A crescentic left paramedian extra-axial collection is noted at the vertex, underlying the anterior fontanelle, which on coronal reconstruction system crosses the midline, possibly involving the superior sagittal sinus. Given this location and appearance, the differential diagnosis includes venous epidural hemorrhage versus subdural hemorrhage. Separately, there is a 24-mm AP by 19-mm transverse by 25-mm craniocaudal collection within the mid falx demonstrating a fluid or level consistent with an intra-falcine subdural hematoma. Subdural hemorrhage is also noted elsewhere involving the falx as well as along bilateral tentorial leaflets. Scattered subarachnoid hemorrhage is also evident. An intracranial pressure monitoring device is been placed via the right frontal bone without evidence of post-procedural complication. Overlying scalp swelling is noted. The ventricles and sulci are normal in size. There is no midline shift. Fluid is present within bilateral middle ear cavities and mastoid air cells. The patient is intubated.
anatomical entity_fin: {'vertex': {}, 'fontanelle': {'location descriptor': 'anterior'}, 'superior sagittal sinus': {}}location descriptor_fin: ['left', 'anterior', 'midline']clinical findings_fin: {'crescentic left paramedian extra-axial collection is noted at the vertex , underlying': {'clinical finding': 'crescentic left paramedian extra-axial collection is noted at the vertex , underlying'}}clinical findings_fin: {'venous epidural hemorrhage': {'clinical finding': 'venous epidural hemorrhage', 'cf_snomed': {'hemorrhage': 50960005}, 'existence': 'pos_dx', 'descriptive_term': 'venous epidural', 'observation': 'hemorrhage'}, 'subdural hemorrhage': {'clinical finding': 'subdural hemorrhage', 'cf_snomed': {'subdural hemorrhage': 35486000}, 'existence': 'pos_dx', 'descriptive_term': 'subdural', 'observation': 'hemorrhage'}}size_fin: [{'size': '24-mm', 'size_descriptor': 'ap'}, {'size': '19-mm', 'size_descriptor': 'transverse'}, {'size': '25-mm', 'size_descriptor': 'collection'}]anatomical entity_fin: {'fluid': {}}imaging observation_fin: ['falx']clinical findings_fin: {'intra-falcine subdural hematoma': {'clinical finding': 'intra-falcine subdural hematoma', 'cf_snomed': {'subdural hematoma': 95453001}, 'existence': 'unc_dx', 'descriptive_term': 'intra-falcine subdural', 'observation': 'hematoma'}}imaging observation_fin: ['falx']location descriptor_fin: ['bilateral']clinical findings_fin: {'subdural hemorrhage': {'clinical finding': 'subdural hemorrhage', 'cf_snomed': {'subdural hemorrhage': 35486000}, 'existence': 'pos_dx', 'descriptive_term': 'subdural', 'observation': 'hemorrhage'}}clinical findings_fin: {'scattered subarachnoid hemorrhage': {'clinical finding': 'scattered subarachnoid hemorrhage', 'cf_snomed': {'subarachnoid hemorrhage': 21454007}, 'existence': 'pos_dx', 'descriptive_term': 'scattered subarachnoid', 'observation': 'hemorrhage'}}anatomical entity_fin: {'frontal bone': {'location descriptor': 'right'}}location descriptor_fin: ['right']clinical findings_fin: {'intracranial pressure': {'clinical finding': 'intracranial pressure', 'cf_snomed': {'pressure': 13543005}, 'existence': 'pos_dx', 'descriptive_term': 'intracranial', 'observation': 'pressure'}, 'post-procedural complication': {'clinical finding': 'post-procedural complication', 'existence': 'neg_dx', 'descriptive_term': 'post-procedural', 'observation': 'complication'}}anatomical entity_fin: {'scalp': {}}clinical findings_fin: {'overlying scalp swelling': {'clinical finding': 'overlying scalp swelling', 'cf_snomed': {'swelling': 65124004}, 'existence': 'pos_dx', 'descriptive_term': 'overlying scalp', 'observation': 'swell'}}clinical findings_fin: {'ventricles and sulci are normal in size': {'clinical finding': 'ventricles and sulci are normal in size'}}location descriptor_fin: ['midline']clinical findings_fin: {'midline shift': {'clinical finding': 'midline shift', 'cf_snomed': {'shift': 9546005}, 'existence': 'neg_dx', 'descriptive_term': 'midline', 'observation': 'shift'}}anatomical entity_fin: {'fluid': {}, 'middle ear cavities': {'location descriptor': 'bilateral'}, 'mastoid air cells': {}}location descriptor_fin: ['bilateral']clinical findings_fin: {'mastoid air cells': {'clinical finding': 'mastoid air cells', 'existence': 'pos_dx', 'descriptive_term': 'mastoid air', 'observation': 'cell'}}
<s>[INST] Write the finding section for a radiology report based on the following information: anatomical entity_fin: {'vertex': {}, 'fontanelle': {'location descriptor': 'anterior'}, 'superior sagittal sinus': {}}location descriptor_fin: ['left', 'anterior', 'midline']clinical findings_fin: {'crescentic left paramedian extra-axial collection is noted at the vertex , underlying': {'clinical finding': 'crescentic left paramedian extra-axial collection is noted at the vertex , underlying'}}clinical findings_fin: {'venous epidural hemorrhage': {'clinical finding': 'venous epidural hemorrhage', 'cf_snomed': {'hemorrhage': 50960005}, 'existence': 'pos_dx', 'descriptive_term': 'venous epidural', 'observation': 'hemorrhage'}, 'subdural hemorrhage': {'clinical finding': 'subdural hemorrhage', 'cf_snomed': {'subdural hemorrhage': 35486000}, 'existence': 'pos_dx', 'descriptive_term': 'subdural', 'observation': 'hemorrhage'}}size_fin: [{'size': '24-mm', 'size_descriptor': 'ap'}, {'size': '19-mm', 'size_descriptor': 'transverse'}, {'size': '25-mm', 'size_descriptor': 'collection'}]anatomical entity_fin: {'fluid': {}}imaging observation_fin: ['falx']clinical findings_fin: {'intra-falcine subdural hematoma': {'clinical finding': 'intra-falcine subdural hematoma', 'cf_snomed': {'subdural hematoma': 95453001}, 'existence': 'unc_dx', 'descriptive_term': 'intra-falcine subdural', 'observation': 'hematoma'}}imaging observation_fin: ['falx']location descriptor_fin: ['bilateral']clinical findings_fin: {'subdural hemorrhage': {'clinical finding': 'subdural hemorrhage', 'cf_snomed': {'subdural hemorrhage': 35486000}, 'existence': 'pos_dx', 'descriptive_term': 'subdural', 'observation': 'hemorrhage'}}clinical findings_fin: {'scattered subarachnoid hemorrhage': {'clinical finding': 'scattered subarachnoid hemorrhage', 'cf_snomed': {'subarachnoid hemorrhage': 21454007}, 'existence': 'pos_dx', 'descriptive_term': 'scattered subarachnoid', 'observation': 'hemorrhage'}}anatomical entity_fin: {'frontal bone': {'location descriptor': 'right'}}location descriptor_fin: ['right']clinical findings_fin: {'intracranial pressure': {'clinical finding': 'intracranial pressure', 'cf_snomed': {'pressure': 13543005}, 'existence': 'pos_dx', 'descriptive_term': 'intracranial', 'observation': 'pressure'}, 'post-procedural complication': {'clinical finding': 'post-procedural complication', 'existence': 'neg_dx', 'descriptive_term': 'post-procedural', 'observation': 'complication'}}anatomical entity_fin: {'scalp': {}}clinical findings_fin: {'overlying scalp swelling': {'clinical finding': 'overlying scalp swelling', 'cf_snomed': {'swelling': 65124004}, 'existence': 'pos_dx', 'descriptive_term': 'overlying scalp', 'observation': 'swell'}}clinical findings_fin: {'ventricles and sulci are normal in size': {'clinical finding': 'ventricles and sulci are normal in size'}}location descriptor_fin: ['midline']clinical findings_fin: {'midline shift': {'clinical finding': 'midline shift', 'cf_snomed': {'shift': 9546005}, 'existence': 'neg_dx', 'descriptive_term': 'midline', 'observation': 'shift'}}anatomical entity_fin: {'fluid': {}, 'middle ear cavities': {'location descriptor': 'bilateral'}, 'mastoid air cells': {}}location descriptor_fin: ['bilateral']clinical findings_fin: {'mastoid air cells': {'clinical finding': 'mastoid air cells', 'existence': 'pos_dx', 'descriptive_term': 'mastoid air', 'observation': 'cell'}} [/INST] A crescentic left paramedian extra-axial collection is noted at the vertex, underlying the anterior fontanelle, which on coronal reconstruction system crosses the midline, possibly involving the superior sagittal sinus. Given this location and appearance, the differential diagnosis includes venous epidural hemorrhage versus subdural hemorrhage. Separately, there is a 24-mm AP by 19-mm transverse by 25-mm craniocaudal collection within the mid falx demonstrating a fluid or level consistent with an intra-falcine subdural hematoma. Subdural hemorrhage is also noted elsewhere involving the falx as well as along bilateral tentorial leaflets. Scattered subarachnoid hemorrhage is also evident. An intracranial pressure monitoring device is been placed via the right frontal bone without evidence of post-procedural complication. Overlying scalp swelling is noted. The ventricles and sulci are normal in size. There is no midline shift. Fluid is present within bilateral middle ear cavities and mastoid air cells. The patient is intubated. </s>