Instruction: Generate impression based on findings.

Input: 77 years, Male, evaluate meningioma, history of resection, postop 3 months.. Again seen are postoperative changes of right frontotemporal craniotomy for meningioma resection. Compared to 11/18/2015, evolution of postsurgical changes are seen including evolution of blood products within the right basal ganglia, right inferior frontal lobe, and along the right frontotemporal craniotomy. There has been development of volume loss involving the right frontal periventricular white matter and right basal ganglia with ex vacuo dilatation of the right lateral ventricle. There is enhancement surrounding the residual hematoma at the level of the right caudate head which can be expected. FLAIR hyperintensity related to gliosis extends to the surface of the right frontal lobe. Again seen is residual extra-axial tumor along the anterior medial aspect of the right middle cranial fossa and extending into the right cavernous sinus. Medial extension along the planum sphenoidale and crossing the midline is also noted. Residual mass measures approximately 3.6 x 3.2 x 2.6 cm, series 11 image 62 and series 1101 image 119. Compared to prior there is no evidence of tumor progression. Scattered foci of T2/FLAIR hyperintensity in the bilateral periventricular and subcortical white matter are compatible with mild chronic small vessel ischemic disease. No new mass or mass effect. No midline shift or herniation. No hydrocephalus. The mass is again noted to circumferentially involve the right cavernous and supraclinoid internal carotid artery segments and is also intimately associated with the M1 segment of the right middle cerebral artery.

Output: Evolution of postsurgical changes related to subtotal resection of meningioma as described above. Residual tumor which involves the right middle cranial fossa, extends into the right cavernous sinus, and along the planum sphenoidale is not significantly changed.


Instruction: Generate impression based on findings.

Input: History of Hippel-Lindau syndrome. Pheochromocytoma status post removal. Following pancreatic cyst. Renal cell cancer surveillance. ABDOMEN:LIVER, BILIARY TRACT: Punctate hyperintense hepatic foci likely represent very small hepatic cysts. The liver is normal in morphology, size, signal intensity and enhancement. No suspicious liver lesion. No intra or extrahepatic biliary ductal dilatation.SPLEEN: The spleen is normal in morphology, size and enhancement without a focal lesion.PANCREAS: Punctate cystic lesion in the pancreatic tail is unchanged in size, measuring approximately 6 mm (series 4/15) without suspicious features.The pancreas is otherwise normal morphology and enhancement. The main pancreatic duct is normal in caliber.ADRENAL GLANDS: Status post right adrenalectomy. There is a non-specific punctate 5 mm T2-weighted hyperintense nodule which appears to involve the medial limb of the left adrenal gland, not well seen on prior study, but likely present on 2013 study. No associated restricted diffusion. KIDNEYS, URETERS: The kidneys are normal in morphology and size without a suspicious lesion. No hydroureteronephrosis.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: Bibasilar dependent consolidation/atelectasis, new from the prior study.

Output: 1.Stable punctate pancreatic cyst measuring 6 mm without suspicious imaging characteristics.2.Status post right adrenalectomy without evidence of local recurrence.3.New bibasilar consolidation/atelectasis.4.5 mm left adrenal medial limb non-specific T2-weighted hyperintense focus is non-specific. Attention to this lesion on follow-up imaging is recommended.


Instruction: Generate impression based on findings.

Input: 26 year old woman lactating, retrobulbar headaches. Evaluate for mass, pituitary adenoma. There is no evidence of intracranial hemorrhage, mass or edema. There is a lateral temporal hypodensity visualized on a single slice (series 2 image 10). This is likely volume averaging artifact. There is no definite pituitary adenoma, however MRI is superior for detection of pituitary adenomas.The ventricles and basal cisterns are normal in size and configuration.The calvaria and skull base are radiographically normal. The visualized paranasal sinuses and mastoid air cells are normally pneumatized.

Output: 1. Normal brain CT. Unclear from the history if patient has galactorrhea or normal lactation. It galactorrhea is present, MRI would be appropriate to evaluate for pituitary adenoma.


Instruction: Generate impression based on findings.

Input: Clinical question: Bladder cancer with new lung primary. Evaluate for CNS metastases. Signs and symptoms: Lung and bladder cancer. CT of brain with contrast:Examination demonstrates multiple bilateral hemispheric and cerebellar metastatic lesions with enhancement and central necrosis and surrounding vasogenic edema. The metastatic lesion within the left cerebellum measures 16.8-mm x 20.7-mm. There is mass effect on the fourth ventricle without complete collapse of the fourth ventricle. There are multiple supratentorial metastatic lesions. The largest of these lesions is along the medial aspect of right temporal lobe and measures 16 mm times 60-mm on axial image 9. There is no evidence of midline shift or hydrocephalus. There is no evidence of leptomeningeal enhancement. Edema surrounding the metastatic lesions produces subtle focal mass effect only. No detectable hemorrhage.The bony density of calvarium is diffusely abnormal with numerous small areas of low density. This is concerning for diffuse miliary metastases lesions to the calvarium. Further study would nuclear medicine scan or an MRI is recommended.108 cc of Omnipaque 350 was utilized for the above study.

Output: 1.Multiple intracranial metastatic lesions two bilateral cerebral hemispheres and left cerebellum as detailed.2.There is only focal mass effect secondary to surrounding vasogenic edema of these tumors.3.There is no evidence of hemorrhage or midline shift or hydrocephalus.4.Diffusely abnormal density of the calvarium concerning for miliary metastatic lesions.


Instruction: Generate impression based on findings.

Input: A patient submitted outside study for review. Submitted for review are digital mammographic images (4/21/15, 10/14/15), ultrasound images of right breast (10/14/15), images from ultrasound guided biopsy of right breast and postprocedural right mammographic images (10/21/2015) performed at Advocate Lutheran General Hospital. For comparison, digital mammographic images (5/27/14, 12/6/13) are available. DIGITAL MAMMOGRAPHIC IMAGES (4/21/15, 10/14/15):The breast parenchyma is composed of scattered fibroglandular elements (BiRADS Density Category B), unchanged in pattern and distribution. Multiple surgical clips are present at 12:00 position in the right breast, at the site of prior surgery. There is a developing mass at the site of prior surgery in the right breast, measuring 35 x 30 mm on CC view of 10/14/2015. No abnormal findings are seen in the right retroareolar region, where breast MRI (11/2/15) demonstrated an enhancing mass.No dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in left breast. ULTRASOUND IMAGES OF RIGHT BREAST (10/14/15):An irregularly shaped hypoechoic mass is visualized at 12:00 position in the right breast, measuring 21 x 18 x 23 mm, corresponding to the mass seen on the mammogram. No abnormal lymph nodes are visualized in 4 images of right axilla.IMAGES FROM ULTRASOUND GUIDED BIOPSY OF RIGHT BREAST AND POSTPROCEDURAL RIGHT MAMMOGRAPHIC IMAGES (10/21/2015):Ultrasound guided needle biopsy was performed for the mass in the right breast with an appropriate needle placement. A marker clip (coil shaped) is present within the mass at anterior aspect.Per outside radiology report, the result was malignant; invasive ductal carcinoma.

Output: Biopsy proven carcinoma in the right breast. BIRADS: 6 - Known cancer.RECOMMENDATION: X - No Letter.


Instruction: Generate impression based on findings.

Input: Ms. Rudolph is a 52 year old female with known right breast malignancy currently undergoing neoadjuvant therapy. She presents for MRI to evaluate for treatment response. There is heterogeneous amount of fibroglandular tissue in both breasts. Mild parenchymal enhancement is noted bilaterally.Susceptibility artifact from biopsy marker clip is identified in the right superior breast, at site of biopsy-proven malignancy. However, there is no residual abnormal enhancement seen at this location. There is no abnormal enhancement seen in the remainder of the right breast or the left breast. No abnormal lymph nodes are identified in either axillary or internal mammary region.

Output: Complete imaging response of biopsy proven malignancy in the right superior breast. Clip was appropriately placed at time of diagnosis. If breast conservation therapy is desired, a single wire can be placed in the right breast for preoperative surgical guidance.BIRADS: 6 - Known cancer.RECOMMENDATION: T - Take Appropriate Action - No Letter.


Instruction: Generate impression based on findings.

Input: Compared to/2/2014, there is no significant change in enhancing lesion filling the left internal auditory canal measuring 8 x 13 x 5 mm in the AP, transverse, and craniocaudal dimensions. It extends laterally to level just proximal to the cochlear aperture. Bilateral cerebellopontine angle cisterns and the right internal auditory canal appear unremarkable. There is mild fluid in the left mastoid air cells, unchanged.There are few scattered foci of T2/flair hyperintensity in the periventricular and subcortical white matter which are nonspecific but compatible with mild chronic small vessel ischemic changes. Tiny focus of susceptibility is seen in the left occipital lobe consistent with chronic microhemorrhage. Remainder of the brain is unremarkable. There is no acute infarct, intracranial mass effect, or midline shift. No extra-axial collections or hydrocephalus. Bone marrow and extra cranial soft tissues are unremarkable.

Output: 1. Compared to 8/2/2014, unchanged enhancing lesion involving the left internal auditory canal consistent with a vestibular schwannoma.2. Mild chronic small vessel ischemic changes. Punctate focus chronic microhemorrhage in the left occipital lobe.


Instruction: Generate impression based on findings.

Input: Patient used prophylactic antibiotics before and after the procedure as prescribed. The patient received antibiotic prophylaxis with oral Ciprofloxacin 500mg and Vantin 200mg. The patient took 1 tablet of Ciprofloxacin 500mg the night before and morning of the procedure. The patient also took 2 tablets of Vantin 200mg the morning of the procedure. After the procedures, the patient will take 2 tablets of Ciprofloxacin 500mg and 2 tablets of Vantin 200mg.Following the discussion of the risks, benefits, and alternatives of the procedure, informed consent was obtained. DynaCad was used to localize right mid gland peripheral zone of the prostate at the site of the T2 hypointense enhancing lesions. Using the Dynatrim guidance system an 18-gauge MR- compatible needle was inserted into the right side of the prostate. Upon confirmation of the tip of the needles close to the suspected lesion, MR guided biopsy using an 18 gauge biopsy needle was performed and 3 cores were obtained.The cores were hand delivered to the pathology lab.The patient tolerated the procedure well and was discharged without any immediate complications.ESTIMATED BLOOD LOSS: Less than 5 cc.

Output: 1. Successful core-biopsies of the right mid gland prostate gland peripheral zone lesion.


Instruction: Generate impression based on findings.

Input: 34-year-old female with lower abdominal pain for two weeks and elevated white blood cell count. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: No significant abnormality notedSPLEEN: No significant abnormality notedPANCREAS: There is a small, subcentimeter hypodense lesion in the body of the pancreas (series 3 image 43/162). Recommend follow up with MRI to further characterize this lesion.ADRENAL GLANDS: No significant abnormality notedKIDNEYS, URETERS: Hypodense, well circumscribed lesion in the lower pole of the left kidney, likely a simple cyst and without clinical significance.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality notedPELVIS:UTERUS, ADNEXA: There are two cystic lesions in the left adnexa with surrounding inflammation compatible with pelvic inflammatory disease. There may be a left sided tubo-ovarian abscess and it is recommended to follow-up with pelvic ultrasound to further characterize this lesion.BLADDER: No significant abnormality notedLYMPH NODES: No significant abnormality notedBOWEL, MESENTERY: There is fluid in the left paracolic gutter. BONES, SOFT TISSUES: No significant abnormality notedOTHER: No significant abnormality noted

Output: 1. There are two cystic lesions in the left adnexa with surrounding inflammatory changes consistent with pelvic inflammatory disease. There is also some concern for possible tubo-ovarian abscess and it is recommended to follow up with pelvic ultrasound to further characterize the left adnexa. 2. There is a small subcentimeter hypodense lesion in the body of the pancreas which should be followed up with MRI to further characterize its nature.


Instruction: Generate impression based on findings.

Input: Pain MENISCI: There is fragmentation of the body of the lateral meniscus, with globular degenerative signal in the remaining lateral meniscus. There is globular degenerative signal in the posterior horn of the medial meniscus, extending to the superior surface, without discrete linear signal. ARTICULAR CARTILAGE AND BONE: There are large full thickness cartilage defects in the lateral compartment, the largest of which measures 16 mm at the lateral femoral condyle. Mild bone marrow reactive changes are present in the lateral femoral condyle. There is otherwise mild diffuse cartilaginous degeneration.LIGAMENTS: There is increased signal in the ACL graft, however, the fibers appear intact. No evidence of an ACL cyst. EXTENSOR MECHANISM: No significant abnormality noted.ADDITIONAL

Output: 1. Large full thickness cartilage defects in the lateral compartment of the knee.2. Fragmentation of the body of the lateral meniscus.3. Intact ACL graft.


Instruction: Generate impression based on findings.

Input: Weakness. Evaluate for ischemia/infarction. Similar to the same day head CT, there is evidence of a large hematoma within the right cerebellar hemisphere with intraventricular hemorrhagic extension. Again seen is subdural hemorrhage along the right tentorium. There is upward transtentorial herniation of the brainstem and medial cerebellar contents along as well as extensive restricted diffusion involving the brainstem, cerebellar peduncles and cerebellum bilaterally compatible with extensive ischemic infarct. Again seen are postsurgical changes of a suboccipital craniectomy for posterior fossa decompression as well as a right frontal approach ventriculostomy catheter which terminates in the right foramen of Monro similar in position to the previous head CT. There has been interval reduction in the right ventricular dilatation. However the left lateral ventricle, including the left temporal horn, has slightly enlarged compared to the previous CT indicating possible left lateral ventricular entrapment.

Output: 1.Postsurgical changes of a suboccipital craniectomy for posterior fossa decompression of a large right cerebellar hemisphere hematoma with intraventricular extension and right tentorial subdural hemorrhage.2.Persistent upper transtentorial herniation3.Restricted diffusion involving the brainstem, cerebellar peduncles and cerebellar hemispheres bilaterally indicating acute ischemic infarct.4.Unchanged position of the right frontal approach ventriculostomy catheter with reduction in size of the right lateral ventricles. However the left lateral ventricle has become more somewhat more dilated compared to the previous head CT including the left temporal horn suspicious for possible ventricular entrapment.


Instruction: Generate impression based on findings.

Input: 64-year-old male with RCC, status post right nephrectomy. Metastatic evaluation. ABDOMEN:LIVER, BILIARY TRACT: No intra or extrahepatic biliary ductal dilatation. Small periportal lymph node.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Interval right nephrectomy. No evidence of residual or recurrent tumor. The left kidney demonstrates normal enhancement. There is a subcentimeter nonenhancing T2 hyperintense focus compatible with a small cyst (series 11 image 14, series 12 image 304). Incidental note is made of a retroaortic left renal vein.RETROPERITONEUM, LYMPH NODES: Small subcentimeter retroperitoneal lymph nodes.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: The T9 vertebral body lesion demonstrating increased signal on T2 and fat sensitive sequences is compatible with a benign osseous hemangioma (series 3 image 23, series 1500 image 57).OTHER: No significant abnormality noted.

Output: 1.Status post right nephrectomy. No evidence for residual or recurrent tumor.2.Small subcentimeter retroperitoneal lymph nodes. Attention on subsequent imaging is recommended.


Instruction: Generate impression based on findings.

Input: 68-year-old female patient with adrenal hemangioma per CT. Evaluate right adrenal mass for malignancy. ABDOMEN:LIVER, BILIARY TRACT: There is a small amount of non-specific pericholecystic fluid. No intra- or extrahepatic biliary ductal dilatation. SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: There is a 2.2 x 2.3 cm mass within the medial limb of the right adrenal gland which demonstrates mild T2 hyperintensity and progressive enhancement. The lesion questionably contains fat which may demonstrate loss of signal on out of phase imaging (best seen on image 35, series 301 and image 36, series 301).KIDNEYS, URETERS: There is a left renal cyst. RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: Compression deformity of the L1 vertebral body.OTHER: No significant abnormality noted.

Output: 1.Progressively enhancing right adrenal mass is favored to represent a benign lesion such as a hemangioma or adenoma. However, follow up MRI in 6 months is recommended to prove stability. Furthermore, correlate with appropriate serum markers to exclude pheochromocytoma.2.Non-specific pericholecystic fluid.


Instruction: Generate impression based on findings.

Input: 40 year-old male, assess right posterior thigh mass A marker was placed along the posterior medial aspect of the proximal thigh at the site of concern. There is no evidence of underlying mass or soft tissue abnormality. The muscles of the thigh appear normal for the patient's age. There is no abnormal enhancement. The osseous structures are within normal limits for the patient's age.Note is made of small bilateral hydroceles.

Output: No mass or other finding to account for the patient's symptoms.


Instruction: Generate impression based on findings.

Input: History of lung cancer. Altered mental status. Examination demonstrates numerous enhancing lesions with surrounding vasogenic edema in the bilateral cerebral and cerebellar hemispheres and in the right cerebral peduncle. Some of the lesions appear hyperdense on the precontrast images. No significant mass effect, midline shift or abnormal extra-axial fluid collection is identified. The ventricles are normal in size and are symmetric.Incidental finding is a soft tissue lesion within the sella. After reviewing the prior MRI date dated 1/25/07, it is considered either an adenoma or cyst involving the pituitary stalk. Visualized paranasal sinuses and mastoid air cells are normally pneumatized. The calvarium is intact.

Output: 1.Multiple hemorrhagic metastatic lesions in light of the clinical history provided. 2.Likely an adenoma or cyst in the pituitary stalk.


Instruction: Generate impression based on findings.

Input: Male, 33 years old, with paresthesias and white matter changes on MRI of the brain. Evaluate for demyelinating disease. Cervical:No focal spinal cord signal abnormality is seen. No pathologic enhancement of the cord or osseous structures is detected. Spinal alignment is anatomic. Vertebral body height and morphology are within normal limits. No evidence of marrow replacement or edema is seen. A small disc protrusion is present at C5-6 without significant spinal canal stenosis. The remaining intervertebral discs are preserved. No significant compromise of the spinal canal or neural foramina is seen.Thoracic:No focal spinal cord signal abnormality is seen. No pathologic enhancement the cord is detected. A focus of signal abnormality and enhancement within the left T9 pars interarticularis, and a larger area within the right posterior T11 vertebral body, are favored to represent benign hemangiomas. Otherwise, vertebral body morphology and signal characteristics are within normal limits. Spinal alignment is anatomic. A left paracentral disc protrusion at T5-6 may very slightly impinge upon the spinal cord. No significant spinal canal or foraminal stenosis is observed.Lumbar:Assuming rudimentary ribs at the T12 vertebral body, there are four fully lumbar type vertebral bodies and a transitional S1.No evidence of pathologic intrathecal enhancement is seen. The distal spinal cord, conus and nerve roots of the cauda equina are within normal limits. No epidural abnormalities are suspected.Spinal alignment is anatomic. Vertebral body height and morphology are within normal limits. Mild degenerative endplate signal change and enhancement are seen at L3-4. Otherwise, no pathologic marrow space signal abnormality is detected.At L3-4, there is facet arthropathy, disc bulging and a mild central disc protrusion. No significant spinal canal stenosis is seen. The neural foramina are mildly narrowed.At L4-5, there is facet arthropathy, disc bulging and a small superimposed central protrusion. No significant spinal canal stenosis is seen. The neural foramina are mildly narrowed.

Output: 1.No evidence of demyelinating disease is seen within the spinal cord.2.Scattered mild degenerative findings are noted as above.


Instruction: Generate impression based on findings.

Input: 77 year-old female, evaluate for tendon injury, infection, or foreign body A marker was placed along the volar aspect of the distal thenar region/palm and the field of view was enlarged to include this region. Nonspecific edema-type signal is present along the flexor pollicis longus tendon as it courses volar to the first MCP joint. There is also mild nonspecific inflammation of the subcutaneous fat of the thumb and surrounding the proximal phalanx. Other than a small amount of fluid in the flexor pollicis longus tendon sheath, the tendon itself appears intact. The bone marrow signal intensity appears normal. There is no artifact to suggest foreign body. No fluid collection/abscess is evident. Mild edema of the subcutaneous fat along the radial aspect of the second metacarpophalangeal joint is noted. The thenar musculature appears intact. Trace fluid within the flexor tendon sheaths of the fingers is likely of no current clinical significance. Although not protocoled for detailed evaluation of the collateral ligaments of the thumb, these appear grossly intact. Note is made of osteoarthritis of the wrist and hand, as well as a possible TFCC tear, although this is not well imaged on this exam.

Output: Mild nonspecific inflammatory changes along the flexor pollicis longus tendon and proximal phalanx of the thumb as well as osteoarthritis of the wrist. We see no tendon injury, foreign body or fracture.


Instruction: Generate impression based on findings.

Input: History of Crohn's disease and rectal vaginal pain. PELVIS:UTERUS, ADNEXA: Anteverted anteflexed uterus. Normal endometrial canal thickness. Post cesarean section scar in the lower uterine segment. The inner myometrium/junctional zone is normal in thickness. Small cervical nabothian cysts are noted. Left adnexal simple appearing cysts are within physiologic limits.BLADDER: No significant abnormality noted.LYMPH NODES: Small inguinal lymph nodes are nonspecific and likely reactive.BOWEL, MESENTERY: There is a transsphincteric fistula tract extending from the 6:00 position of the anal canal extending leftward's in the ischioanal fossa terminating on the left gluteal cleft. There is a 2 mm associated blind-ending sinus tract along the course of the fistula. There is no associated fluid collection. Note is made of fluid/inflammatory changes along the surface of the skin in the intergluteal cleft.Small amount of free pelvic fluid in the rectouterine pouch, within physiologic limits.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: Transsphincteric fistula originating at the 6:00 position of the anal canal terminating along the left gluteal cleft. No drainable fluid collection. Fluid/inflammatory changes along the surface of the skin in the intergluteal cleft.


Instruction: Generate impression based on findings.

Input: 57 years Female (DOB:3/30/1959)Reason: eval for stenosis History: Difficulty raising arms above head. Numbness in both handsPROVIDER/ATTENDING NAME: EDWIN RAMOS EDWIN RAMOS Cervical spine:The cervical vertebral bodies are appropriate in overall height. The cervical spinal cord has normal signal characteristics and overall morphology. There is mild reversal of the normal cervical curvature present. There is mild bilateral facet hypertrophy at this level. At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is very mild anterior subluxation of C2 on C3. At C3-4 there is no significant compromise to the spinal canal. There are left-sided uncovertebral osteophytes associated with disc material and encroachment of left-sided exiting nerve roots within the neural foramen. There is facet hypertrophy present bilaterally at this level but worse on the left than the right side.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there are endplate and uncovertebral osteophytes associated with loss of disc space height this desiccation and diffuse disc bulge. There is narrowing of the neural foramina bilaterally which is worse on the left side where there is some encroachment of the left-sided exiting nerve roots. There is also effacement of spinal fluid ventral and posterior the spinal cord with a mild to moderate degree of spinal stenosis resulting.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There is some disc desiccation and a mild disc bulge at this level.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.Lumbar spine: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. The patient status post posterior fusion using pedicle screws and interconnecting rods L34 level. There is a disc spacer present anteriorly at L3-4. The patient status post laminectomy at this level.At L5-S1 there is no significant compromise to spinal canal or neural foramina. There is mild facet and ligamentum flavum hypertrophy at this level.At L4-5 there is no significant compromise to spinal canal or neural foramina. There is a diffuse disc bulge present at this level associated with some narrowing of the neural foramina bilaterally and some effacement of the fat at the lateral recesses sees at this level disc material extends into the neural foramina bilaterally. Neuroforamina are partially obscured from artifact from the adjacent pedicle screws.At L3-4 there is metal artifact present from pedicle screws which partially obscures visualization at this level.At L2-3 there is metal artifact present from pedicle screws which partially obscures visualization at this level.At L1-2 there is no significant compromise to spinal canal or neural foramina.

Output: 1.There are degenerative changes present in the cervical spine with mild to moderate spinal stenosis at C5-6 associated bilateral encroachment of exiting nerve roots as well as encroachment of left-sided exiting nerve roots at C3-4.2.The patient status post anterior and posterior fusion with laminectomy at L3-4. There is no spinal stenosis appreciated in the lumbar spinal canal.3.There are degenerative changes present in the lumbar spine. Effect at the L4-5 level is not clear based on this exam. There appears to be some narrowing of the neural foramina but no convincing evidence for encroachment of exiting nerve roots. However, the exam is partially degraded by metal artifact from adjacent pedicle screws.


Instruction: Generate impression based on findings.

Input: Reason: cuff tear? History: pain ROTATOR CUFF: There is a partial-thickness articular surface tear of the supraspinatus at the level of its insertion on the greater tuberosity measuring approximately 4 mm in AP dimension. There is no significant retraction. There is thickening and signal intensity within the supraspinatus indicating moderate tendinosis. The infraspinatus muscle and tendon appear intact. There is undersurface fraying of the subscapularis. There is a focus of low signal intensity within the subscapularis just proximal to its insertion on the lesser tuberosity suggestive of calcific tendinopathy. The subscapularis muscle appears intact. The teres minor muscle and tendon appear intact.SUPRASPINATUS OUTLET: There is a trace amount of fluid within the subacromial subdeltoid bursa. Mild osteoarthritis affects the acromioclavicular joint.GLENOHUMERAL JOINT AND GLENOID LABRUM: The glenohumeral joint alignment is anatomic. There is heterogeneity and increased signal abnormality within the anterior inferior labrum suggestive of degeneration.BICEPS TENDON: The tendon of the long head of the biceps appears intact. ADDITIONAL

Output: 1. Tendinosis and small insertional tear of the supraspinatus without evidence of a full-thickness rotator cuff tear or retraction.2. Calcific tendinopathy of the rotator cuff as described above.3. Osteoarthritis of the right shoulder. Other findings as described above.


Instruction: Generate impression based on findings.

Input: 48 years Female (DOB:4/1/1967)Reason: hydrocephalous History: haPROVIDER/ATTENDING NAME: PETER C WARNKE PETER C WARNKE There is ventriculomegaly present prior exams and has not changed. There is redemonstration of bilateral ventriculostomy tubes coursing to the frontal lobes bilaterally extending respectively right and left frontal horns of the lateral ventricles.No abnormal enhancing 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: Examination performed for stereotactic guidance during surgery. There is ventriculomegaly present associated with bilateral ventriculostomy tubes..


Instruction: Generate impression based on findings.

Input: 71-year-old man with history of biopsy in 2014 with one core of atypical small acinar proliferation, PSA of 5.85 Jan 2016 and 4.64 Sept 2016. PELVIS:PROSTATE:Prostate Size: 50 x 38 mmPeripheral Zone: Within the left mid prostate (401/71) there is an approximately 11 mm area of decreased T2 signal with mild ADC abnormality. The remainder of the peripheral zone appears normal.Central Gland: Markedly enlarged and impressing upon the bladder.Seminal Vesicles: Unremarkable.Extracapsular Extension: No evidence of extracapsular extension.BLADDER: No significant abnormality noted.LYMPH NODES: Nonspecific inguinal lymph nodes are likely reactive.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: Signal abnormality in the left lateral mid prostate peripheral zone which is indeterminate for tumor but is a candidate for biopsy.


Instruction: Generate impression based on findings.

Input: Disease of spinal cord, unspecified [G95.9], Reason for Study: ^Reason: evaluate for myelopathic process History: spastic gait, T10 sensory level There is normal cervical lordosis. The cranial-cervical junction is normal. There is normal thoracic kyphosis. The spine alignment is anatomic. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The cord signal is normal. There is no evidence of abnormal enhancement, cord compression or mass. There is minimal bulging of disc at the level of C56.On series 1701, there is subtle high signal intensity of the right side spinal cord at the level of T7. Since the abnormal signal intensity is only seen on 1 slice and there was some motion artifacts, this lesion favors an artifact.There is no other abnormal signal intensity on this patient's cervical and thoracic spine MRIs.There is no abnormal enhancement.

Output: 1. No evidence of abnormal signal intensity on both cervical and thoracic spinal cord. No abnormal enhancement.2. Minimal bulging of disc at the level of C56 without spinal canal stenosis. 3. No evidence of spinal stenosis. No neuroforaminal stenosis.


Instruction: Generate impression based on findings.

Input: 70 year old male with history of atrial fibrillation, hypertension, diabetes presenting for evaluation of cardiac size and function. Left VentricleThe left ventricle is normal in size with moderately reduced systolic function. The overall LV ejection fraction is 33%, the LV end diastolic volume index is 76 ml/m2 (normal range: 74+/-15), the LVEDV is 178 ml (normal range 142+/-34), the LV end systolic volume index is 51 ml/m2 (normal range 25+/-9), the LVESV is 120 ml (normal range 47+/-19), the LV mass index is 79 g/m2 (normal range 85+/-15), and the LV mass is 185 g (normal range 164+/-36). The LV dysfunction is global. There is no clear localized late gadolinium enhancement to suggest the presence of an underlying fibrosing, infiltrative, or inflammatory process.Left AtriumThe left atrium is severely dilated (152ml). Right VentricleThe right ventricle is normal in size with mildly reduced systolic function. The overall RV ejection fraction is 48%, the RV end diastolic volume index is 67 ml/m2 (normal range 82+/-16), the RVEDV is 158 ml (normal range 142+/-31), the RV end systolic volume index is 35 ml/m2 (normal range 31+/-9), and the RVESV is 82 ml (normal range 54+/-17).Right AtriumThe right atrium is mild to moderately dilated.Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is mild mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is trace tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal "pseudobovine" brachiocephalic branching pattern. The aortic root is normal in size.Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium. The pulmonary vein dimensions are: RUPV: 28x25mmRLPV: 26x23mmLUPV: 24x20mmLLPV: 22x15mmPulmonary ArteryThe main pulmonary artery is normal in size.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium.PericardiumThere is no obvious pericardial disease.Extracardiac FindingsThis study is not designed for the specific evaluation of extra-cardiac findings; therefore, the differentiation between artifacts and real extracardiac pathology may be difficult. If clinically indicated, a separate dedicated evaluation should be considered.

Output: 1. Normal LV size with moderately reduced systolic function (LVEF 33%) without evidence of obvious underlying myocardial fibrosis, inflammation, or infiltration.2. Normal RV size with mildly reduced systolic function (RVEF 48%).3. Severe left atrial volume4. Mild to moderate right atrial dilation. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: Male, 54 years old, with newly diagnosed squamous cell lung cancer. Baseline evaluation for metastases. The cerebral and cerebellar hemispheres and brainstem show normal signal intensity and morphology. No restricted diffusion is seen. No abnormal intracranial enhancement is noted.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. Signal intensity of the bone marrow is unremarkable. No significant abnormalities of the paranasal sinuses are detected. The right mastoid air cells are partially opacified.

Output: No evidence of intracranial metastatic disease.


Instruction: Generate impression based on findings.

Input: Re-evaluate disease status following immunotherapy intolerance: Stage III melanoma. There is no evidence of intracranial hemorrhage, mass, or acute infarct. There is unchanged minimal cerebral white matter T2 hyperintensity. There is no abnormal intracranial enhancement. 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 unchanged, including a probable hemangioma in the left parietal calvarium.

Output: No evidence of intracranial metastases.


Instruction: Generate impression based on findings.

Input: Question new onset seizure. LD, ADHD. There is a suprasellar solid/cystic mass extending into the third ventricle and left frontal horn. The mass contains punctate areas of calcification. The mass extends posteriorly causing effacement of the midbrain and the quadrigeminal cistern. There is bony remodeling of the sella. This mass most likely represents a craniopharyngioma, and an MRI is recommended for further evaluation. There is mild leftward midline shift. No evidence of intracranial hemorrhage.The lateral ventricles are mildly dilated.An air-fluid level is present in the left sphenoid sinus. The remaining visualized paranasal sinuses and mastoid air cells are normally pneumatized.

Output: Suprasellar solid/cystic mass as described above. This most likely represents a craniopharyngioma and an MRI is recommended for further evaluation.


Instruction: Generate impression based on findings.

Input: Parotid mass, which FNA revealed to be poorly differentiated carcinoma. There is a heterogeneous mass that measures up to 37 mm in the superficial left parotid gland, with what appears to be central necrosis and extension into the overlying subcutaneous tissues. There is also an enhancing mass that measures up to 23 mm centered in the body of C2, with cortical dehiscence and prevertebral extension, but no gross epidural spine extension. The right parotid gland and bilateral submandibular glands are unremarkable. There is herniation of the bilateral sublingual glands via mylohyoid dehiscences. There is no significant level 2 or 3 lymphadenopathy. There is mild prominence of the tongue base lymphoid tissues. The orbits and imaged intracranial structures are grossly unremarkable.

Output: 1. A heterogeneous mass that measures up to 37 mm in the superficial left parotid gland, with what appears to be central necrosis and with dermal invasion is compatible with the reported poorly differentiated carcinoma.2. A mass that measures up to 23 mm centered in the body of C2, with cortical dehiscence and prevertebral extension, but no gross epidural spine extension, likely represents metastatic disease. General staging imaging is recommended.


Instruction: Generate impression based on findings.

Input: 27 year old woman with history of multinodular goiter, hypothyroidism on synthroid who presents for cardiac MRI to evaluate for infiltrative disease as possible etiology of supraventricular tachycardia Left VentricleThe left ventricle is normal in size with normal systolic function. The overall LV ejection fraction is 63%, the LV end diastolic volume index is 63 ml/m2 (normal range: 65+/-11), the LVEDV is 99 ml (normal range 109+/-23), the LV end systolic volume index is 23 ml/m2 (normal range 18+/-5), the LVESV is 37 ml (normal range 31+/-10), the LV mass index is 32 g/m2 (normal range 67+/-11), and the LV mass is 50 g (normal range 114+/-24). There are no regional wall motion abnormalities present. There is no late gadolinium enhancement to suggest the presence of an underlying fibrosing, infiltrative, or inflammatory process.No intracardiac thrombus is present.Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 53%, the RV end diastolic volume index is 74 ml/m2 (normal range 69+/-14), the RVEDV is 114 ml (normal range 110+/-24), the RV end systolic volume index is 35 ml/m2 (normal range 22+/-8), and the RVESV is 55 ml (normal range 35+/-13).No evidence of micro or macro aneurysm is present. No enhancement. Right AtriumThe right atrium is normal in size. Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is no significant mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is no significant tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal brachiocephalic branching pattern. The aortic root is normal in size.Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is normal in size. Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium. PericardiumThere is no pericardial effusion.Extracardiac FindingsThere is partial visualization of the thyroid on this study with no evidence of thyromegaly.

Output: 1. The left ventricle is normal in size with normal systolic function (LVEF 63%)2. The right ventricle is normal in size with normal systolic function (RVEF 53%)3. There is no late gadolinium enhancement to suggest the presence of an underlying fibrosing, infiltrative, or inflammatory process.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: 73 years, Male, Reason: brainstem lesion to explain oculomotor palsy History: upgaze palsy, strabismus. Multiple myeloma. BRAIN

Output: 1. Chronic left PCA territory infarct involving the left occipital lobe with additional chronic lacunar infarcts involving the left thalamus and left paramedian midbrain. No evidence of acute ischemia or intracranial mass effect. 2. Multiple scattered supra- and infratentorial chronic microhemorrhages.3. No discrete myelomatous lesions are evident in the cervical, thoracic, or lumbar spine within the limits of noncontrast imaging.4. Multilevel degenerative changes with no significant spinal canal stenosis in the cervical or thoracic spine. In the lumbar spine there is moderate L3-L4 spinal canal stenosis and to a milder degree at the L4-L5 and L2-L3 levels. Additional details including foraminal stenoses as described above.


Instruction: Generate impression based on findings.

Input: 45-year-old male with Achilles pain. Evaluate Achilles tendon. TENDONS: Best seen on the sagittal sequences is linear intrasubstance signal within the distal fibers of the Achilles tendon, suggesting mild tendinosis. There is also mild increased signal intensity along the posterior margin of the tendon, distally, suggesting a mild peritenonitis. There is flattening of the peroneus brevis tendon as it courses posterior and beneath the fibular tip, which may represent a partial-thickness longitudinal split tear. This is not necessarily of any current clinical significance as there is no suggestion of peroneal tenosynovitis. The flexor and extensor tendons appear intact. LIGAMENTS: The anterior talofibular ligament appears thinned, which may reflect an old injury. The calcaneofibular ligament appears intact. The posterior talofibular ligament appears intact. The distal tibiofibular syndesmotic complex appears intact. The visualized components of the deltoid ligament appear intact.ARTICULAR SURFACES AND BONE, AND OTHER

Output: "Haglund's syndrome" with retrocalcaneal bursitis, mild Achilles tendinosis, and other findings as described above.


Instruction: Generate impression based on findings.

Input: Reason: please evaluate for cause of diffuse soft tissue swelling, more lateral than medial. Evaluate for achilles tendinopathy as well History: ankle pain and diffuse swelling TENDONS: The flexor and extensor tendons appear intact. The peroneal tendons appear intact. There is thickening and intermediate signal intensity within the distal fibers of the Achilles tendon indicating moderate tendinosis. There is linear increased signal abnormality within the distal fibers of the Achilles tendon at the level of its insertion on the calcaneus indicating a partial thickness tear without significant retraction. There is a small amount of fluid within the retrocalcaneal bursa which may reflect a very mild bursitis.LIGAMENTS: The lateral collateral ligament complex appears intact. The distal tibiofibular syndesmotic complex appears intact. The imaged components of the deltoid ligament appear intact.ARTICULAR SURFACES AND BONE: There is subchondral cyst formation within the navicular bone about the talonavicular joint likely degenerative in etiology. Otherwise no bone marrow signal abnormality is identified. ADDITIONAL

Output: Achilles tendon tendinopathy and partial thickness tearing as described above. Other findings as described above.


Instruction: Generate impression based on findings.

Input: 9-year-old male with history of perirectal abscess status post I/T/D and ceton placement. Continued induration and drainage. BONE MARROW: No significant abnormality noted.SOFT TISSUES: Persistent focal left perineal abnormal high T2 signal intensity consistent with inflammation, similar to prior. There are 3 foci of rim enhancement, with low T2 signal internally, suggestive of abscess or could represent packing material in an abscess cavity. The largest (1001/94), left of midline, measures 1.7 x 0.7 cm. A smaller, left perineal enhancing collection (1001/82) measures 0.7 x 0.6 cm. A third collection (1001/90), on the right, measures 0.7 x 0.5 cm. Adjacent inflammatory-type signal extends to the posterior base of the scrotum.JOINTS: No significant abnormality noted.ADDITIONAL

Output: Perineal inflammation with suspected abscesses as above.


Instruction: Generate impression based on findings.

Input: History of metastatic adenoid cystic carcinoma status post radiation. Evaluate response. Redemonstration of enhancing lesions in both the supratentorial and infratentorial brain predominantly in a subcortical distribution. There is extensive adjacent vasogenic edema surrounding the lesions, and most demonstrate internal susceptibility compatible with internal microhemorrhage.Compared to prior there are no definite new lesions. Almost all of the previously noted lesions are, however, increased in both size and surrounding edema when compared to prior compatible with progression. The referenced left caudate lesion measures 16 x 13 mm (series 11 image 77), previously 14 x 7 mm. The reference right parietal lesion is difficult to measure on axial images as it moves obliquely out of the axial plane, but measures 25 x 14 mm (series 11 image 52), previously 22 x 13 mm. The reference right cerebellar lesion now measures 37 x 24 mm (series 11 image 5), previously 22 x 13 mm.Again seen is a focus of nonspecific enhancement within the left parietal bone, without significant change from the prior exam.The ventricles and basal cisterns are normal in size and configuration. No pathologic extra-axial fluid collection. Normal flow void is demonstrated in the major intracranial vascular structures.

Output: Interval increase in size and number of metastatic lesions within the brain compatible with disease progression. There has also been interval increase in perilesional vasogenic edema.


Instruction: Generate impression based on findings.

Input: Multiple myeloma with a large lesion on PET impinging on T6/T7: No pain or neurologic deficits. There is an infiltrative, enhancing left posterior chest wall mass with left neural foraminal and epidural extension at theT6-7 level with mild narrowing of the thecal sac, but no spinal cord compression. The vertebral column alignment is within normal limits. There are multilevel small intravertebral disc herniations. The vertebral body are otherwise preserved. There is a small focus of left ligamentum flavum calcification that projects into the spinal canal at T10-11, without spinal cord impingement. The spinal cord displays normal signal and morphology. The paravertebral soft tissues are unremarkable. There is a small right renal cyst.

Output: Left posterior chest wall multiple myeloma extends into left neural foramen and epidural space at theT6-7 level with mild narrowing of the thecal sac, but no spinal cord compression.


Instruction: Generate impression based on findings.

Input: Female, 62 years old, status post L4-5 fusion for stenosis with metal plate and 2010, with worsening of lower extremity tingling and numbness. Evidence of posterior instrument fusion is seen from L3 through L5 with bilateral pedicle screws affixed to posterior stabilization rods. Bilateral laminectomy has been performed at L3-4 and L4-5 with placement of interbody fusion devices within the L3-4 and L4-5 disc spaces. Small fluid locules are evident within the laminectomy bed, likely chronic and related to surgery.A focal kyphotic angulation of the lumbar spine is seen centered at L2-3. Otherwise, sagittal alignment is unremarkable. Vertebral body heights are preserved. No areas pathologic marrow replacement or marrow edema are observed.The visualized distal spinal cord and conus are within normal limits. L1-2: Mild facet arthropathy. Otherwise unremarkable. L2-3: Marked facet arthropathy and ligamentum flavum thickening. Bulging disc. Moderate to severe spinal canal stenosis with crowding of the nerve roots and near complete effacement of CSF. Severe bilateral foraminal narrowing. L3-4: Postoperative findings. No significant spinal canal or foraminal stenosis. L4-5: Postoperative findings. No significant spinal canal or foraminal stenosis. L5-S1: Advanced facet arthropathy, left more than right. Ligamentum flavum thickening. No significant spinal canal stenosis. Mild to moderate bilateral foraminal narrowing.

Output: Expected findings are seen status post posterior instrumented fusion from L3 through L5. The spinal canal is well decompressed through this region and the neural foramina are not significantly compromised.At L2-3, however, posterior element hypertrophy and disc bulging contribute to produce a moderate to severe spinal canal stenosis with crowding of the nerve roots and significant neural foraminal narrowing as well. Note is also made of mild to moderate foraminal narrowing at L5-S1 due largely to facet arthropathy.


Instruction: Generate impression based on findings.

Input: Right upper extremity numbness, memory loss and right-sided headache x 6 weeks. No intracranial mass or mass-effect. There is mild global parenchymal volume loss which appears within normal limits for age. No restricted diffusion to suggest acute ischemia. No intracranial hemorrhage. Several foci of T2/FLAIR hyperintensity are seen in the bilateral subcortical and periventricular white matter, which are nonspecific. Brain parenchyma is otherwise unremarkable for age. No abnormal parenchymal or meningeal enhancement. Major flow-voids are preserved.Sella and orbits are grossly within normal limits. There is mild mucosal thickening throughout the paranasal sinuses. Mastoid air cells are clear. Bone marrow signal and extracranial soft tissues are within normal limits.

Output: 1. Examination is essentially unremarkable for age. No intracranial mass or mass effect. Mild global parenchymal volume loss.2. Scattered T2/FLAIR hyperintensities in the white matter, which are nonspecific and may represent mild small vessel ischemic change I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: Dizziness and giddiness [R42], Reason for Study: ^Reason: etiology of vertigo spells History: dizziness spells Brain MRIThere is no evidence of acute ischemic or hemorrhagic lesion.Scattered multifocal bihemispheric periventricular white matter and centrum semiovale T2/flair high signal intensity lesions are seen. These lesions are nonspecific likely represent nonspecific small vessel ischemic disease. Comparing to prior scan, the number and extent of high signal intensity lesions appear to be increased slightly.The ventricles, sulci and cisterns are unremarkable. There is no mass, mass effect, edema, midline shift, intra or extra-axial fluid collection/hemorrhage, restricted diffusion/acute ischemia. The midline structures and cranial-cervical junction are normal. The paranasal sinuses and mastoid air cells are clear.Brain MRA3D time of flight MOTSA MRA brain images with maximum intensity projections of the anterior/posterior intracranial circulation demonstrate normal ICAs, MCAs and ACAs. Vertebrobasilar system appears to be normal. Specifically, there is no evidence of arterial luminal stenosis or intracranial arterial aneurysm.

Output: 1. No evidence of acute ischemic or hemorrhagic lesion.2. Slight interval progress of T2/flair high signal intensity lesions which likely represent nonspecific small vessel ischemic disease on bilateral periventricular white matter and centrum semiovale since prior scan. 3. No evidence of significant intracranial arterial luminal stenosis. No evidence of intracranial arterial aneurysm.


Instruction: Generate impression based on findings.

Input: Thyroid cancer with metastasis to the brain. Evaluate for change.. Postsurgical changes related to lesion resection in the left parietal lobule are again seen. There is stable dural thickening, mild T2 hyperintensity and hemosiderin staining in the resection bed as on the previous exams but no evidence of enhancing tumor in the resection cavity. Again seen is a 5 mm enhancing lesion with susceptibility artifact in the left superior parietal lobule (series 1102, image 152), a 3 mm focus of enhancement in the left precentral gyrus (series 1102, image 154), and minimal enhancement in the left inferior temporal lobe with associated blooming artifact (series 1102, image 71). The previously seen vague focus of enhancement in the right middle frontal gyrus has no definitive enhancement (series 1102, image 148). The focus of susceptibility along the right caudate head has no associated enhancement and is unchanged. There are no new areas of abnormal enhancement or susceptibility artifact. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. Mucous retention cysts are seen within the bilateral maxillary sinuses. There is opacification and mucosal enhancement of the majority of the ethmoid air cells and mild mucosal thickening in the left frontal sinus. The major cerebral flow voids are intact. The orbits, skull, and scalp soft tissues are grossly unremarkable.

Output: 1.Stable postoperative changes related to left inferior parietal lobule metastasis resection. No evidence of residual or recurrent tumor in the resection bed.2.Stable small enhancing foci in the left superior parietal lobule and left precentral gyrus. The previously seen metastatic lesion in the left inferior temporal lobe demonstrates only faint enhancement compatible with treated metastasis. The lesion in the right middle frontal gyrus no longer enhances. No new intracranial lesions are identified.


Instruction: Generate impression based on findings.

Input: 73-year-old female with transient alteration of awareness. Rule out CVA/bleed. There is no evidence of intracranial hemorrhage, mass or edema. Multiple areas of diffuse periventricular and subcortical white matter hypoattenuation consistent with small vessel ischemic disease, age undetermined. If there is clinical concern for acute ischemia, MRI may be considered.The ventricles and basal cisterns are normal in size and configuration.The calvaria and skull base are radiographically normal. The visualized paranasal sinuses and mastoid air cells are normally pneumatized.

Output: Small vessel disease age indeterminate. If there is clinical concern for acute ischemia, MRI may be considered.


Instruction: Generate impression based on findings.

Input: 86-year-old female with severe degenerative disk disease and pain. History of metastatic breast cancer and L3 L5 laminectomy Vertebral body heights are intact. There are degenerative endplate marrow signal changes at L2-L3 and L3-L4. Bone marrow edema seen on the prior exam at these levels has resolved. Focal increased T1 and T2 signal within the left L4 lamina and T12 vertebral body without enhancement are unchanged and likely represent hemangiomas. No abnormal enhancement is seen throughout the lumbar spine to suggest metastases. There is severe degenerative disk disease with disk desiccation at all levels and severe disk space narrowing at L4-L5, L3-L4, and L2-L3, not significantly changed since the prior exam. Multiple small Schmorl's nodes are noted. There is grade 1 anterolisthesis of L4 relative to L3. Signal within the distal cord and conus is normal. Postsurgical changes of L3 and L5 laminectomies are redemonstrated with increased STIR signal within the operative bed, likely representing scarring.T12-L1: No spinal canal or neural foraminal stenosis.L1-L2: Mild diffuse disk bulge. Mild facet arthropathy and ligamentum flavum hypertrophy. No spinal canal or neuroforaminal stenosis.L2-L3: Mild diffuse disk bulge, asymmetric to the right, is worse than the prior exam. Mild facet arthropathy and ligamentum flavum hypertrophy. Mild central canal stenosis, unchanged. Mild bilateral neuroforaminal stenosis, unchanged.L3-L4: Diffuse disk bulge with left paracentral extrusion extending inferiorly is decreased in size from the prior exam. There is moderate facet arthropathy. Moderate central canal stenosis is improved from the prior exam. Severe right-sided neuroforaminal stenosis is worse than the prior exam. Moderate left-sided neural foraminal stenosis is unchanged.L4-L5: Mild diffuse disk bulge with new annular fissuring within the disk on the left. Mild facet arthropathy. No spinal canal stenosis. Minimal bilateral neuroforaminal stenosis.L5-S1: Diffuse disk bulge is unchanged. No spinal canal stenosis. Moderate bilateral neuroforaminal stenosis, unchanged.Partially visualized bilateral renal cysts with a cyst adjacent to the right kidney are unchanged.

Output: 1.Severe degenerative disk disease without evidence of metastatic disease or compression fracture.2.Postsurgical changes with improvement in central canal stenosis and herniation at the L3-L4 level, however right-sided neuroforaminal stenosis at this level has increased.3.Asymmetric disk bulge at L2-L3 is slightly worst with mild bilateral spinal canal and neuroforaminal stenosis at this level.4.Additional multilevel neuroforaminal narrowing is unchanged.


Instruction: Generate impression based on findings.

Input: 2-year-old male with a history of reported "brain abscess" currently on extended IV antibiotics, evaluate for interval change. Continued improvement of a right temporooccipital intra-axial hemorraghic lesion which continues to decrease in size measuring 12 x 8 mm, previously 17 x 13 mm (series 601, image 22). Previously seen surrounding edema has nearly resolved. No new nodule, mass, or new focus of edema is identified to suggest worsening infection. There is redemonstration of a punctate residual enhancing focus involving the left inferior parietal lobule/posterior superior temporal gyrus. Multiple foci of susceptibility in the bilateral cerebellar hemispheres without corresponding edema or enhancement are unchanged. There is no evidence of acute intracranial hemorrhage or acute infarct. The ventricles and sulci 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: 1. Continued improvement of size of hemorrhagic right temporooccipital lesion.2. Punctate residual enhancing nodule involving the left inferior parietal lobule/posterior superior temporal gyrus is unchanged.3. No new nodule or mass, or new focus of edema to suggest worsening infection.4. Unchanged multiple foci of susceptibility in the bilateral cerebellar hemispheres which may represent chronic microhemorrhages versus mineralization, possibly related to remote infection.


Instruction: Generate impression based on findings.

Input: 51-year-old male with obstructive jaundice secondary to choledocholithiasis status post CBD stone removal. Hepatic duct stricture, elevated LFTs. ABDOMEN:LIVER, BILIARY TRACT: Subcentimeter T2 hyperintense foci are too small to further characterize although reflect cysts cysts or hematomas. There is a contracted gallbladder containing stones. No intrahepatic or extrahepatic biliary ductal dilatation. No loculated fluid collection.SPLEEN: No significant abnormality noted.PANCREAS: The pancreas enhances homogeneously. Remaining pancreatic ductal dilatation.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: Prominent porta hepatis and para-aortic lymph nodes, likely reactive.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: Nonspecific T2 hyperintense focus in the upper thoracic vertebra. T11 vertebral body lesion is favored to represent a hemangioma. T2 hyperintense lesion within the left iliac wing is nonspecific. Diffuse edema type signal within bilateral sacral alae.OTHER: No significant abnormality noted.

Output: 1.Contracted gallbladder with cholelithiasis. No intrahepatic or extrahepatic ductal dilation. No pericholecystic fluid. 2.Indeterminate osseous findings as detailed above. Consider dedicated imaging if clinically warranted.


Instruction: Generate impression based on findings.

Input: Left-sided weakness Again seen is evidence of cerebellar tonsillar ectopia, which measure up to 5 to 6 mm on the right and 4 to 5 mm on the left. Subtle differences in measurement compared to recent brain MRI may be related to differences in slice thickness. CSF spaces in the posterior fossa are mildly diminished.There is a prominence of the central canal throughout the cervical cord with more focal dilatation/syringohydromyelia measuring 1.6 x 1.1 mm at the mid C2 level and 1.8 x 2.4 mm at the mid C3 level (AP and transverse dimensions).Incidentally noted are multiple small perineural cysts involving the bilateral neural foramina throughout the cervical spine. T1 hyperintense lesion involving the T2 vertebral body is consistent with a hemangioma. There is a small focus of low T1 and low T2 signal involving the right posterior lateral aspect of the C3 vertebral body which may represent a sclerotic lesion and nonspecific. No abnormal enhancement within the cord or spine within the limitations of mildly motion degraded sequences. Vertebral body heights in the cervical spine are normal. There is loss of normal cervical lordosis; alignment is otherwise maintained. There is mild narrowing of the spinal canal on a congenital basis. There also mild degenerative changes as described below:C2-3: No significant compromise to the spinal canal or neural foramina.C3-4: No significant compromise to the spinal canal or neural foramina.C4-5: Small disc osteophyte complex. No significant compromise to the spinal canal or neural foramina.C5-6: Small disc osteophyte complex. No significant compromise to the spinal canal or neural foramina.C6-7: Small disc osteophyte complex. No significant compromise to the spinal canal or neural foramina.C7-T1: No significant compromise to the spinal canal or neural foramina.There is significant enlargement of the thyroid gland with right-sided nodule measuring up to 6 cm in the craniocaudal dimension.

Output: 1. Cerebellar tonsillar ectopia and small cervical syringohydromyelia, findings which are compatible with Chiari I. Please see details above.2. No significant spinal canal or neural foraminal stenosis at any level in the cervical spine.3. Partially imaged goiter with right-sided thyroid nodule measuring up to 6 cm in the craniocaudal dimension. Suggest ultrasound for further evaluation.


Instruction: Generate impression based on findings.

Input: Clinical question: History of L5-S1 discectomy. Evaluate scar tissue on the right, or herniation. Patient had a non infused MRI September. Signs and symptoms: Back pain, left foot numbness, right thigh pain. Pre and post enhanced lumbar MRI:The alignment of the vertebral column is anatomical.The signal intensity of the vertebral column is unremarkable.Examination at T11-T12 through L3-L4 levels is unremarkable other than mild hypertrophic changes of the posterior elements.L4-L5 demonstrate mild disc dessication, mild bilateral facet and ligamentum flavum hypertrophy without central spinal stenosis. There is a central and rightward shallow disc protrusion at this level with resultant right lateral recess and right L5 nerve root mass effect ( Axial T2 series 801 image 14 and sagittal T2 series 401 image 13). Mild right neural foraminal compromise, patent left and no central spinal stenosis.There is post operative changes of left laminotomy (axial T2 series 801 images 14 through 17) with resultant mild expansion of thecal sac and without significant epidural scaring (axial T2 series 801 images 14 through 17). There is no postoperative changes on the right as is requested clinically to be evaluated. L5-S1 demonstrate moderate disc disease and loss of disc height, mild bilateral ligamentum flavum and facet hypertrophy changes and no evidence of spinal stenosis or neural foraminal compromise. There is a linear increased T2 signal intensity in the annulus of the disc in the midline with expected enhancement representing an annular fissure.Normal signal intensity of the cor, conus and the cauda equina without abnormal enhancement.The paraspinal soft tissues remain unremarkable.

Output: 1.L4-L5 demonstrate degenerative changes as detailed. There is a central and rightward enhancing disc protrusion with resultant mass effect on the right lateral recess and right L5 nerve root. No spinal stenosis however mild right neural foraminal compromise secondary to degenerative changes is also detected. There is evidence of a chronic left-sided laminotomy with minimal epidural scarring. 2.L5-S1 demonstrate degenerative changes without neural foraminal or spinal stenosis. A central enhancing annular fissure at this level is detected.3.Unremarkable exam at other levels.4.There is no detectable postoperative changes on the right as is clinically questioned for evaluation for epidural scarring.


Instruction: Generate impression based on findings.

Input: 60 year old with metastatic breast cancer. Now with new stroke seen on MRI. Signs and symptoms: new stroke stroke seen on brain MRI. CTA of intracranial circulation:65 cc of omni-350 is administered for this study.3-D reformatted images of this study were obtained utilizing a independent workstation. These images were utilized for interpretation on this exam. Additional 2-D reformatted images as well as MIP images were also utilized.CTA of intracranial circulation:Examination demonstrates patent and normal appearing bilateral internal carotid arteries across to skull base and in their supraclinoid portions. There are normal appearing patent bilateral posterior communicating arteries.Bilateral ophthalmic arteries are also visualized and unremarkable.Bilateral anterior and middle cerebral arteries with no evidence of pathology. Anterior communicating artery is unremarkable.There is a small left vertebral artery (hypoplastic nondominant). The left pica is visualized and unremarkable. The distal portion of left vertebral artery is extremely small and hypoplastic. This is a normal anatomical variation.The patent dominant right vertebral artery is also very small in size in a uniform fashion. The right pica is visualized and unremarkable. The basilar artery is small in it's caliber in a uniform fashion however remains patent throughout its course.The small size of the vertebral -- basilar system is believed to be secondary to prominent bilateral posterior communicating arteries.None infuse head CT:Examination again demonstrates a large area of vasogenic edema surrounding a mass in the right lateral aspect of the cerebellum measuring approximately 34 x 25-mm in size as was noted on prior MRI exam. There is significant mass effect on the fourth ventricle and anterior displacement and partial collapse of the fourth ventricle. This results in early onset of hydrocephalus of supratentorial ventricular system. Mass-effect in the posterior fossa and results in minimal effacement of the quadrigeminal plate cistern as well.Images through supratentorial space again demonstrate a focus of attenuation in the left periventricular white consistent with patient's known acute stroke described on prior MRI. There is no evidence of hemorrhagic transformation. There is no evidence of any new finding since prior exam.

Output: 1.CTA of intracranial circulation demonstrates no detectable abnormality of bilateral internal carotid arteries, middle and anterior cerebral arteries and their branches. There are prominent bilateral posterior communicating arteries. There is small caliber of bilateral vertebral arteries and basilar artery in a uniform fashion which is believed to be due presence of large bilateral posterior communicating arteries. There is however no evidence of any definitive vascular lumen compromise of the vertebral -- basilar system infectious carotid disease and or dissection.2.None infuse head CT demonstrates right cerebellar tumor with surrounding vasogenic edema and mass effect on the fourth ventricle. Resultant mild hydrocephalus and supratentorial ventricles. These findings remain stable since prior MRI exam. Stable left periventricular white matter stroke with no interval change.


Instruction: Generate impression based on findings.

Input: 38-year-old female with pain. Rule out ankle ligamentous injury. TENDONS: The flexor and extensor tendons appear intact. The peroneal tendons appear intact. The Achilles tendon is normal in appearance.LIGAMENTS: The lateral collateral ligament complex appears intact. The distal tibiofibular syndesmotic complex appears intact. The imaged components of the deltoid ligament appear intact.ARTICULAR SURFACES AND BONE: There is increased bone marrow signal abnormality within the distal fibula and talus which may reflect a combination of bone contusion and degenerative change. Again seen is a comminuted fracture of the calcaneus with intra-articular extension to involve the posterior and middle facet of the subtalar joint as well as extending anteriorly to involve the calcaneocuboid articulation. There is serpentine signal abnormality within the calcaneal fracture fragment about the posterior facet of the subtalar joint, consistent with avascular necrosis. There is linear decreased signal abnormality within the body of the talus along the anterior aspect of the posterior facet of the subtalar joint which may represent a nondisplaced subchondral fracture. There is narrowing of the anterior aspect of the tibiotalar joint with subjective thinning of the articular cartilage. The tibiotalar joint alignment is otherwise anatomic. Mild degenerative changes affect the talonavicular articulation.ADDITIONAL

Output: Comminuted fracture of the calcaneus with intra-articular extension as described above. There is avascular necrosis of the calcaneal fracture fragment about the posterior facet of the subtalar joint. Probable nondisplaced subchondral fracture of the talus as described above. No evidence of ligamentous injury, as clinically questioned.


Instruction: Generate impression based on findings.

Input: Clinical question: Rule out mass. Signs and symptoms: Acute headache. Pre and post enhanced brain MRI:No acute intracranial process and negative diffusion-weighted images.Examination redemonstrates diffuse punctate foci of FLAIR hyperintensity in the subcortical white matter of bilateral cerebral hemispheres which are nonspecific and demonstrate no appreciable interval change since prior study. Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and brain myelination otherwise.The signal void of major intracranial arterial branches are identified.Post contrast images demonstrate no abnormal parenchymal or leptomeningeal enhancement.Normal signal intensity of intracranial venous sinuses and the normal pattern of enhancement.Unremarkable images through the orbits and including axial fat sat post enhanced series.Unremarkable calvarium and scalp and without abnormal enhancement.All the paranasal sinuses and bilateral mastoid air cells and middle ear cavities demonstrate normal pneumatization signal pattern.

Output: 1.No acute intracranial process and negative diffusion weighted series.2.Stable minute punctate and ventricular foci of hyperintensity which is a nonspecific finding.3.Unremarkable pre and post enhanced MRI exam otherwise.4.All paranasal sinuses and bilateral mastoid air cells and middle ear cavities demonstrate normal pneumatization signal patterns.


Instruction: Generate impression based on findings.

Input: The pituitary gland is not enlarged and there is no evidence of gross mass lesions, although the assessment is limited by the lack of intravenous contrast. The pituitary stalk lies in the midline. The suprasellar cistern, optic chiasm, cavernous sinuses and intracranial portions of the optic nerves appear to be intact. There is no evidence of intracranial hemorrhage or acute infarct. However, there are scattered T2 hyperintense lesions in the periventricular and subcortical white matter, a few of which are flame shaped in configuration. The ventricles and basal cisterns are unchanged in size and configuration. There is no midline shift or herniation. The skull and extracranial soft tissues are unremarkable. There is minimal mucosal thickening of the bilateral maxillary sinuses.

Output: 1. Limited non-contrast examination without evidence of gross mass lesions in the pituitary gland. 2. Several lesions in the periventricular and subcortical white matter likely represent demyelinating lesions, although these are incompletely characterized due to the lack of intravenous contrast.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: 63-year-old female with left knee pain, evaluate for re-tear of meniscus MENISCI: The posterior horn of the medial meniscus contains mixed signal and is blunted compatible with tearing. The body of the medial meniscus is near completely extruded medially. There is linear signal extending towards the articular edge of the medial meniscus at the body compatible with tearing. There is blunting of the posterior horn of the lateral meniscus compatible with a tear. Mild intrasubstance signal within the lateral meniscus compatible with intrasubstance degeneration. ARTICULAR CARTILAGE AND BONE: The articular surfaces of the medial tibiofemoral compartment are near completely devoid of articular cartilage. Abnormal marrow signal within the medial femoral condyle and tibial spine. There is severe thinning of the articular cartilage of the lateral tibiofemoral compartment.There are focal near full-thickness articular cartilage defects at the medial and lateral facets of the patella. Focal cartilage defect also seen within the intratrochanteric cartilage of the femur.LIGAMENTS: The cruciate and collateral ligaments are within normal limits.EXTENSOR MECHANISM: The extensor mechanism is intact.ADDITIONAL

Output: 1.Complex tearing of the posterior horn of the medial meniscus with near complete extrusion of the body of the medial meniscus. Peripheral tear within the body of the medial meniscus. 2.Blunting of the posterior horn of the lateral meniscus may represent a radial tear. 3.Severe osteoarthritis affects the knee, worst at the medial tibiofemoral compartment. 4.Articular cartilage defects, particularly at the patella as described above.


Instruction: Generate impression based on findings.

Input: A 65 year old male with history of coronary artery disease (myocardial infarction in 1990, left catheterization with stent implantation in 1998), normal left ventricular ejection fraction by a recent echocardiography, COPD, s/p cholecystectomy and primary amyloidosis. Referred to cardiac MRI to evaluate cardiac involvement of amyloidosis. Left VentricleThe left ventricle is normal in size with mild systolic dysfunction. The overall LV ejection fraction is 46%, the LV end diastolic volume index is 67 ml/m2 (normal range: 74+/-15), the LVEDV is 146 ml (normal range 142+/-34), the LV end systolic volume index is 36 ml/m2 (normal range 25+/-9), the LVESV is 79 ml (normal range 47+/-19). There is mild hypertrophy of the basal anterior septum (11-12mm). There is hypokinesis of the basal and middle segments of the inferior and infero-lateral walls. There is high signal of late gadolinium enhancement at the basal and middle segments of the inferior and infero-lateral walls. This finding suggest the presence of an underlying fibrosing process compatible with an old myocardial infarction. The involvement of this late gadolinium enhancement is more than 50% suggesting it is non-viable. There is a small area of the basal most infro-lateral segments with < 50% enhancement suggesting viability. In addition, there is a diffuse patchy enhancement in the septum and anteroseptum. Non-contrast T1 time of the IVS was 1212 msec.No evidence of iron overload.No LV thrombus noted.Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size with normal systolic function. The overall RV ejection fraction is 50%, the RV end diastolic volume index is 57 ml/m2 (normal range 82+/-16), the RVEDV is 125 ml (normal range 142+/-31), the RV end systolic volume index is 29 ml/m2 (normal range 31+/-9), and the RVESV is 63 ml (normal range 54+/-17).Right AtriumThe right atrium is mildly dilated.Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is no significant mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is trace pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is mild tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal brachiocephalic branching pattern. The aortic root is normal in size.Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is normal in size.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium.PericardiumThere is no obvious pericardial disease.Extracardiac FindingsThere is trace bilateral pleural effusion. This study is not designed for the specific evaluation of extra-cardiac findings; therefore, the differentiation between artifacts and real extracardiac pathology may be difficult. If clinically indicated, a separate dedicated evaluation should be considered.

Output: 1. The left ventricle is normal in size with mild systolic dysfunction, the LVEF is 46%. There is mild hypertrophy of the basal anterior septum (11-12mm). There is hypokinesis of the basal and middle segments of the inferior and infero-lateral walls.2. There is high signal of late gadolinium enhancement at the basal and middle segments of the inferior and infero-lateral walls. This finding suggest the presence of an underlying fibrosing process compatible with an old myocardial infarction. The involvement of this late gadolinium enhancement is more than 50% suggesting it is non-viable. There is a small area of the basal most infro-lateral segments with < 50% enhancement suggesting viability. 3. In addition, there is a diffuse patchy enhancement in the septum and anteroseptum. Non-contrast T1 time of the IVS was 1212 msec. This is consistent with cardiac amyloid.4. The right ventricle is normal in size with normal systolic function, the RVEF is 50%.


Instruction: Generate impression based on findings.

Input: 47 years, Female, worsening headaches, evaluate for Chiari malformation.. Again seen is caudal descent of the cerebellar tonsils, which measure 7 to 8 mm below the foramen magnum and similar to prior study from 6/2/2015. There is some loss of normal rounded contour of the cerebellar tonsils. There is crowding of the CSF spaces and diminished biphasic CSF flow ventrally and dorsally at the foramen magnum. Unchanged nonspecific punctate focus of T2/FLAIR hyperintensity in the left frontal lobe white matter. Unchanged T2/FLAIR hyperintensity in the left aspect of the pons. Unchanged subtle T2/FLAIR hyperintensity involving the globi pallidi. No restricted diffusion to suggest acute ischemia. No intracranial hemorrhage. No intracranial mass. No midline shift or uncal herniation. The ventricles are within normal limits in size and configuration. Again noted is a partially empty sella, similar to prior, with mild deformity of the pituitary gland. Major flow-voids are preserved. There is opacification of the right sphenoid sinus as before. Orbits, calvarium, and remainder of the extracranial soft tissue structures are grossly unremarkable.

Output: 1. Findings consistent with Chiari 1 and similar to prior study from 6/2/2015. There is diminished biphasic CSF flow at the foramen magnum.2. Partially empty sella with mild deformity of the pituitary gland. This finding may be postsurgical given reported history of pituitary tumor resection, but would suggest correlation with clinical findings for possibility of pseudotumor cerebri.3. Unchanged nonspecific focus of T2/FLAIR hyperintensity in the left aspect of the pons. There is also subtle T2/FLAIR hyperintensity in the bilateral globi pallidi which is also unchanged since 7/23/2014. These findings are nonspecific but may be related to remote toxic-metabolic injury.4. Chronic opacification of the right sphenoid sinus.


Instruction: Generate impression based on findings.

Input: Anesthesia of skin [R20.0], Reason for Study: ^Reason: stroke vs. stenosis History: left numbness Brain MRINo evidence of acute ischemic or hemorrhagic lesion.Multiple scattered high signal intensities on FLAIR/T2 images at bilateral periventricular white matter indicate non specific small vessel ischemic disease.The ventricles, sulci and cisterns are symmetric and unremarkable. There is no mass, mass effect, edema, midline shift, intra or extra-axial fluid collection/hemorrhage, restricted diffusion/acute ischemia, or abnormal contrast enhancement. The midline structures and cranial-cervical junction are normal. Normal flow voids are identified in the major intracranial vessels. The paranasal sinuses and mastoid air cells are clear.Neck MRA:3D MRA neck post-gadolinium images with maximum intensity projections of the cervical vasculature demonstrate, although tortuous course, normal flow enhancement in a normal aortic arch origin of the right brachiocephalic, left common carotid, and left subclavian arteries. The vertebral artery origins are normal. There is normal flow enhancement through the bilateral common carotid, carotid bifurcations, internal carotid, and vertebral arteries. There is web like lesion on the proximal left external carotid artery.

Output: 1. No evidence of acute ischemic or hemorrhagic lesion.2. Non specific small vessel ischemic disease.3. Web like structure on the proximal left ECA, otherwise there is no significant luminal narrowing or occlusion of major vessel on carotico-cervical arterial system. Vertebrobasilar system appears to be normal.


Instruction: Generate impression based on findings.

Input: 36 year old status post left breast stereotactic biopsy showed ALH and breast calcifications, Gail score at 5 years is 2.3%, lifetime risk in 35.5%. MRI requested for screening There is heterogeneous amount of fibroglandular tissue in both breasts. Few subcentimeter cysts noted in both breasts. Marked parenchymal enhancement is noted bilaterally limiting the sensitivity of MRI.Right Breast: Clip artifact identified in the right lower inner quadrant without adjacent abnormal enhancement. Left breast: Clip artifact identified in the upper outer quadrant posterior depth without abnormal enhancement adjacent to it. Clip placed at the time of benign biopsy at 6:00 position is difficult to identify on MRI but no abnormal enhancement is seen at 6:00 position. Benign oval slowly enhancing mass measuring 14 x 7 x 12 mm (AP x ML X CC) in the central posterior breast with a sonographic correlate (dated 8/12/16) most likely represents a benign fibroadenoma. Similar morphology mass measuring 5 x 5 x 3 mm (AP x ML X CC) is noted at 1:00 position, mid depth, most likely representing a benign fibroadenoma. No abnormal enhancement is seen in either breast. No abnormal axillary lymph nodes are identified in either axillary region.

Output: Limited evaluation due to marked parenchymal enhancement. Given these limitations, no MRI evidence for malignancy. Benign morphology masses in the left breast most likely represent benign fibroadenomas. Annual surveillance with MRI should be considered given the high risk of the patient based on the Gail score. BIRADS: 2 - Benign finding.RECOMMENDATION: NS - Routine Screening Mammogram.


Instruction: Generate impression based on findings.

Input: 56-year-old female with pelvic pain status post hysterectomy, vaginectomy and reconstruction, and sclerosis of pelvic cysts. Patient was pain-free for years. PELVIS:UTERUS, ADNEXA: Postoperative changes of hysterectomy without residual tissue.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: Again noted are bilateral subcentimeter foci within the labia that demonstrate T1 hyperintensity without contrast enhancement. The larger one on the left measures 1.0 x 0.7 cm (series 901, image 11) disease, previously measuring 0.8 x 0.7 cm.

Output: 1.Small unchanged bilateral Bartholin gland cysts containing high proteinaceous/hemorrhagic content.2.Postoperative changes of hysterectomy and vaginal reconstruction.


Instruction: Generate impression based on findings.

Input: Craniopharyngioma, status post resection. Abnormal involuntary movements. Previously seen heterogeneous, enhancing, cystic and solid lesion centered on the suprasellar cistern demonstrates further slight decrease in size, currently measuring approximately 3.7 x 3.5 cm in the AP and transverse dimensions, previously 3.9 x 3.7 cm in the axial plane. Craniocaudally, the lesion measures 3.2 cm, previously 3.3 cm. Slight decrease in cystic components involving the superior aspect of the mass is noted. Mass effect involving the sella and suprasellar cistern including the optic apparatus, proximal circle of Willis, as well as the cerebral peduncles is similar to prior. Splaying of the interpeduncular cistern is also similar to prior. Mild prominence of the lateral ventricles is not significantly changed and likely related to mass effect on the foramen of Monro. No additional parenchymal lesions are seen. Diffusion and susceptibility weighted sequences are significantly degraded related to artifact, presumably from dental hardware. Sequelae of prior right frontal craniotomy are noted.

Output: Continued slight decrease in size of the craniopharyngioma


Instruction: Generate impression based on findings.

Input: Reason: r/o stenosis History: upper extremity weaknessAdditional history from EMR: Recent cerebral angiogram showed spinal epidural fistula on the right C8 root sleeve draining into the posterior perimedullary vein and eventually draining into bilateral epidural plexus. Postcontrast axial images are limited due to inhomogeneous fat suppression.There are no subluxations. There is straightening of cervical lordosis. Vertebral body heights are maintained. Discs are desiccated but disc heights are maintained. The marrow signal is benign. The cervical cord is normal in signal. The cervicomedullary junction is normal. Spinal cord has a smooth contour and is without focal atrophy, edema, myelomalacia. Prominent serpentine flow voids are seen posterior to the spinal cord within the thecal sac, most conspicuous from approximately C4 to C7 vertebral bodies although also visualized more cranially along the rest of the cervical spine with corresponding enhancement, corresponding to prior CTA neck findings, and again suggestive of dural arteriovenous fistula. There is no associated cord signal abnormality at any level.Redemonstration of recent right anterolateral cerebellar infarct with additional foci of other bilateral cerebellar and medullary T2 hyperintensity and susceptibility artifacts that are difficult to compare directly due to slice differences but grossly present. This includes the more recent right lateral cerebellar infarct, which is evolving. Fluid in the visualized left mastoid air cells, middle ear cavity, and paranasal sinuses. There is increased STIR signal in the musculature and subcutaneous tissue overlying the suboccipital region with mild enhancement of the deep soft tissues in this region.There are small foci of T2 hyperintensities in the right thyroid. Tracheostomy tube in place with fluid noted deep to the tip. Enlarged lymph node noted medial to the left inferior parotid gland and abutting the sternocleidomastoid muscle, which increased in size from prior CT, nonspecific but likely reactive.C1/2: No significant spinal canal stenosis or foraminal narrowing.C2/3: No significant spinal canal stenosis. Bilateral mild facet arthropathy with mild narrowing of the left foramina.C3/4: Mild posterior disc bulge with mild spinal canal stenosis. There is moderate bilateral foraminal narrowing.C4/5: Mild posterior disc bulge with mild spinal canal stenosis. There is moderate bilateral foraminal narrowing.C5/6: Mild posterior disc bulge with mild spinal canal stenosis. There is mild bilateral foraminal narrowing.C6/7: Mild to moderate posterior disc bulge with mild to moderate spinal canal stenosis. No significant foraminal narrowing.C7/T1: Partial fusion of the posterior elements and the vertebral bodies with diminutive disk, consistent with a segmentation anomaly. There is bilateral mild to moderate developmental foraminal narrowing.T1/T2: Hypertrophy of the ligamentum flavum with mild to moderate bilateral foraminal narrowing, seen on sagittal view only.

Output: 1.Multiple tiny serpentine flow voids seen predominantly posterior to the cervical cord, consistent with previously diagnosed dural AF fistula. This is better seen on prior angiogram. No associated cord signal abnormality.2.Multilevel degenerative disc disease of the C3/4-C5/6 levels and upper thoracic spine.3.Partial fusion of C7 and T1, consistent with segmentation anomaly, with developmental narrowing of foramina.4.Redemonstration of cerebellar and medullary ischemia and foci of chronic hemosiderin deposition.


Instruction: Generate impression based on findings.

Input: 9 months old with post-operative seizure secondary to hypoglycemia. There is no evidence of intracranial hemorrhage, mass, or acute infarct. The brain parenchyma appears normal. The medial temporal lobes appear symmetric. The anterior and posterior pituitary normal in appearance. 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, paranasal sinuses, and scalp soft tissues are unremarkable. There are minimal bilateral mastoid effusions.

Output: 1. No discernible seizure focus or stigmata of hypoglycemic encephalopathy.2. Nonspecific minimal bilateral mastoid effusions.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: Clinical question: Evaluate brain, abnormal VNG- upbeating nystagmus. Dizziness. Signs and symptoms: Dizziness. Pre-and post enhancement MRI:No diffusion weighted abnormalities.Examination demonstrates patchy foci of flair hyperintensity in the periventricular and subcortical white matter of bilateral cerebral hemispheres, bilateral basal ganglial, bilateral thalamus and a single focus in the pons. Considering patient's stated age of 69 the findings are highly suggestive of chronic small vessel ischemic strokes and mild to moderate decreased.There is mild prominence of supratentorial ventricles and subtle prominence of cortical sulci.Susceptibility MRI images demonstrate several punctate foci of susceptibility in bilateral cerebellar hemispheres, pons and bilateral cerebral hemispheres consistent with chronic microhemorrhages.Post enhanced images demonstrate no abnormal parenchymal or meningeal enhancement. There is normal enhancement of intracranial venous sinuses. No abnormal enhancement of the calvarium or the orbits.The signal voids of major intracranial arterial branches are identified.

Output: 1.Negative diffusion weighted images.2.Findings of mild to moderate chronic small vessel ischemic strokes as detailed. Several small foci of susceptibility in bilateral cerebral, cerebellar hemispheres and pons consistent with chronic microhemorrhages.3.No detectable abnormal enhancement of brain parenchyma, leptomeninges, calvarium or the orbits.


Instruction: Generate impression based on findings.

Input: Increasing headache. History of resected third ventricular colloid cyst. There are post-operative findings related to transcallosal resection of a ventricular colloid cyst, a small amount of encephalomalacia in the right superior frontal gyrus. There are punctate foci in the region along the margins of the third ventricle, which may represent chronic blood products, but no discernible lesion in the ventricular system, which appears to be unchanged in size and configuration. There is no evidence of intracranial hemorrhage, mass, or acute infarct. There is no abnormal intracranial enhancement. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, paranasal sinuses, and scalp soft tissues are grossly unremarkable. There is plagiocephaly.

Output: Post-operative findings related to transcallosal resection of a ventricular colloid cyst without discernible evidence of recurrence.


Instruction: Generate impression based on findings.

Input: Ms. Powers is a 54 year old female with complicated surgical history including recent excisional biopsy in 11/2015 for recurrent secretory carcinoma with close cranial inked surgical margin. She presents today for MRI for further evaluation. There is heterogeneous amount of fibroglandular tissue in both breasts. Mild background parenchymal enhancement is noted bilaterally.Bilateral retroglandular silicone implants are intact.RIGHT BREAST:In the right retroareolar region, there is irregular enhancement along with associated architectural distortion identified, measuring approximately 2.6 x 2.9 x 2.2 cm (AP x ML x SI). This measures approximately 3.2 cm in AP oblique dimension. The enhancement extends from the anterior aspect of the implant to the nipple. Based on the history of multiple excisional biopsies/lumpectomies, it is unclear whether this enhancement represents residual disease versus post-surgical changes.However, there is no additional abnormal enhancement identified elsewhere in right breast. LEFT BREAST:There is no abnormal enhancement in the left breast. AXILLAE:No abnormal axillary lymph nodes are identified in either axillary region.

Output: (1) 3.2 cm area of irregular enhancement in the right retroareolar region, spanning from the implant to the nipple. Based on the history of multiple excisional biopsies/lumpectomies, it is unclear whether this enhancement represents residual disease versus post-surgical changes. However, this MR-detected area of enhancement does correspond in distribution and location to the mammographically detected residual calcifications on recent diagnostic workup (from 05/24/2016), favoring residual disease.(2) No MRI evidence of malignancy in the left breast. BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: B - Surgical Consultation.


Instruction: Generate impression based on findings.

Input: Invasive right tongue squamous cell carcinoma pT2N0 status post glossectomy with margin positive at deep lateral edge, repeat excision margin negative. There are postoperative findings related to right glossectomy with flap reconstruction and neck dissection. There is no gross tumor in this region. There are a few nodules in the right parotid gland that are unchanged and likely represent lymph nodes. There is no evidence of significant cervical lymphadenopathy. There is mild mucosal thickening in the maxillary sinuses. The osseous structures appear to be grossly intact. The thyroid gland, orbits, and imaged intracranial structures are unremarkable.

Output: 1. Post-treatment findings in the oral cavity without evidence of gross tumor recurrence. 2. Postoperative findings related to neck dissection, without evidence of significant lymphadenopathy in the neck.