacent vaginal wall, similar to prior.BONES, SOFT TISSUES: Note is made of grade 1/2 anterolisthesis of L5 relative to S1.OTHER: No significant abnormality noted.

Output: 1.Interval marked decrease in size of the low rectal tumor with persistent asymmetric wall thickening of the anterior lower rectal wall demonstrating intermediate and markedly low T2-weighted signal intensity compatible with a combination of residual and/or postradiation therapeutic changes. Marked interval decrease in the mesorectal lymphadenopathy.2.Abnormal marked circumferential thickening of the urethra is suspicious for malignancy until proven otherwise. Tissue sampling is recommended. This was relayed to Dr. David Caba (surgery) at 1345 on 12/14/2015.3.Numerous uterine fibroids.


Instruction: Generate impression based on findings.

Input: Female, 24 years old, with headache and tremor. Concern for CADASIL. Diffusion imaging is unremarkable. A single focus of nonspecific FLAIR hyperintensity is seen within the orbital gyrus of the left inferior frontal lobe. No other significant parenchymal signal abnormality, edema or mass effect is observed. No acute intracranial hemorrhage or any abnormal extra-axial fluid collections are seen. The ventricles are normal in size and morphology. There may be a small cystic structure within the posterior aspect of the sella, incompletely evaluated on this exam. The osseous structures of skull show normal signal characteristics. A mucous retention cyst is present in the right maxillary sinus.

Output: 1.No findings are seen to account for the patient's symptoms. In particular, no imaging evidence of CADASIL is present.2.There appears to be a small cystic structure within the posterior aspect of the sella. This lesion is incompletely evaluated on the present study, but could represent a Rathke cleft cyst or some other intrinsic pituitary lesion. If clinical concern warrants, dedicated pituitary imaging can be considered.


Instruction: Generate impression based on findings.

Input: There are postsurgical findings related to right frontal lobe tumor resection. There is increased posterior of the peripherally enhancing T2 hyperintense tumor in the bilateral anterior frontal lobes and corpus callosum, particularly on the right side with diffuse diffusion restriction and edema. Otherwise, relative cerebral blood volume in the region of the soft tissue is not significantly elevated. There is mild volume loss in the right temporal lobe and ex vacuo dilatation of the anterior and of the right lateral ventricle. The third ventricle remains dilated. There is no evidence of acute territorial infarction. The skull and extracranial soft tissues are unchanged.

Output: Post-treatment findings in the frontal region with interval increased posterior extension of tumor involving the bilateral frontal lobes and corpus callosum, particularly on the right side, with associated confluent restricted diffusion and edema. This may represent tumor progression perhaps with superimposed treatment effects.


Instruction: Generate impression based on findings.

Input: Male, 15 years old, with Chiari malformation. Evaluate for syrinx and for tethered cord. The cerebellar tonsils are pointed and descend 7 mm below the level of the foramen magnum. There is crowding at the level of the posterior foramen magnum. Robust biphasic CSF flow is seen along the anterior brainstem through the foramen magnum. Minimal CSF flow is seen posteriorly and along the cervical tonsils.There is a normal complement of vertebral bodies. No evidence of any segmentation anomaly is seen. Spinal alignment is anatomic. Vertebral body morphology and signal characteristics are within normal limits. The intervertebral discs are normal. No significant compromise of the spinal canal or neural foramina is noted.The visualized spinal cord demonstrates normal signal intensity and morphology throughout. No evidence of syrinx formation is seen. The conus tip terminates at the L1 level which is normal. The nerve roots of the cauda equina disperse evenly through the thecal sac. No intraspinal mass lesion or fibrofatty infiltration of the filum terminale is seen. No epidural abnormalities are suspected. On prone imaging, a mild anterior displacement of the conus and cauda equina nerve roots is demonstrated.

Output: 1.Findings compatible with Chiari I malformation.2.No evidence of syrinx formation or any findings to suggest tethered cord.


Instruction: Generate impression based on findings.

Input: Weakness and numbness. Brain: The anterior part of the head is partly obscured by dental brace artifact. Within this limitation, there is no evidence of intracranial hemorrhage, mass, or acute infarct. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.Cervical Spine: The vertebral column alignment is within normal limits. The vertebral body and disc space heights are preserved. The vertebral bone marrow signal is unremarkable. There is no significant spinal canal stenosis. The spinal cord displays normal signal and morphology. The paravertebral soft tissues are unremarkable.

Output: 1. No evidence of acute intracranial hemorrhage, mass, or acute infarct, although the exam is partly degraded by dental brace artifact.2. No evidence of cervical spinal cord compression or lesions.


Instruction: Generate impression based on findings.

Input: Evaluate for PSC. Elevated alkaline phosphatase. ABDOMEN:LIVER, BILIARY TRACT: No significant abnormality noted.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Retroaortic left renal vein, a normal variant. No hydronephrosis or suspicious renal lesion.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: Unremarkable MRCP. No biliary ductal dilatation. No evidence of dominant or flow-limiting biliary stricture.


Instruction: Generate impression based on findings.

Input: Clinical question: Status post cavernoma bleed. Signs and symptoms: Cavernoma. Pre-and post-enhanced brain MRI:Diffusion-weighted images are negative.There is a focus of susceptibility indeed a right centrum semi-ovale with minimal blooming. On T2 weighted images the lesion has characteristic appearance of a cavernous malformation with a rim and internal septations of T2 hypointensity and loculated internal T2 hyperintensity as well as mild surrounding hemosiderin staining parenchyma. There is no evidence of surrounding edema or convincing evidence of hemorrhage. This mass abuts the ventricular wall. This lesion measures approximately 10 x 6.5-mm in transaxial dimensions.On susceptibility MRI series # 901 images 66 through 73 there is suggestion of an additional small cavernoma in the anterior tip of the left temporal lobe measuring at 6-mm in transaxial dimensions. This finding cannot be confirmed with certainty on any of the other MRI sequences.Flair and T2-weighted images demonstrate few tiny foci of hyperintensity in the subcortical and periventricular white matter, a single focus in the posterior limb of left internal capsule and left pos. Although nonspecific this appearance in proper clinical setting could represent chronic small vessel ischemic strokes.Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and brain myelination otherwise.Post-enhanced images demonstrate no evidence of abnormal enhancement and including the right hemispheric cavernoma. Signal void of major intracranial arterial branches are identified.

Output: 1.Negative diffusion weighted images.2.A right centrum semi-ovale cavernoma measuring at 10 x 6.5-mm without evidence of hemorrhage or surrounding edema.3.A second 6mm cavernoma suspected in the anterior left temporal lobe on susceptibility MR images as detailed.4.Few punctate foci of flair hyperintensity in subcortical/periventricular white matter, posterior limb of left internal capsule and left paramedian pons which could represent minimal chronic small vessel ischemic strokes in proper clinical setting.


Instruction: Generate impression based on findings.

Input: 46 year-old female with history of right foot pain between second and third MTP joint. A marker was placed on the plantar aspect of the foot between the first and second MTP. Moderate osteoarthritis affects the first MTP joint with subchondral cysts present at the metatarsal head. There is a bipartite medial sesamoid bone. There is minimal intermediate signal intensity within the proximal pole of the sesamoid which is of indeterminant significance. The flexor hallucis longus tendon is normal. The sesamoidal phalangeal and sesamoidal-phalangeal ligaments are intact. Mild osteoarthritis affects scattered interphalangeal joints. Bone marrow signal intensity is within normal limits. There is no evidence of stress fracture. There is a mild amount of edema in the plantar aspect of the proximal phalanx of the second toe, however the underlying tendon appears normal. No evidence of Morton neuroma.

Output: Moderate osteoarthritis of the first MTP joint, however we see no stress fracture or Morton's neuroma.


Instruction: Generate impression based on findings.

Input: History of glioma status post surgery. MRI for RT treatment planning. Recent postoperative findings related to biopsy of an irregularly rim-enhancing mass centered in the right temporal stem and posterior right insula that measures up to approximately 3 cm, with multiple adjacent smaller peripherally-enhancing nodules and extensive surrounding edema involving right thalamus, right middle cerebral peduncle, right basal ganglia, and right parietal lobe. There are T1 hyperintense subacute blood products within the central portion of the otherwise necrotic tumor. There are areas of T2 hyperintensity in the right parietal lobe white matter without corresponding enhancement. There is effacement of the temporal horn of the right lateral ventricle and most of the third ventricle, but mild prominence of the bodies of the lateral ventricles. There is mild midline shift to the left, but no herniation. There is no evidence of acute infarct. The major cerebral flow voids are intact. The orbits, skull, and scalp soft tissues are grossly unremarkable. There are retention cysts in the left maxillary sinuses.

Output: Recent postoperative findings related to biopsy of the dominant mass centered in the right temporal stem and posterior right insula, with multiple satellite lesions, which are compatible with a high grade glial neoplasm.


Instruction: Generate impression based on findings.

Input: Headaches, history of multiple myeloma. Brain: Compared to prior brain MRI from 11/23/2013, there is been marked interval decrease in size of previously seen extra-axial lesion along the medial/posterior middle cranial fossa. There is small focus of residual enhancement along the posterior aspect of the left Meckel's cave measuring 9 x 17 x 12 mm. There is no abnormal parenchymal or meningeal enhancement on the current study. No new intracranial mass or mass-effect. No hydrocephalus or extra-axial collections. No evidence of acute ischemia or hemorrhage.Compared to 11/23/2013, there is been marked interval increase in areas of abnormal T1 signal, enhancement, and diffusion restriction throughout the calvarium. Marrow signal abnormality involves the skull base including the clivus and occipital condyles.Cervical spine:Vertebral body heights in the cervical spine are normal. Alignment is normal. There is diffuse slightly heterogeneous low T1 marrow signal throughout the cervical spine which is markedly progressed since 6/18/2014. There are new more focal small enhancing lesions, relatively more prominent at C7, T1, and T2 levels, compared to prior post gadolinium study from 3/20/2014. No evidence of compression fracture or epidural tumor. Cervical cord is normal in signal and contour.Osseous and soft tissue lesion at the right C1 to C3 level is markedly decreased when compared to remote MRI studies from 2013. No new soft tissue masses are seen within the cervical spine. There are mild multilevel degenerative changes including small disk osteophyte complex at C5-C6 and uncovertebral hypertrophy with minimal right neural foramina narrowing. There is no significant spinal canal or neural foramina stenosis otherwise in the cervical spine.

Output: 1. Compared to brain MRI from 11/23/2013, there is been marked interval decrease in size of previously seen extra-axial lesion along the left medial posterior middle cranial fossa with small residual focus of extra axial enhancement measuring 9 x 17 x 12 mm posterior to the left Meckel's cave. No new intracranial mass or mass effect.2. Compared to prior brain MRI, there is been marked interval increase in diffuse heterogeneous marrow signal abnormality. There is also marked progression of diffuse heterogeneous marrow signal abnormality in the cervical spine. There are new more focal small enhancing lesions, relatively more prominent at C7, T1, and T2 levels, compared to 3/20/2014. While the more diffuse changes may be related to treatment related marrow reconversion, overall findings are suspicious for disease progression and compatible with findings of progression seen on most recent PET from 9/12/2014.3. MRI of the cervical spine demonstrates no large lesions, compression fractures, or epidural tumor. There is no significant spinal canal or neural foramina stenosis.


Instruction: Generate impression based on findings.

Input: Reason: abnormality History: swelling and painful movement The fourth and fifth proximal interphalangeal joints are held in flexion. There is apparent fluid within the flexor digitorum profundus tendon sheath of the fourth and fifth digits indicating a tenosynovitis (best seen on sagittal STIR sequence, image 5 series 12). The flexor and extensor tendons appear intact. There is suboptimal evaluation of the pulleys of the fourth and fifth digits due to the inability to optimally position the patient due to the aforementioned flexion deformities. There is increased signal abnormality within the head of the fifth metacarpal which appears to be linear on coronal T1 weighted sequences which is nonspecific but may be posttraumatic in etiology in the correct clinical setting. There is a small amount of fluid within the first through fifth MCP joints which is not necessarily of any clinical significance. No additional bone marrow signal abnormality is identified. The imaged musculature of the hand is otherwise unremarkable.

Output: 1. Flexion deformity of the fourth and fifth fingers as described above. Findings indicating a tenosynovitis of the flexor digitorum profundus tendons of the fourth and fifth digits.2. Nonspecific bone marrow reactive change within the fifth metacarpal head may be posttraumatic in etiology. Dedicated hand radiographs are recommended for further evaluation. Infectious and inflammatory etiologies could be considered in the correct clinical context.


Instruction: Generate impression based on findings.

Input: Left arm pain. History of lymphoma (humerus). There is slight disorganization of the trabecular pattern of the mid humeral diaphysis that corresponds to the lesion seen on an MRI examination from 2015. The degree of lucency within the mid humeral diaphysis has perhaps decreased slightly when compared with the prior study, and I see no findings to suggest disease progression or fracture. Minimal osteoarthritis affects the glenohumeral and acromioclavicular joints. A tiny density in the soft tissues adjacent to the posterolateral aspect of the humeral head may represent calcific tendinosis of the rotator cuff, but is of uncertain current clinical significance.

Output: Poorly defined lucency within the mid humeral diaphysis likely corresponds to the presumably treated lymphomatous lesion seen on prior MRI, but I see no fracture or evidence of disease progression. Other findings as above.


Instruction: Generate impression based on findings.

Input: Diagnosis: Sciatica, right sideClinical question: pain with right sided sciatica Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild facet hypertrophy present at this level.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is a moderate degree of bilateral facet hypertrophy present at this level.At L3-4 there is no significant compromise to spinal canal or neural foramina. There is mild ligamentum flavum hypertrophy present at this level.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.

Output: There is no compromise to lumbar spinal canal or neural foramina. There are mild degenerative changes present in the lumbar spine.


Instruction: Generate impression based on findings.

Input: There are postoperative findings related to right frontotemporal approach for resection of a right parasellar meningioma. There is mild residual dural thickening and enhancement along the right anteromedial portion of the middle cranial fossa, lateral aspect of the cavernous sinus, and right posterior clivus that measures up to approximately 3 mm in thickness. There is a small amount of residual confluent T2 hyperintensity in the anterior right temporal lobe adjacent to the resection bed, which may represent encephalomalacia or gliosis. The ventricles and basal cisterns are unchanged in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.

Output: Postoperative findings related to resection of a right parasellar meningioma with what may represent a small amount of residual tumor versus residual reactive dural thickening in the resection bed.


Instruction: Generate impression based on findings.

Input: BRAIN: There are numerous, greater than 15, supratentorial nonenhancing white matter T2 hyperintensities lesions in the subcortical and periventricular white matter with involvement of the corpus callosum. While most of these lesions are unchanged, a linear lesion in the left precentral gyrus appears to have increased in size. Many of the lesions demonstrate T1 hypointensity. There is no evidence of acute cerebral infarct or mass effect. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids appear to be intact.ORBITS: There is no intraorbital signal abnormality, mass lesion, or abnormal enhancement. The optic apparatus appears to be intact. CERVICAL: There are new foci of high T2 signal in the cord posteriorly at C1 and T2-3 level. There is a stable to slight increase in size of the high T2 signal spinal cord lesion at the C2 level posteriorly. However, the lesion in the spinal cord at the C5 level is less conspicuous. There is no pathologic enhancement within the spinal cord. There is a eccentric right disc protrusion and uncovertebral hypertrophy at C5-6 that result in severe right neural foramen stenosis. There is no spinal stenosis or disc herniation at other levels of the cervical spine. There is mild straightening of the cervical spine alignment in the sagittal plane. There are cystic lesions in the midline posterior nasopharynx that measure up to 12 mm, which may represent a Thornwaldt and/or retention cysts.

Output: 1.Numerous (greater than 15) supratentorial white matter T2 hyperintense lesions are compatible with demyelination given history of multiple sclerosis. A linear lesion in the left precentral gyrus appear increased from the prior exam, while the other lesions appear to be stable. 2.No detectable lesions involving the optic apparatus.3.Two new demyelinating spinal cord lesions at C1 and T2-3 levels and an unchanged to slightly larger demyelinating lesion at C2 level, but involution of the lesion at C5 level.4.No enhancing demyelinating lesions in the brain or cervical spine.5.New severe right C5-6 neural foraminal stenosis due to right uncovertebral and disc degenerative changes.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: A patient submitted outside study for review. Submitted for review are digital mammographic images (3/31/15, 4/6/15, 10/9/15, 11/2/15), ultrasound images of right breast (10/12/15), images from ultrasound guided biopsy and postprocedural right mammographic images (11/2/2015), breast MRI (11/10/2015), ultrasound images of right breast (11/12/2015), images from stereotactic needle biopsy of right breast and postprocedural right mammographic images (11/19/2015) performed at Presence St. Joseph Medical Center. For comparison, digital mammographic images (1/11/14) are available. DIGITAL MAMMOGRAPHIC IMAGES (3/31/15, 4/6/15, 10/9/15, 11/2/15): The breast parenchyma is composed of scattered fibroglandular elements (BiRADS Density Category B), unchanged in pattern and distribution.In the right breast at lateral aspect around 9:00 position, there are pleomorphic calcifications, including fine linear type with a developing focal asymmetry. The calcifications are extending segmentally in discontiguous fashion, measuring 60 x 40 mm (AP x LR). The focal asymmetry is present at posterior aspect of these calcifications, measuring 11 mm. There is another asymmetry seen best on CC view at medial anterior aspect of the right breast measuring 7 mm.A circumscribed oval mass with multiple coarse benign-appearing calcifications is present at 12:00 position in the right breast, likely a fibroadenoma.No dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in left breast. ULTRASOUND IMAGES OF RIGHT BREAST (10/12/15):Ill-defined hypoechoic mass measuring 7 x 9 mm at 9:00 position with echogenic rim is detected, corresponding to the focal asymmetry seen on the mammogram at posterior aspect of the segmentally distributed calcifications.IMAGES FROM ULTRASOUND GUIDED BIOPSY AND POSTPROCEDURAL RIGHT MAMMOGRAPHIC IMAGES (11/2/2015):Ultrasound guided biopsy was performed for the mass at 9:00 position with an appropriate needle placement. Postprocedural mammograms demonstrate a marker clip (Hydromark) at the site of the focal asymmetry at 9:00 position in the right breast.Per outside radiology report, the result was malignant.BREAST MRI (11/10/2015):The study was performed with a protocol outlined in the outside report.There are 2 enhancing masses in the right breast, one at 9:00 position measuring 19 x 13 x 12 mm (AP x LR x CC), and the other at 3:00 position measuring 14 x 21 x 11 mm. The one at 9:00 position is proven carcinoma and the marker clip is present at the anterior aspect of this mass. Non-mass enhancement is present between the two masses, measuring 49 x 71 x 20 mm.No abnormal enhancement is seen in the left breast.No abnormal lymph nodes are present in either axilla.ULTRASOUND IMAGES OF RIGHT BREAST (11/12/2015):The study was performed as second look ultrasound to look for a correlate of MR detected mass at 3:00 position in the right breast. No sonographic correlate was detected in this study.IMAGES FROM STEREOTACTIC NEEDLE BIOPSY OF RIGHT BREAST AND POSTPROCEDURAL RIGHT MAMMOGRAPHIC IMAGES (11/19/2015):Stereotactic biopsy was performed for the asymmetry best seen on CC view at medial right breast, because the asymmetry is likely correlating to the MR detected mass at 3:00 position. Postprocedural mammograms demonstrate a marker clip at upper inner aspect of the right breast, near the site of the enhancing mass seen on the MRI. Distance between 2 clips is 135 mm on CC view.Per outside radiology report, the biopsy result was malignant; invasive ductal carcinoma.

Output: 1. Biopsy proven carcinoma in the right breast, 2 sites; one at 9:00 position and the other at 3:00 position. Mammograms demonstrate suspicious calcifications segmentally at lateral right breast and MRI demonstrates extensive non-mass enhancement between the two malignant masses in the right breast.2. No mammographic or MR evidence of malignancy in the left breast.3. No MR evidence of abnormal lymph nodes in either axilla.BIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter.


Instruction: Generate impression based on findings.

Input: Metastatic thyroid cancer with multiple bone mets, PET 6/29/15 with possible T12 thecal lesion Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. A low T1 and high T2 signal is seen in C4 vertebral body, which is nonenhancing.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or neural foramina.At C4-5 there is mild disc bulge and hypertrophy of the posterior ligament.At C5-6 there is mild bulge with no significant compromise to the spinal canal or neural foramina.At C6-7 there is mild disc bulge with no significant compromise to the spinal canal or neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.MRI thoracic spine:There are 11 rib bearing vertebrae and T12 hypoplastic rib in the right side. There are 4-type lumbar vertebrae present.The thoracic vertebral bodies are appropriate in the overall alignment and height. The thoracic spinal cord has normal signal characteristics and overall morphology. There is no compromise of thoracic spinal canal or exiting nerve roots. Lumbar spine:There are 11 rib bearing vertebrae and T12 hypoplastic rib in the right side. There are 4-type lumbar vertebrae present. There is T2 and STIR increased signal in the anterior inferior aspect of L2 and in the anterior superior aspect of L3.At L4-S1 there is loss of disc space height, disc desiccation and a diffuse disc bulge the fat surrounding the nerve roots at the lateral recess bilaterally is only partially effaced. The fat surrounding the exiting nerve roots within the neural foramina is effaced on the left side but not effaced on the right side.At L3-4 there is loss of disc space height and disc desiccation associated with the a disc bulge. There is mild narrowing of the neural foramina bilaterally. The fat surrounding the exiting nerve roots within the neural foramina is not effaced. There is only partial effacement of the fat at the lateral recesses bilaterally at this level.At L2-3 there is no significant compromise to the spinal canal or neural foramina. There are some endplate reactive changes present at this level associated with some loss of disc space height and disc desiccation.At L1-2 there is no significant compromise to spinal canal or neural foramina. There is mild disc bulge.At T12-L1 there is no significant compromise to spinal canal or neural foramina.

Output: 1.The lesion suspected to be present within the spinal canal at the T12 level is suggested on the the PET CT scan report from 6/29/2015 is not identified on the current exam.2.Please note that there are 11 rib-bearing vertebrae present and a hypoplastic rib on the right sided T12. There are only 4 nonrib-bearing lumbar vertebrae present. This affects enumeration of the thoracic and lumbar vertebrae.3.There is encroachment of the left-sided exiting nerve root at L4-S1 due to disc material which would affect the left L4 nerve root.


Instruction: Generate impression based on findings.

Input: Small cell lung cancer, refractory nausea and vomiting. Evaluate for metastasis. No evidence of intracranial metastatic disease. No abnormal parenchymal or meningeal enhancement. No intracranial mass or mass effect. No evidence of parenchymal edema. No midline shift or herniation. Again seen is extensive patchy T2 hyperintensity within the periventricular and subcortical white matter as well as the pons which is nonspecific but consistent with chronic small vessel ischemic disease. Ventricles and sulci are slightly prominent consistent with mild volume loss inappropriate for patient's advanced age. No evidence of acute ischemia or hemorrhage. No extra-axial collections. Multiple subcentimeter enhancing lesions are seen scattered in the calvarium which may represent osseous metastases. At least most of these appear to be unchanged since prior study but difficult to compare due to their small size. No large lesions or evidence of epidural extension of tumor.

Output: 1. No evidence of metastatic disease to the brain. No intracranial mas or mass effect.2. Multiple small enhancing foci are noted in the calvarium which are suspicious for osseous metastatic disease. No large destructive lesions. Bone scan may be considered for further assessment of extent of osseous metastatic disease if clinically indicated.3. Extensive chronic small vessel ischemic disease similar to prior.


Instruction: Generate impression based on findings.

Input: 49 years, Female, 1.5 yrs swallowing difficulty and hoarseness, normal neuro exam w/ some hyperreflexia No intracranial mass or mass-effect. No restricted diffusion to suggest acute ischemia. No intracranial hemorrhage. The ventricles are within normal limits in size and configuration. Cerebellar tonsils are borderline low measuring up to 5 mm below the foramen magnum without clear evidence of Chiari I. No significant crowding in the posterior fossa. Minimal foci of T2/FLAIR hyperintensity are seen in the white matter including the left frontal and left parietal lobe which are nonspecific. There is otherwise no significant parenchymal signal abnormality. No abnormal parenchymal or meningeal enhancement. Major flow-voids are preserved.Sella and orbits are grossly within normal limits. Paranasal sinuses and mastoid air cells are grossly clear. No focal lesions are seen in the calvarium. There is nonspecific T1 hypointensity in the bone marrow which is nonspecific.

Output: 1. Brain MRI is essentially unremarkable for patient's age. There are minimal foci of T2/FLAIR hyperintensity in the white matter which are nonspecific and not unusual for patient's age. There is also mild cerebellar tonsillar ectopia without significant crowding in the posterior fossa or clear evidence of Chiari I.2. Nonspecific T1 hypointensity of the bone marrow which can be seen with a variety of hematologic conditions such as chronic anemia.


Instruction: Generate impression based on findings.

Input: Male, 54 years old, with sensory deficit below the nipples. A single nonspecific focus of T2 hyperintensity is seen within the white matter of the left inferior frontal lobe. Otherwise the cerebral and cerebellar hemispheres and brainstem show normal signal intensity and morphology. No restricted diffusion is seen. No pathologic parenchymal or extra-axial enhancement is detected.No evidence of parenchymal edema, mass, or mass effect is seen. There is no evidence of intracranial hemorrhage or abnormal extra-axial fluid. The ventricular system is normal in caliber and morphology.

Output: No specific findings are seen to account for the patient's symptoms.


Instruction: Generate impression based on findings.

Input: 82 year old male with multiple myeloma and weakness. Evaluate for spinal lesions or cord compression. No evidence of spinal cord compression. There are subtle apparent punctate foci of increased STIR signal in the cervical spinal cord, for instance posterior to the C3-4 vertebral body, which are presumably artifactual and are not well assessed.Multiple small T1 hypointense lesions are seen at multiple vertebral levels including T6, T8 and T9, which are nonspecific and may be related to patient's history of multiple myeloma. There are no large lesions.The oblique T7 vertebral body fracture is again seen without significant loss of height or evidence of edema associated with the fracture to suggest that the fracture is recent. There is normal height of the remaining vertebral bodies in the spine. There is is loss of the cervical lordosis and increased kyphosis of the thoracic spine. There is grade 1 anterolisthesis of L4 on L5 and minimal retrolisthesis of L5 on S1. Multilevel degenerative changes are also seen most prominent in the cervical and lower lumbar spine, which contributes to suspected mild spinal canal stenosis at the L2-3 and L3-4 levels.

Output: 1.This is a limited exam specific for the exclusion of cord compression only and does not exclude more subtle lesions such as intrinsic cord abnormalities. No cord compression is identified.2.Scattered small T1 hypointense ossific lesions in the thoracic spine, which may relate to patient's history of multiple myeloma. There are no large lesions.3.Oblique linear fracture involving the T7 vertebral body without edema to suggest acuity or significant loss of height.Due to the screening nature of this protocol details are not as evident on imaging as dedicated protocols of the spine.


Instruction: Generate impression based on findings.

Input: Evaluate for the growth of NSCLC brain metastases. There are postoperative findings in the left parietal lobe with persistent confluent T2 hyperintensity surrounding the resection cavity, but no evidence of recurrent tumor in this area. However, punctate foci of enhancement and susceptibility effect in the medial temporal lobe anteriorly, with surrounding confluent T2 hyperintensity. There is an unchanged focus of encephalomalacia in the left caudate nucleus region and areas of encephalomalacia in the bilateral cerebellar hemispheres, but no evidence of acute infarct. The ventricles and basal cisterns are unchanged in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are unchanged.

Output: 1. Punctate foci of enhancement in the medial temporal lobe anteriorly may represent hemorrhagic metastasis. 2. Postoperative findings in the left parietal lobe without evidence of recurrent tumor in this area. 3. Chronic left caudate and bilateral cerebellar hemisphere infarcts.


Instruction: Generate impression based on findings.

Input: Radiculopathy, lumbar region [M54.16], Reason for Study: ^Reason: stenosis? History: increasing L foot pain, s/p extensive surgery 2 years ago For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1.Redemonstration of posterior fusion status between L3 and L4 as well as L5 laminectomy and L45 and L5S1 anterior fusion.Previously shown operation site fluid collections especially at the level of L5 laminectomy site has been significantly decreased since prior scan [29.3mm (AP) x 21.7mm (CC) x 11.1mm (RL), was 5.6cm x 4.5cm]. The T2 images show multiple internal linear signal intensities which may indicate internal septae formation. The laminectomy site as well as adjacent muscle show enhancement including the peripheral aspect of the residual fluid signal intensity lesion. Soft tissue enhancement around the L3 and L4 pedicular screws are also seen, no significant interval change since prior scan.Rotational deformity of the L4, L5 and S1 vertebral bodies, unchanged since prior scan.The signal of the visualized cord is normal. The conus medullaris terminates at the T12-L1 level. Degenerative changes are specified by the intervertebral level as follows: T12-L1: broad based disc bulging central to left with disc dessication. No neuroforaminal narrowing or spinal stenosis, unchanged since prior scan. L1-L2: Diffuse bulging of disc which abuts thecal sac with bilateral ligamentum flavum thickening, unchanged since prior scan. L2-L3: Minimal facet hypertrophy, unchanged since prior scan. L3-L4: Broad based disc bulge toward left neural foramen, unchanged since prior scan. L4-L5: Broad based disc bulge toward left side lateral recess which abuts thecal sac, unchanged since prior scan. L5-S1: Redemonstration of bilateral laminectomy defects. Deformed L5 and S1 spinal canal and bilateral neural foramen are again seen, no significant interval change since prior scan.

Output: 1. Interval significant decrease of L5 laminectomy site fluid collection lesion size with evidence of internal septae formation.2. Multilevel degenerative and congenital alignment deformity are again seen, unchanged since prior scan.3. No evidence of instrumentation related unusual finding.


Instruction: Generate impression based on findings.

Input: Reason: r/o stroke History: as above. Malaise and fatigue 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.There is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses demonstrate minor mucosal thickening. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.

Output: 1.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 2.No evidence for acute ischemic cerebral infarction is appreciated.


Instruction: Generate impression based on findings.

Input: 89-year-old female status post exploratory laparotomy for lysis of adhesions for small bowel obstruction now with right facial droop and tongue deviation. There is no evidence of intracranial hemorrhage, mass or edema. Multiple patchy hypodensities in a periventricular distribution throughout the subcortical white matter consistent with advanced small vessel disease. Small vessel disease of undetermined age may be further evaluated with an MRI if there is clinical suspicion of acute ischemia. Prominence of the sulci and ventricles are proportional. The skull base is radiographically normal. The calvaria demonstrates multiple patchy foci of high density and cortical thickening consistent with Paget's disease. The visualized paranasal sinuses and mastoid air cells are normally pneumatized.

Output: 1. Small vessel disease, age indeterminate. If there is clinical concern for acute ischemia, an MRI may be considered.2. Paget's disease affects the skull.


Instruction: Generate impression based on findings.

Input: History of left parotid region squamous cell carcinoma with radiation necrosis of the temporal bone status post resection and reconstruction 3 weeks ago now with concern for possible abscess/cerebritis History: fevers, chills, AMS. There are postoperative findings related to left lateral temporal bone resection with myocutaneous graft reconstruction. There is heterogeneous fluid within the anterior portion of the surgical bed, which extends to the overlying skin incision and measures approximately 25 mm in width, 15 mm anteroposteriorly, and 20 mm in height. There appears to be a defect in the left tegmen, with mild herniation of the inferior temporal lobe, where there is patchy cortical and subcortical T2 hyperintensity and enhancement, as well as diffuse, confluent T2 hyperintensity of the white matter. There is no large intracranial fluid collection or evidence of acute territorial infarction. There is mild enhancement of the left cochlea and cranial nerves in the left internal auditory canal. There also appears to be mild thickening and enhancement of a portion of the V3 segment of the left trigeminal nerve in the region of foramen ovale and mild asymmetric prominence of the left cavernous sinus. There are denervation changes in the left masticator and facial expression muscles. Low T1 and T2 bone marrow signal in the irregular left mandibular condyle may be attributable to degenerative changes with subchondral sclerosis. There is mucosal thickening and secretions in the left posterior ethmoid sinus and a small retention cyst in the right sphenoid sinus.

Output: 1. Postoperative findings related to left lateral temporal bone resection with myocutaneous graft reconstruction. There is heterogeneous fluid within the anterior portion of the surgical bed, which extends to the overlying skin incision and measures approximately 25 mm, which may represent s seroma with superimposed infection.2. Apparent defect in the left tegmen, with mild herniation of the inferior temporal lobe, where there is evidence of inflammatory changes, which may represent cerebritis superimposed upon underlying radiation necrosis.3. Mild enhancement of the left cochlea and cranial nerves in the left internal auditory canal may represent infectious and/or radiation-induced labyrinthitis and neuritis.4. Apparent mild thickening and enhancement of a portion of the V3 segment of the left trigeminal nerve in the region of foramen ovale and mild asymmetric prominence of the left cavernous sinus.


Instruction: Generate impression based on findings.

Input: Female, 58 years old, with low back pain and left-sided radiculopathy. Spinal alignment is anatomic. Mild anterior wedging of the L3 vertebral body is unchanged. The remaining vertebral bodies demonstrate normal height and morphology. No areas of concerning marrow replacement or marrow edema are detected.The visualized distal spinal cord, conus and nerve roots of the cauda equina are unremarkable except as discussed below. No epidural abnormalities are suspected. The lumbar spinal canal is congenitally slender to which prominence of the dorsal epidural fat contributes.L1-2: No significant spinal canal stenosis or neuroforaminal narrowing. L2-3: Mild facet arthropathy. Ligamentum flavum thickening. Minimal bulging disc. Mild spinal canal narrowing. Mild right foraminal narrowing. No interval changes. L3-4: Facet arthropathy. Ligamentum flavum thickening. Bulging disc. Moderate spinal canal narrowing with crowding of the cauda equina and near complete exclusion of CSF. Findings have progressed. Moderate bilateral foraminal narrowing is unchanged. L4-5: Facet arthropathy. Ligamentum flavum thickening. Bulging disc. Moderate spinal canal stenosis with crowding of the cauda equina and near complete exclusion of CSF. Findings have progressed. Moderate to severe bilateral foraminal narrowing, also slightly progressed. L5-S1: Facet arthropathy. Ligamentum flavum thickening. Bulging disc and osteophytic ridging. No significant spinal canal stenosis. Severe left foraminal narrowing with nerve root impingement. Severe right neuroforaminal narrowing with possible nerve root impingement. Findings are unchanged.

Output: 1.Mild worsening of degenerative disease is seen at L3-4 and L4-5 where spinal canal stenosis has progressed and there is crowding of the cauda equina.2.Severe bilateral neuroforaminal narrowing is redemonstrated at L5-S1, but particularly on the left where there is nerve root impingement. These abnormalities, however, have not significantly changed from prior.


Instruction: Generate impression based on findings.

Input: 27 year old female pregnant patient, 32 weeks gestational age, with area of placenta with concern for focal placenta accreta. Vaginal delivery in 2014 with retained placenta requiring D&C. PELVIS:UTERUS, ADNEXA: There is an intrauterine gestation with the placenta located anteriorly within the uterus. The placenta does not abut the cervix, no placenta previa. There is irregularity along the placenta/myometrial junction, particularly along the right anterolateral aspect of the uterus (image 18, series 4); placenta accreta is not excluded. Furthermore, the uterine myometrium and wall is thinned secondary to the gestation and abuts the anterior abdominal wall, which limits evaluation. No specific evidence of placental percreta. The uterus measures 20 x 10 x 30 cm.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: Grossly normal appearance of the fetus within the uterus, please refer to recent fetal ultrasound study for additional findings. A focus of signal void within the fetal bladder on a single sequence is likely related to flow artifact.

Output: Irregularity of the placental/myometrial junction along the right anterior aspect of the uterus; placenta accreta is not excluded. No MR findings to suggest placenta percreta.


Instruction: Generate impression based on findings.

Input: Clinical question: Rule out dural sinus thrombosis and assess Chiari. Signs and symptoms: Headaches and postural lightheadedness. CT of brain without the infusion:No evidence of hemorrhage, edema, mass-effect, midline shift or hydrocephalus is detected. Cortical sulci, ventricular system and all CSF cisterns remain within normal for patient stated age. Redemonstration of slight crowding of the cerebellar tonsils at the level of foramen magnum. No change since prior exam.CTA of intracranial circulation:Vertebral -- basilar system.There is normal visualization of bilateral vertebral arteries across the skull base (dominant left vertebral). Basilar artery, posterior cerebral arteries and superior cerebellar arteries are all within normal limits. No evidence of vascular lesion in particular aneurysm or any atherosclerotic stenosis is detected.Carotid system.Patent normal appearing internal carotid arteries across to skull base and in their supraclinoid portions. Anterior and middle cerebral arteries and their branches are well visualized and no evidence of vascular lesions of aneurysm or atherosclerotic disease is detected.CTV of the intracranial venous sinuses.Superior sagittal sinus, confluence of sinuses, bilateral transverse sinuses, sigmoid sinuses, jugular bulbs and proximal portion of bilateral internal jugular veins are within normal limits.There is normal visualization of bilateral internal cerebral veins, vein of Galen and straight sinus.On the reformatted MIP images both on sagittal and coronal plane low positioning of the cerebellar tonsils with effacement of subarachnoid space is noted. This is believed to represent ectopia of the cerebellar tonsil and not Chiari malformation due to its minimal protrusion through the foramina magnum. This finding can be further evaluated if clinically is indicated with an MRI of cervical spine and cranial/cervical junction as well as CSF flow study65 cc of Omnipaque 350 with the injection rate of 4.5 CC/sec was utilized for the above studies.

Output: 1.Unremarkable CTA of the intracranial circulation.2.Unremarkable CT of the of intracranial venous sinuses.3.Minimally ectopic cerebellar tonsils. Correlate with history and neurological findings and if clinically indicated further follow-up with MRI of cranial cervical junction and with CSF the study across the foramen magnum.4.Negative CT of brain without the infusion and stable since prior study.


Instruction: Generate impression based on findings.

Input: Shoulder pain and difficulty with external rotation ROTATOR CUFF: There is increased signal and thickening of both the infra- and supraspinatus tendons consistent with moderate tendinosis. At the junction of the superior and infraspinatus tendons is a 1 cm linear focus of increased signal intensity at the rotator cuff insertion indicating an interstitial tear. This tear does not appear to extend to either articular surface. A small degenerative cyst is seen in the underlying greater tuberosity.More posteriorly, there is longitudinal signal intensity extending longitudinally along the myotendinous junction of the infraspinatus tendon representing an additional interstitial tear. The tear measures 1.5 cm in the longitudinal dimension and there is no definite extension to the bursal surface.Evaluation of the subscapularis tendon is somewhat limited by internal rotation. The distal fibers of the subscapularis tendon also demonstrate thickening and increased signal, consistent with tendinosis.The teres minor tendon appears normal.The muscles of the rotator cuff are normal. SUPRASPINATUS OUTLET: An os acromiale is present and there are mild osteoarthritic changes of the acromioclavicular joint. There is no subacromial/subdeltoid fluid however there is mild impression of the acromium upon the superior fibers of the supraspinatus muscle at the level of the distal clavicle.GLENOHUMERAL JOINT AND GLENOID LABRUM: A trace amount of fluid is noted in the glenohumeral joint but there is no large joint effusion. There are mild osteoarthritic changes of the glenohumeral joint including subchondral cystic changes of the anterior glenoid. There is abnormal signal within the labrum both anteriorly and posteriorly suggesting degenerative tearing. There is additional fraying of the superior labrum. There is intermediate signal within the subscapularis recess which may reflect a component of synovitis.BICEPS TENDON: Evaluation of the biceps is slightly limited due to internal rotation. The intra-articular portion of the long head tendon of the biceps is enlarged and increased in signal consistent with moderate tendinosis. A small focus of intermediate signal is noted along the extra-articular biceps which may reflect a small cartilaginous fragment.

Output: 1. Moderate rotator cuff tendinosis with interstitial tearing further detailed above. No definite full-thickness tear is seen.2. Osteoarthritis of the glenohumeral and acromioclavicular joint.3. Moderate biceps tendinosis.


Instruction: Generate impression based on findings.

Input: Radiculopathy, lumbosacral region [M54.17], Reason for Study: ^Reason: r/o disc herniation or mass of the lumbar sacral spine. History: low back pain, radiculopathy For the purpose of this dictation, the lowest visualized intervertebral disc space is labeled L5-S1. There is normal lumbar lordosis. The spine alignment is anatomic. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The signal of the visualized cord is normal. The conus medullaris terminates at the L1-L2 level. The paraspinal soft tissues are unremarkable.Degenerative changes are specified by the intervertebral level as follows: T12-L1: no neuroforaminal narrowing or spinal stenosis. L1-L2: no neuroforaminal narrowing or spinal stenosis. L2-L3: no neuroforaminal narrowing or spinal stenosis. L3-L4: mild diffuse bulging of disc, no neuroforaminal narrowing or spinal stenosis. L4-L5: broad based disc protrusion toward left side neural foramen. no spinal stenosis. L5-S1: disc dessication, central focal protrusion of disc which abuts thecal sac. no neuroforaminal narrowing or spinal stenosis.

Output: 1. Disc protrusion toward left side neural foramen at the level of L452. Central disc protrusion at the level of L5S1.