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10005858-RR-122

RR

2172-07-16 15:12:00

2172-07-17 19:13:00

STUDY: MRI of the lumbar spine. CLINICAL INDICATION: ___ female patient, with history of right lower extremity weakness, low back pain, assess for fracture or nerve root compression. COMPARISON: Multiple prior MRI examinations of the lumbar spine, the most recent dated ___. TECHNIQUE: Sagittal T1, T2 and sagittal STIR sequences were obtained throughout the lumbar spine. Axial T2-weighted images were also obtained. FINDINGS: Again grade 1 anterolisthesis is redemonstrated at L3 upon L5 level. There is an unchanged posterior disc protrusion and disc degenerative changes at T10/T11, causing anterior thecal sac deformity and impinging the thecal sac, unchanged since ___. The conus medullaris is normal and terminates at the level of T12. At L1/L2 level, there is disc desiccation and posterior disc bulging, causing bilateral neural foraminal narrowing, unchanged since the prior study. Moderate articular joint facet hypertrophy is present at this level. At L2/L3 level, there is disc desiccation and posterior broad-based disc bulge, causing bilateral neural foraminal narrowing, unchanged since the prior study. Bilateral articular joint facet hypertrophy is present, with bilateral joint effusions, apparently new since the prior examination (image #18, series #5). At L3/L4 level, there is disc desiccation and uncovering disc related with mild retrolisthesis, which is unchanged since the prior study. Bilateral articular joint facet hypertrophy and ligamentum flavum thickening are present, resulting in moderate-to-severe spinal canal stenosis, more pronounced since the prior study. At L4/L5 level, there is disc desiccation, posterior broad-based disc protrusion and uncovering disc related with anterolisthesis as described above, unchanged since the prior study, causing bilateral neural foraminal narrowing. Unchanged articular joint facet hypertrophy is present. At L5/S1 level, there is disc desiccation and posterior disc bulging, causing left side neural foraminal narrowing, unchanged since the prior study. The sacroiliac joints are unremarkable. IMPRESSION: 1. Articular joint facet hypertrophy and new articular joint effusions are demonstrated at L2/L3 level. 2. At L3/L4 level, there is bilateral articular joint facet hypertrophy and ligamentum flavum thickening, resulting in moderate-to-severe spinal canal stenosis, more pronounced since the prior study. 3. At L5/S1 level, there is disc desiccation and posterior disc bulging, causing left side neural foraminal narrowing, unchanged since the prior study.

10005858-RR-123

RR

2172-07-17 22:36:00

2172-07-18 11:11:00

CLINICAL HISTORY: Preop chest x-ray for lumbar surgery. CHEST, AP FILM: Cardiac size is at the upper limits of normal. The lung fields are clear. The costophrenic angles are sharp. IMPRESSION: No acute disease.

10005858-RR-124

RR

2172-07-18 15:24:00

2172-07-19 07:41:00

INDICATION: L2-L5 fusion and laminectomy COMPARISON: MR lumbar spine ___. TECHNIQUE: Three views obtained in the OR without a radiologist present. FINDINGS: The initial image shows surgical device posterior to L5. Subsequent images show placement of posterior pedicle screws at what appears to be L3, L4 and L5. Spondylolisthesis of L3 relative to L4 and L4 relative to L5 noted, similar in appearance compared to the prior MRI from ___. IMPRESSION: Intraoperative images from a posterior spinal fusion.

10005858-RR-126

RR

2172-08-10 16:45:00

2172-08-10 17:32:00

EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Fever. ___. FINDINGS: The patient is rotated to the left. No definite focal consolidation is seen. There is persistent mild elevation of the right hemidiaphragm. No pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable. IMPRESSION: Persistent mild elevation of the right hemidiaphragm. Otherwise, no acute cardiopulmonary process.

10005858-RR-127

RR

2172-08-10 20:44:00

2172-08-10 23:34:00

HISTORY: ___ s/p L laminectomy & fusion with fever, back pain, redness @ incision. Total laminectomy of L2, L3, L4 and L5. Fusion and instrumentation L3-5. Autograft. TECHNIQUE: Multi planar multisequence MR images of the lumbar and thoracic spine were obtained the without the administration of intravenous contrast. Contrast was not administered due to patient request for exam termination, rendering suboptimal evaluation. COMPARISON: MRI L-spine ___. FINDINGS: Patient motion artifact degrades image quality rendering suboptimal evaluation. Within these confines: MR thoracic spine: Review of the osseous structures demonstrates normal vertebral alignment. Bone marrow signal is mildly heterogeneous without focal suspicious signal abnormality. At T8-T9 and T10-T11, there is disc protrusion partially effacing the ventral thecal sac causing mild spinal canal narrowing in conjunction with ligamentum flavum thickening, as well as mild left-greater-than-right neural foraminal narrowing. The remaining intervertebral disc spaces appear to be within normal limits without disk herniation, or significant spinal canal or neural foraminal narrowing. The visualized portion of the spinal cord has normal contours and signal characteristics. MR lumbar spine: Axial images through the lumbar spine were not obtained due to early termination of the examination per patient request. The patient is status post L2-L5 laminectomy with fusion of L3-L5. There is a 9.8 SI x 5.1 AP cm fluid collection within the laminectomy sites causing moderate to severe mass effect upon the thecal sac with anterior displacement and at least moderate compression of the nerve roots. No definite tract is identified to the thecal sac. There is a another 17.8 x 5.2 cm fluid collection within the dorsal subcutaneous tissues posterior to the laminectomy site extending from the level of T12-S2. There appears to be a possible connecting channel between the 2 fluid collections just beneath the L1 spinous process. Edematous changes are noted within the paraspinal soft tissues, which may be postsurgical in nature ; however, superimposed infection cannot exclude. Again noted is grade 1 anterolisthesis of L3 over L4 and L4 over L5 with uncovering of disk space posteriorly. The visualized portion of the lower thoracic cord and conus are within normal limits. The conus is at the level of L1. IMPRESSION: Markedly limited examination secondary to patient motion artifact, patient request for early termination and preclusion of intravenous contrast administration. Status post L2-L5 laminectomy and fusion of L3-L5 with fluid collection within the laminectomy sites causing moderate to severe mass effect upon the thecal sac and compression of nerve roots anteriorly. Second fluid collection within the dorsal subcutaneous tissues posterior to the laminectomy site with a possible connecting channel just beneath L1 spinous process. Findings may be related to postoperative seroma, hematoma, pseudomeningocele, or abscess. Thoracolumbar spondylosis as described above.

10005858-RR-128

RR

2172-08-15 10:10:00

2172-08-15 11:44:00

HISTORY: PICC placement. FINDINGS: In comparison with study of ___, there has been placement of a left subclavian PICC line that extends to about the junction of the brachiocephalic vessel and the SVC. Cardiac silhouette remains somewhat enlarged with tortuosity of the aorta. There is displacement of the lower cervical trachea to the left, consistent with a right thyroid mass. The position of the central catheter has been telephoned to ___, a venous access nurse.

10005858-RR-129

RR

2172-08-16 09:50:00

2172-08-16 11:58:00

HISTORY: PICC exchange. FINDINGS: In comparison with study of ___, the left subclavian PICC line now extends to the lower portion of the SVC. No evidence of acute cardiopulmonary disease.

10005866-RR-31

RR

2149-02-11 10:32:00

2149-02-11 11:23:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ with h/o cirrhosis c/o 3 days worsening ruq abdominal pain// ?portal venous thrombosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___ ultrasound FINDINGS: LIVER: The liver is coarsened and nodular in echotexture. The contour of the liver is nodular, consistent with cirrhosis. There is a 1.6 cm echogenic focus within the mid right hepatic lobe, peripherally, for which follow-up MR for further evaluation is recommended. There is a new partially occlusive thrombus visualized within the main portable vein. The central branches of the main pulmonary artery are not well assessed. The main portable vein demonstrates normal hepatopetal flow. There is a large volume ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm. GALLBLADDER: There is no evidence of stones. PANCREAS: Overlying bowel gas limits adequate visualization and assessment of the pancreas. SPLEEN: 13.7 cm splenomegaly is noted today, previously measuring 12 cm ___. Normal echogenicity. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cirrhosis with new partially occlusive thrombus within the main portal vein. 2. Large volume ascites. 3. Worsening splenomegaly measuring 13.7 cm today, previously measuring 12 cm ___. 4. New 1.6 cm focus within the right hepatic lobe is incompletely characterized. Follow-up MR for further evaluation is recommended.

10005866-RR-32

RR

2149-02-11 12:39:00

2149-02-11 13:16:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with h/o cirrhosis c/o 3 days worsening ruq abdominal pain// ?pneumonia COMPARISON: ___ FINDINGS: PA and lateral views of the chest provided. There is blunting of the right CP angle indicative of a small effusion. Otherwise the lungs are clear. Cardiomediastinal silhouette appears normal. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: Tiny right pleural effusion, otherwise unremarkable exam.

10005866-RR-33

RR

2149-02-11 12:51:00

2149-02-11 13:56:00

EXAMINATION: CT abdomen and pelvis INDICATION: ___ with h/o cirrhosis and multiple abdominal surgeries c/o 3 days worsening ruq abdominal pain and vomiting TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 665 mGy-cm. COMPARISON: Prior CT of the abdomen pelvis from ___ FINDINGS: LOWER CHEST: Trace right pleural effusion noted with associated atelectasis in the right lower lobe. The heart appears within normal limits of size. Multiple periesophageal varices are noted near the GE junction. ABDOMEN: HEPATOBILIARY: The liver is nodular and heterogeneous in enhancement consistent with known cirrhosis. Extensive portosystemic varices are noted. No discrete liver lesion is seen though parenchyma appears diffusely heterogeneous. There is partially occlusive thrombus in the main portal vein which is new from prior. The gallbladder appears partially distended containing a stone. No biliary ductal dilation is seen. PANCREAS: The pancreas appears normal. SPLEEN: The spleen is normal in size without focal abnormality. There is a splenule. The splenic vein is patent. ADRENALS: Both right and left adrenal glands are normal. URINARY: The kidneys enhance symmetrically and demonstrate prompt excretion of contrasts. There are renal cortical hypodensities most suggestive of simple cysts, largest in the interpolar right kidney measuring to 3.1 x 4.2 cm. GASTROINTESTINAL: Stomach and duodenum appear grossly unremarkable. There is a moderate volume of ascites, which is partially loculated in the right upper quadrant abutting the liver. Partial loculation may reflect prior bowel surgery versus prior paracentesis. Loops of small bowel appear mildly distended, contrast filled without transition point to suggest a bowel obstruction. This appearance likely reflect a mild ileus. The appendix appears normal. The colon is minimally thickened along the right upper quadrant likely due to portal colopathy. No free air. PELVIS: The urinary bladder is only partially distended. Prostate does not appear enlarged. No pelvic sidewall or inguinal adenopathy. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Aortoiliac calcification is notable without aneurysmal dilation. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Degenerative disc disease most pronounced at at L5-S1 with loss of disc space and vacuum disc phenomenon. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Cirrhosis with evidence of portal hypertension with moderate volume ascites partially loculated in the right upper quadrant, extensive portosystemic varices. Partially occlusive thrombus in the main portal vein. 2. Small bowel distention without obstruction may reflect ileus. Mild thickening of the proximal colon may reflect portal colopathy. 3. Trace right pleural effusion with chronic appearing atelectasis in the right lower lung. 4. Extensive atherosclerotic disease of the aorta.

10006029-RR-61

RR

2169-09-29 05:06:00

2169-09-29 05:42:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with history of biliary obstruction now with jaundice and fever.// eval for CBD dilation TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___ liver gallbladder ultrasound, ___ MRCP. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is persistent mildleft intrahepatic biliary dilation. The CHD measures 7 mm. A CBD stent is partially visualized GALLBLADDER: Sludge is again noted within the gallbladder without gallbladder wall thickening or pericholecystic fluid. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 10.1 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. Patient is status post left nephrectomy. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Persistent mild left intrahepatic biliary dilation in presence of a partially visualized CBD stent raises concern for stent malfunction. Compared to the prior ultrasound, the degree of intrahepatic biliary dilation has not changed significantly. 2. Persistent gallbladder sludge. RECOMMENDATION(S): Please note that MRCP will not add any additional benefit. ERCP may be considered. NOTIFICATION: The updated findings and recommendations were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:01 am, 1 minutes after discovery of the findings.

10006029-RR-62

RR

2169-10-01 11:25:00

2169-10-01 16:16:00

INDICATION: ___ year old man with PICC// Pt had a L PICC,49cm ___ ___ Contact name: ___: ___ TECHNIQUE: Single AP view of the chest. COMPARISON: Multiple prior chest CTs, most recently dated ___. FINDINGS: Left PICC line tip terminates in the distal SVC near the superior cavoatrial junction. Lung volumes are relatively expanded. There is a focal opacity projecting over the left midlung consistent with pneumonia. The cardiomediastinal silhouette and hilar silhouette are normal. Pleural surfaces are normal. IMPRESSION: 1. Left midlung pneumonia. 2. Left PICC line terminates in the distal SVC. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 16:14 into the Department of Radiology critical communications system for direct communication to the referring provider.

10006029-RR-63

RR

2169-10-01 17:40:00

2169-10-01 17:56:00

EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST INDICATION: ___ year old man with metastatic clear cell RCC on experimental trial due for surveillance CT// surveillance CT TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was done as part of CT torso with IV contrast. A single bolus of IV contrast was injected and the abdomen and pelvis were scanned in the portal venous phase, followed by scan of the abdomen in equilibrium (3-min delay) phase. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 10.6 s, 68.9 cm; CTDIvol = 14.0 mGy (Body) DLP = 954.8 mGy-cm. 2) Spiral Acquisition 4.9 s, 31.9 cm; CTDIvol = 15.9 mGy (Body) DLP = 498.4 mGy-cm. Total DLP (Body) = 1,453 mGy-cm. COMPARISON: CT dated ___. MR dated ___. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is mild intrahepatic and extrahepatic biliary ductal dilatation, with the CBD measuring 8 mm. A CBD stent is in place, terminating in the duodenum. A focus of pneumobilia in the left hepatic lobe likely relates to stent placement. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. Relative increased density of the distal pancreatic tail was previously characterized on MR as normal parenchyma, with lipomatosis of the body and proximal pancreatic tail. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The patient is status post left total nephrectomy. There is a 2.4 x 1.2 cm soft tissue mass in the nephrectomy bed, unchanged from prior when measured with similar technique. The left kidney enhances normally. Focal cortical thinning in the interpolar region and in the upper pole of the right kidney is re-demonstrated, likely representing scarring from prior insult. A 1.2 cm hypodensity arising from the lower pole of the right kidney is again seen, previously characterized on MRI as a simple cyst. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Diverticulosis of the colon is noted, without evidence of wall thickening and fat stranding. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged and the seminal vesicles are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Nonocclusive thrombus is noted in the main portal vein (2:60), difficult to compare to MR due to differences in imaging technique, though appears slightly increased in size, with no extension to the intrahepatic branches. There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: A left inguinal hernia containing fat is noted. IMPRESSION: 1. No evidence of local recurrence or metastatic disease in the abdomen and pelvis. 2. Mild intrahepatic and extrahepatic biliary ductal dilatation, with CBD stent in place. 3. Known nonocclusive main portal vein thrombus appears increased in size, though difficult to directly compare to MR due to differences in imaging technique.

10006029-RR-64

RR

2169-10-01 09:51:00

2169-10-01 17:59:00

EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ man metastatic renal cell carcinoma on experimental trial. Surveillance CT. TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with intravenous infusion of nonionic, iodinated contrast agent, following oral administration of contrast agent for selected abdominal studies, and/or followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck will be reported separately. All images of the chest were reviewed. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. COMPARISON: Compared to chest CT scans since ___, most recently ___. Read in conjunction with conventional chest radiographs ___. FINDINGS: CHEST PERIMETER: There are no thyroid findings warranting further imaging evaluation. Supraclavicular and axillary lymph nodes are not enlarged and there is no soft tissue abnormality in the imaged chest wall concerning for malignancy. Findings below the diaphragm will be reported separately. CARDIO-MEDIASTINUM:Mid and upper esophagus are severely dilated with air, more so today than in ___. Esophageal dysmotility should be considered. Atherosclerotic calcification is mild in head and neck vessels, substantial in major coronary arteries. Aortic valve is not calcified. Aorta and pulmonary arteries and cardiac chambers are normal size and pericardium is physiologic. THORACIC LYMPH NODES: Mild enlargement left hilar and right posterior paraesophageal mediastinal lymph nodes, 13 mm, unchanged since ___. Smaller, measurable lymph nodes in other mediastinal stations and right hilus are minimally larger today. Pattern does not suggest malignancy. LUNGS, AIRWAYS, PLEURAE: Large region of pneumonia in the left upper lobe extends from dense perihilar consolidation inferiorly reaching into the lingula, to peribronchial ground-glass and acinar nodulation in the anterior segment. Central bronchi are patent. Minor bronchiolar nodulation has developed in the right lung, presumably a manifestation same infection. Reticulation at the lung bases associated with new tiny pleural effusions is probably residual edema. CHEST CAGE: Degenerative ankylosis in the thoracic spine is heavy. There is no pathologic or compression fracture or destructive bone lesion. IMPRESSION: Non obstructive pneumonia, left upper lobe. Minimal residual pulmonary edema and pleural effusions attributable to heart failure. Atherosclerotic coronary calcification. Left PIC line ends just above the superior cavoatrial junction.

10006029-RR-65

RR

2169-10-03 11:29:00

2169-10-03 17:16:00

EXAMINATION: Fluoroscopic cholangiogram with year CP INDICATION: ___ male, ERCP TECHNIQUE: Fluoroscopic cholangiogram COMPARISON: CT abdomen ___ FINDINGS: 13 intraoperative images were acquired without a radiologist present. Images show existing plastic extent is removed, subsequent injection of contrast opacifies the biliary tree. A metallic stent is then placed with narrowing in the midportion.. IMPRESSION: Intraoperative images were obtained during ERCP stent placement. Please refer to the operative note for details of the procedure.

10006269-RR-5

RR

2124-07-03 19:01:00

2124-07-04 00:56:00

EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS INDICATION: ___ year old man with blood per rectum, cancer on colonoscopy// New diagnosis of colorectal cancer via colonoscopy. Eval for mets. TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Has reached the descending: Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 27.4 cm; CTDIvol = 19.2 mGy (Body) DLP = 513.3 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 3) Stationary Acquisition 38.0 s, 0.2 cm; CTDIvol = 648.5 mGy (Body) DLP = 129.7 mGy-cm. 4) Spiral Acquisition 11.0 s, 71.4 cm; CTDIvol = 14.4 mGy (Body) DLP = 1,015.8 mGy-cm. 5) Spiral Acquisition 4.2 s, 27.4 cm; CTDIvol = 19.2 mGy (Body) DLP = 513.3 mGy-cm. Total DLP (Body) = 2,174 mGy-cm. COMPARISON: None available. FINDINGS: LOWER CHEST: Note that findings pertaining to the chest will be reported separately. ABDOMEN: HEPATOBILIARY: Liver is normal in contour and attenuation. No focal parenchymal lesions identified. Portal veins patent. There is mild periportal edema. Gallbladder demonstrates diffuse wall thickening. No evidence of gallbladder lumen distension. No obvious cholelithiasis. No intrahepatic or extrahepatic bile duct dilatation. PANCREAS: Pancreatic parenchyma is normal in bulk and attenuation. No focal parenchymal lesions identified. No main duct dilatation. SPLEEN: The spleen is enlarged at 15 cm in longest diameter. No focal splenic lesions are identified. ADRENALS: Adrenal glands are normal. URINARY: There is minimal lobulation of the left kidney, potentially related to prior infarct/infection. Renal parenchyma otherwise unremarkable. No focal parenchymal lesions. No hydronephrosis or nephrolithiasis. GASTROINTESTINAL: As seen on colonoscopy, a large fungating mass identified at the level of the lower rectum. Although difficult to measure, this mass extends at least 8 cm above the anorectal junction and nearly completely occludes the lumen of the rectum, mass measures up to 6.2 cm in AP dimension and 7 cm in transverse dimension. No gross extension beyond the muscularis propria, although assessment with CT is limited in this regard. There is minimal distension of the rectosigmoid just above the level of the mass, suggesting some element of obstruction. Large bowel caliber normalizes progressively more proximally. Oral contrast has reached the descending colon. Scattered uncomplicated diverticula are seen in the right and left hemicolon. Appendix in the right lower quadrant is normal. Terminal ileum in the remainder of the small bowel is similarly normal. PELVIS: Urinary bladder is underdistended but otherwise unremarkable. REPRODUCTIVE ORGANS: Prostate gland and seminal vesicles are normal. LYMPH NODES: No inguinal, pelvic, retroperitoneal, periportal, or mesenteric lymphadenopathy is noted. VASCULAR: Mild atheromatous calcification of the abdominal aorta, without aneurysmal dilatation. Major branch vessels patent. BONES: No acute or focal destructive osseous lesions. SOFT TISSUES: There is mild dependent edema within the subcutaneous soft tissues. Small volume free fluid is noted around the liver and spleen. No evidence of peritoneal deposits. IMPRESSION: 1. Known large rectal mass re-demonstrated, extending at least 8 cm above the anorectal junction. Exact ___ are difficult to determine on CT. Mass nearly completely occludes the lumen of the rectum but does not cause overt large-bowel obstruction. 2. No evidence of metastatic disease to the abdomen or pelvis. 3. Diffuse thickening of the gallbladder wall. In the absence of an elevated white blood count, this finding may be related to third spacing. Additional note is made of mild periportal edema and small volume free fluid around the liver and spleen. There is no evidence of peritoneal deposits to substantiate presence of ascites. Findings are likely again related to third spacing. 4. The spleen is enlarged (15 cm). No focal parenchymal lesions are identified. No associated lymphadenopathy.

10006269-RR-6

RR

2124-07-03 19:04:00

2124-07-04 00:47:00

EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with blood per rectum, cancer on colonoscopy// New diagnosis of colorectal cancer via colonoscopy. Eval for mets. TECHNIQUE: Multi detector CT of the chest was performed after the administration of intravenous contrast. Axial coronal and sagittal reconstructions were acquired. Maximum intensity projections were also acquired DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 27.4 cm; CTDIvol = 19.2 mGy (Body) DLP = 513.3 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 3) Stationary Acquisition 38.0 s, 0.2 cm; CTDIvol = 648.5 mGy (Body) DLP = 129.7 mGy-cm. 4) Spiral Acquisition 11.0 s, 71.4 cm; CTDIvol = 14.4 mGy (Body) DLP = 1,015.8 mGy-cm. 5) Spiral Acquisition 4.2 s, 27.4 cm; CTDIvol = 19.2 mGy (Body) DLP = 513.3 mGy-cm. Total DLP (Body) = 2,174 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS) COMPARISON: No priors available for comparisons FINDINGS: THORACIC INLET: There is a small hypodense lesion within the left lobe of thyroid measuring 11 mm. There are no enlarged supraclavicular lymph nodes. BREAST AND AXILLA : There are no enlarged axillary lymph nodes. MEDIASTINUM: The right paratracheal lymph node measures 1.3 cm, there are other smaller mediastinal lymph nodes. There is an AP window lymph node measuring 6 mm in short axis. Heart size is top-normal. There is moderate coronary artery calcification. There is evidence of prior cardiac surgery. A prosthetic mitral valve is in place. There is no pericardial effusion PLEURA: There are small bilateral pleural effusions. LUNG: There is minimal bibasilar atelectasis. No new or growing pulmonary nodules are seen. BONES AND CHEST WALL : Review of bones is unremarkable. UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable IMPRESSION: Small mediastinal lymph nodes the largest in the right paratracheal region measuring 1.3 cm Small bilateral pleural effusions with bibasilar atelectasis. Evidence of prior cardiac surgery. No lung nodules. Left thyroid nodule measuring 1.5 cm. Further evaluation with an ultrasound is recommended

10006269-RR-7

RR

2124-07-05 11:55:00

2124-07-05 16:37:00

EXAMINATION: MRI of the Pelvis INDICATION: ___ year old man with new diagnosis of rectal cancer (pathology showed tubulovillous adenoma), eval for staging and extent of malignancy// Colorectal cancer staging It is suspected that the pathology sample with incomplete and there is likely underlying malignancy. TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis were acquired in a 1.5 T magnet. Intravenous contrast: Gadavist. COMPARISON: CT abdomen pelvis on ___ FINDINGS: RECTUM AND INTRAPELVIC BOWEL: Tumor: There is an enhancing frond like lesion with multiple villi extending from the anorectal junction approximately 8 cm superiorly, measuring up to 7.1 x 6.8 cm in axial diameter and distending the rectum (07:16; 05:25). Distance from anal verge (AV) (mm): 3 cm Extends cranio-caudally (CC) (mm): 8 cm Distal edge lies: at puborectalis sling Upper border lies: 8 mm below peritoneal reflection Please note current pathology sample demonstrated a tubulovillous adenoma, however, it was clinically suspected that the pathology sample was incomplete. Therefore please see below staging information. STAGING Invading tumor edge: None. Muscularis propria: There is rectal wall thickening surrounding the villous lesion, however this is felt to be due to chronic obstruction from the lesion rather than involvement of the lesion with the muscularis propria. Extramural spread (mm): None. Extramural venous invasion (EMVI): no Peritoneal reflection: not involved Adjacent pelvic organs: not involved FOR DISTAL RECTAL TUMORS AT/BELOW LEVATOR ORIGIN Intersphincteric plane: not invaded External anal sphincter: not invaded Ischiorectal fossa: not invaded Minimum tumor distance to MRF: greater than 1 mm Mesorectal lymph nodes- None. Pelvic side wall nodes: no Staging Assessment: Tis Extramural spread (mm): None. CRM: clear EMVI: negative Location: low to mid rectal tumor Nodal: N0 Metastasis: None There is a small amount of free fluid in the pelvis. BLADDER AND DISTAL URETERS: The bladder is underdistended. PROSTATE, SEMINAL VESICLES, AND SCROTUM: The prostate and seminal vesicles are normal in appearance. LYMPH NODES: No pelvic sidewall or inguinal lymphadenopathy. VASCULATURE: There are large draining veins on the left side of the rectal mass which were seen to drain to the splenic vein on prior CT abdomen and pelvis (12:197). Pelvic vasculature is patent. OSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious osseous lesions. There are mild degenerative changes in the lower lumbar spine. IMPRESSION: 1. 8 cm frondlike lesion extending from the anorectal junction approximately 8 cm superiorly and distending the rectum, compatible with tubulovillous lesion. MRI staging is Tis. 2. Surrounding rectal wall thickening is felt to be reactive due to chronic obstruction from this lesion rather than involvement of the muscularis propria. 3. No evidence of suspicious pelvic lymph nodes or metastatic disease in the pelvis. 4. Small amount of free fluid in the pelvis. NOTIFICATION: The findings were discussed with ___ M.D. by ___, M.D. on the telephone on ___ at 3:40 pm.

10006431-RR-23

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2128-03-04 17:21:00

2128-03-04 17:37:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with leukocytosis TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph ___ and chest CT ___ FINDINGS: Left-sided Port-A-Cath tip terminates in the low SVC. Heart size is mildly enlarged, but decreased in size compared to the previous exam. The mediastinal and hilar contours are unchanged with tortuosity of thoracic aorta again noted. Also again noted is indentation upon the right aspect of the trachea at the thoracic inlet due to the presence of a large thyroid goiter, as seen on prior CT. The pulmonary vasculature is normal. The lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. A common bile duct stent is incompletely assessed. IMPRESSION: No acute cardiopulmonary abnormality including no evidence for pneumonia.

10006431-RR-24

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2128-03-23 05:47:00

2128-03-23 06:42:00

INDICATION: ___ with upper abdominal pain, history pancreatic cancer, evaluate for infectious process. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP = 10.8 mGy-cm. 2) Spiral Acquisition 4.2 s, 46.0 cm; CTDIvol = 8.5 mGy (Body) DLP = 388.3 mGy-cm. Total DLP (Body) = 399 mGy-cm. COMPARISON: Prior CTA of the abdomen and pelvis dated ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. The previously seen bilateral pleural effusions have resolved. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A 1.2 cm hypodensity in segment 4A is unchanged from prior study when measured in similar planes (02:15). There is no evidence of intrahepatic or extrahepatic biliary dilatation. Pneumobilia and air within the gallbladder are related to the widely patent CBD stent. The gallbladder contains air and layering debris, likely small stones or sludge and is otherwise unremarkable. PANCREAS: The pancreas is normal in attenuation throughout. The main pancreatic duct is mildly prominent. The subtle hypodensity in the pancreatic head is unchanged with near complete resolution of previously seen soft tissue density contacting the SMA and SMV. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Renal cortical hypodensities bilaterally are too small fully characterize but likely represent simple cysts, unchanged from the prior study. Hypodensities in the renal pelvis likely represent peripelvic renal cysts, also unchanged. There is no suspicious focal renal lesion. There is no hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus contains an unchanged hyperenhancing fibroid measuring up to 1.4 cm (2:61). The left adnexal venous structures are prominent and dilated with dilatation of the left gonadal vein (2:30, 65). LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of acute intra-abdominal process. 2. Pancreatic head hypodensity is unchanged and associated peripancreatic soft tissue density is less conspicuous, potentially due to interval improvement or differences in technique. 3. Left pelvic vein engorgement and left gonadal vein enlargement are nonspecific findings but may be seen in the setting of pelvic congestion syndrome.

10006431-RR-26

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2128-03-28 14:15:00

2128-03-28 14:30:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with pancreatic cancer, c/o persistent cough and sputum production // evidence of pneumonia? evidence of pneumonia? IMPRESSION: In comparison with the study of ___, there is little interval change. The cardiac silhouette remains within normal limits with no evidence of vascular congestion or acute focal pneumonia. There is blunting of the left costophrenic angle on the lateral view, suggesting small interval pleurally fusion. The right Port-A-Cath again extends to the lower SVC.

10006457-RR-25

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2147-12-10 19:53:00

2147-12-10 20:54:00

INDICATION: Left-sided weakness. Evaluate for stroke. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were obtained through the head without the administration of IV contrast. Sagittal, coronal, and thin section bone reformatted images were obtained and reviewed. FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or large vascular territory infarction. A small well-defined hypodensity in the left frontal white matter may represent an old lacunar infarct or a prominent perivascular space. The ventricles and sulci are normal in size and configuration. The basal cisterns are patent. There is preservation of the gray-white matter differentiation. Incidentally noted are vascular calcifications in the intracranial arteries. No fracture is identified. There is minimal mucosal thickening in the ethmoidal air cells. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The soft tissues are unremarkable. IMPRESSION: No acute intracranial abnormality. Left frontal white matter hypodensity may be a small old lacunar infarct versus prominent perivascular space.

10006457-RR-26

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2147-12-10 20:23:00

2147-12-10 21:29:00

EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: Left-sided weakness. ___. FINDINGS: Frontal and lateral views of the chest were obtained. There is minimal left base atelectasis. A lateral right mid lung calcified granuloma is stable. No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are stable and unremarkable. The cardiac silhouette is top normal. The aorta is calcified and tortuous. Osteophytosis is seen along the lower thoracic spine. IMPRESSION: No acute cardiopulmonary process.

10006457-RR-27

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2147-12-11 09:46:00

2147-12-11 19:07:00

HISTORY: Hypertensive urgency, transient neurologic symptoms and possible lacunar infarct. Evaluate for evidence of stroke or posterior reversible leukoencephalopathy syndrome. TECHNIQUE: Multiplanar MR images were acquired through the head including sequences acquired prior to and following the uneventful intravenous administration of contrast. MR angiography is also performed through the head and neck including dedicated three-dimensional and angiographic reconstructions. COMPARISON: Head CT from ___. FINDINGS: MR head: There are multiple small foci of slow diffusion in the left MCA territory consistent with infarcts. The ventricles and sulci are normal in size and configuration. There is no intracranial hemorrhage. MR angiogram neck: There is severe stenosis of the distal left common carotid extending into the proximal internal and external carotid arteries with such signal loss that no residual signal can be seen to be measured, but the stenosis would seem to be severe. There is mild narrowing of the right internal carotid artery but no flow-limiting stenosis. The proximal left vertebral artery is not visualized and there appears to be retrograde filling of the distal vertebral arteries. It is unclear but this may be congenital. The right vertebral artery demonstrates appropriate signal intensity. MR angiogram head: There is narrowing and irregularity of the M1 segment of the left MCA with irregularity and narrowing of the M2 division as well. The right intracranial arterial structures demonstrate appropriate signal intensity. IMPRESSION: Small foci of slow diffusion in the cortex of the left MCA territory consistent with small cortical infarcts. Severe stenosis of the left common carotid artery extending into the proximal internal and external carotid arteries. Stenosis at the left M1 and M2 divisions of the left MCA. Given the severe stenoses, the infarcts likely represent sequelae of hypotension related to low blood flow as opposed to embolic events. NOTIFICATION: Telephone notification to Dr. ___ by Dr. ___ at 12:35 on ___, 10 minutes after discovery of findings.

10006457-RR-28

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2147-12-11 16:40:00

2147-12-11 18:38:00

INDICATION: ___ female with multiple left hemisphere infarcts, and vague symptoms, comes in today for carotid evaluation. COMPARISON: No prior similar study available for comparison. TECHNIQUE: Grayscale and color Doppler ultrasound of bilateral carotid and vertebral arteries was performed. RIGHT: There is moderate atherosclerotic heterogeneous plaque at the origin of the right ICA. The following velocities were measured: Proximal right ICA, 138 cm/sec. Mid right ICA, 111 cm/sec. Distal right ICA, 78 cm/sec. Right common carotid artery is 94 cm/sec. Right external carotid artery is 170 cm/sec. The right ICA/CCA ratio was 1.4. LEFT: There is a severe homogeneous plaque at the origin of the left ICA, with significant compromise of flow. The peak systolic velocity in the left proximal ICA was measured at 623 cm/sec. Mid ICA, 321 cm/sec. Distal left ICA, 28 cm/sec. Left common carotid artery is 54 cm/sec. Left external carotid artery is 21 cm/sec. The left ICA/CCA ratio was 11.5. Bilateral vertebral arteries presented with antegrade flow. IMPRESSION: Significant stenosis at the origin of the left internal carotid artery, estimated between 80 and 99%. On the right, there is also significant stenosis at the origin of the ICA, with estimated 40-59% narrowing.

10006457-RR-29

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2147-12-13 10:06:00

2147-12-13 16:25:00

HISTORY: Postop day 1 status post left carotid endarterectomy with waxing and waning neuro exam. Confirm carotid is open postoperative and assess for progression of previous stroke. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently axial imaging was performed from the aortic arch through the brain during administration of 70 cc of Omnipaque intravenous contrast material. Images were processed on a separate workstation which displayed curved reformats, 3D volume rendered images and maximum intensity projection images. COMPARISON: Nonenhanced head CT from ___ and MRI/MRA brain from ___. FINDINGS: Head CT: Hypodensities in the left basal ganglia and left frontal lobe have increased in size compared to the previous MR. ___ is no evidence of mass effect or hemorrhage. The ventricles and sulci are normal in size and configuration. No fractures identified. Head and neck CTA: The left common carotid artery is widely patent and somewhat ectatic at the bifurcation, likely related to recent endarterectomy. Atherosclerotic plaque is seen at the origin of the right internal carotid artery with no significant stenosis. The vertebral arteries appear patent. The intracranial arteries and their major branches appear patent without filling defects. There is no evidence of aneurysm formation or other vascular abnormality. The distal cervical internal carotid arteries measure 6 mm on the left and 4 mm on the right. IMPRESSION: 1. Increase in size of hypodensities in the left basal ganglia and left frontal lobe compared to the previous MR, which could represent evolution of the infarct; however, new infarcts are also possible. Consider MRI to evaluate for acute or progressive infarct if clinically indicated. 2. The left common carotid artery is widely patent status post endarterectomy. 3. Patent right carotid arterie, vertebral arteries and major branches. Telephone notification to Dr. ___ by Dr. ___ at 11:07 on ___, at time of review study

10006457-RR-30

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2147-12-13 21:30:00

2147-12-14 13:35:00

HISTORY: Worsening confusion and hand weakness, status post carotid endarterectomy. COMPARISON: MR from ___ and CT from ___. TECHNIQUE: Multiplanar MR images are acquired through the head without intravenous contrast. FINDINGS: Ventricles and sulci are mildly enlarged, reflecting parenchymal volume loss. There are multiple foci of abnormally slow diffusion consistent with infarction. Those that were present on the MR from ___ now appear larger, with a reference focus seen in the splenium of the corpus callosum. In addition however there are multiple new foci of abnormally slow to diffusion. Specifically, this includes a confluent area of abnormal slow diffusion in the left frontal lobe (series 8, image 19) as well as areas in the paramedian parietal lobes bilaterally. A small amount of susceptibility artifact within the confluent area of new slow diffusion in the left frontal lobe (series 5, image 19) suggests the interval appearance of a small amount of blood products. IMPRESSION: Multiple, predominantly left infarctions as above, with interval increase in the size of infarctions seen previously, as well as multiple new foci of infarction, including a right paramedian focus. A small amount of interval susceptibility artifact in the confluent left frontal infarction suggests minimal interval intracranial blood. Results discussed via telephone by Dr. ___ with Dr. ___ at 13:29 on ___.

10006457-RR-32

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2147-12-14 21:09:00

2147-12-15 09:02:00

HISTORY: Multiple infarctions. History of recent carotid endarterectomy. COMPARISON: MRI from ___ and ___. TECHNIQUE: Multiplanar MR images are acquired through the head without intravenous contrast. FINDINGS: As was seen on the recent comparison examination, there are numerous foci of abnormally slow diffusion consistent with infarction. Overall, the size and number of the strokes is unchanged from the most recent comparison examination. Minimal susceptibility artifact associated with one these foci in left frontal lobe is no longer apparent. There is no evidence of interval intracranial hemorrhage. Ventricles and sulci are enlarged. There is no worsening mass effect. Primary intracranial flow voids are normal. IMPRESSION: Redemonstration of numerous bilateral cerebral foci of abnormally slow diffusion consistent with infarction, overall unchanged from the most recent comparison. A small amount of left frontal hypointensity on gradient-echo imaging suggesting blood products seen on the most recent examination is no longer apparent.

10006513-RR-39

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2125-05-06 03:14:00

2125-05-06 04:24:00

INDICATION: NO_PO contrast; History: ___ with LLQ painNO_PO contrast// diverticulitis TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 1,174 mGy-cm. COMPARISON: CT of the abdomen and pelvis from ___. FINDINGS: LOWER CHEST: Atelectasis is present in both lung bases. No focal consolidation.. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: In the left mid ureter near the pelvic brim, a conglomerate of radiopaque stones measuring approximately 6 x 22 mm cause moderate hydroureteronephrosis. There is a delayed nephrogram on the left with asymmetric left perinephric stranding and a small amount of free fluid suggesting calyceal rupture (2:47, 601:39). No organized collection or abscess. Numerous residual left renal nonobstructive calculi remain (601:39, 601:42, 601:43). At the left ureterovesicular junction, a 4 mm stone may reside within the bladder or be lodged at the UPJ (2:81). GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: Mild degenerative changes in the spine. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Left mid ureter obstructing stones cause moderate hydroureteronephrosis, periureteral stranding, and likely calyceal rupture. 2. Numerous residual left renal calculi which are nonobstructing. 3. 4 mm stone near the left ureteral vesicular junction may reside within the bladder or be lodged at the UVJ.

10006692-RR-10

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2165-05-12 03:31:00

2165-05-12 04:14:00

EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old man with swelling/erythema/warmth of RLE, s/p bypass graft harvesting years ago // eval for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow is demonstrated in the posterior tibial veins. The peroneal veins are not visualized. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. The peroneal veins are not visualized.

10006692-RR-9

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2165-05-12 03:09:00

2165-05-12 03:55:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with HTN and headache. Evaluate for hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed images were obtained. DOSE: This study involved 3 CT acquisition phases with dose indices as follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced Acquisition 18.0 s, 18.9 cm; CTDIvol = 53.0 mGy (Head) DLP = 1,003.4 mGy-cm. Total DLP (Head) = 1,003 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. Prominence of the ventricles and sulci as indicative of atrophy. No osseous abnormalities seen. There is mild mucosal thickening in the left maxillary sinus and aerosolized secretions and a left posterior ethmoid air cell. Sphenoid sinuses, frontal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: Mild involutional change. No evidence of hemorrhage.

10007058-RR-22

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2167-11-07 20:31:00

2167-11-08 08:05:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with aortic dissection, chest pain // evaluate for acute process evaluate for acute process COMPARISON: There no prior chest radiographs available. IMPRESSION: Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal.

10007058-RR-23

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2167-11-07 22:23:00

2167-11-08 00:24:00

EXAMINATION: CTA chest abdomen and pelvis INDICATION: ___ year old man with acute type b dissection. // r/o extension of type B dissection to type A. Need type a dissection protocol. TECHNIQUE: Axial multidetector CT images were obtained through the chest, abdomen, and pelvis after the uneventful administration of 100 cc of Omnipaque intravenous contrast in the arterial phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP = 13.2 mGy-cm. 4) Spiral Acquisition 9.2 s, 71.9 cm; CTDIvol = 9.9 mGy (Body) DLP = 709.8 mGy-cm. Total DLP (Body) = 723 mGy-cm. COMPARISON: Same day CT chest abdomen pelvis. FINDINGS: VASCULATURE: There is an infrarenal abdominal aortic aneurysm which originates at the takeoff of the ___ and extends into the proximal right common iliac artery, approximately 5 cm in total length. The dissection flap extends across the ___ the aorta, with equal opacification intraluminally on both sides of the flap. The dissection flap splits at the midportion (02:15 6), without thrombus identified. There is no flow limiting stenosis, intramural hematoma, or aneurysm. The internal and external iliac arteries, as well as the common left iliac artery, are normal in appearance. Scattered aortoiliac mild atherosclerotic calcifications. Incidentally noted replaced left hepatic artery arises from the left gastric artery (02:99). The celiac trunk, SMA, and renal arteries are patent and without aneurysm. The thoracic aorta is unremarkable without dissection or aneurysm. Great vessels are unremarkable. The pulmonary arteries are well opacified to the subsegmental level without filling defect to suggest pulmonary embolism. Pulmonary arteries are normal in caliber. There are mild calcifications throughout the coronary vessels. CHEST: There is no evidence of pulmonary parenchymal abnormality. There is no pleural effusion or pneumothorax. The airways are patent to the subsegmental level. Heart is unremarkable. There is no pericardial effusion. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. Included portion of the thyroid is unremarkable. Included portion of the upper abdomen is unremarkable. No lytic or blastic osseous lesion suspicious for malignancy is identified. There is no fracture. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is normal. There is no free intraperitoneal fluid or free air. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate is enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or acute fracture. Old bilateral L1 transverse process fractures. The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Infrarenal abdominal aortic aneurysm as detailed above originating at the level of the ___ and extending into the proximal right common iliac artery. No significant change compared to recent CT. 2. Normal thoracic aorta without dissection.

10007058-RR-24

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2167-11-10 16:12:00

2167-11-10 20:06:00

INDICATION: ___ year old man p/w back pain found to have abdominal aortic dissection and NSTEMI // Please perform EKG-gated MRA of chest/abdomen/pelvis to further evaluate aortic dissection TECHNIQUE: ECG gated MRA images of the chest, abdomen, and pelvis. No IV contrast was administered. COMPARISON: Comparison is made to CT from ___. FINDINGS: There is an infrarenal abdominal aortic dissection extending over 6.7 cm terminating in the aortic bifurcation. Dynamic ECG gated images demonstrate no mobility of the flap during the cardiac cycle. There is opacification of both true and false lumens without thrombus. On limited evaluation, there is no evidence of an organ ischemic change. No abnormal wall thickening of the abdominal aorta. No abnormal restriction on DWI. Overall findings favor chronic age of the dissection. Overall the abdominal aortic caliber is within normal limits, with the infrarenal aorta measuring up to 1.6 x 1.9 cm in the location of the dissection flap. There is background of atherosclerotic disease within the abdominal aorta. No significant flow limiting stenosis appreciated. The liver, spleen, pancreas, and bilateral adrenals are unremarkable. Bilateral kidneys are normal, with no evidence of hydronephrosis. The bladder is unremarkable. The imaged alimentary tract is within normal limits. No free air or free fluid. No intra-abdominal or pelvic lymphadenopathy. There are a few prominent lymph nodes surrounding the site of dissection, without adenopathy. This may be related to prior infection/inflammation. No worrisome osseous findings. IMPRESSION: Infrarenal abdominal aortic dissection unchanged in appearance compared to prior CT, with no evidence of mobility of the dissection flap during the cardiac cycle. This and the lack of other acute findings suggests the dissection is chronic. No evidence of end organ ischemia.

10007058-RR-25

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2167-11-10 11:16:00

2167-11-10 15:18:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with diseection // pulmonary edema, pna? pulmonary edema, pna? COMPARISON: Prior chest radiograph ___. IMPRESSION: Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal.

10007134-RR-15

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2140-05-22 03:03:00

2140-05-22 07:30:00

EXAMINATION: Portable AP chest radiograph INDICATION: ___ year old man with left sided pneumothorax after being run over by a car. // 3 AM PLEASE. PTX progression? TECHNIQUE: Chest PA and lateral COMPARISON: ___ CT chest/abdomen/pelvis FINDINGS: A small left pneumothorax and minimally displaced lateral left sixth left rib fracture are again seen. Adjacent subcutaneous emphysema is overall unchanged to minimally decreased. There is no focal consolidation. Severe emphysematous changes are again seen. No pleural effusion. Heart size is normal. Cardiomediastinal and hilar silhouettes are unremarkable. IMPRESSION: Small left pneumothorax, more fully assessed by recent CT.

10007134-RR-16

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2140-05-23 10:15:00

2140-05-23 12:09:00

INDICATION: ___ year old man with L ___ fx; small left PTX // interval eval PTX TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph dated ___. FINDINGS: The previously seen small left pneumothorax has resolved. The left sixth and seventh rib fractures are stable. No consolidation. The hila and pulmonary vasculature are normal. No pleural effusions. The cardiomediastinal silhouette is normal. IMPRESSION: Resolution of pneumothorax. Unchanged left sixth and seventh rib fractures. No other acute cardiopulmonary process.

10007174-RR-24

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2164-03-02 17:59:00

2164-03-02 19:14:00

EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with abd pain, evaluate for small bowel obstruction, abscess, or UC flare. TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Coronal and sagittal reformations were performed and reviewed on PACS. Oral contrast was administered. DOSE: Total DLP (Body) = 686 mGy-cm. IV Contrast: 130 mL Omnipaque COMPARISON: Prior CT of the abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. Mild prominence of the CBD is likely related to cholecystectomy. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. A 2.5 cm simple cyst arises from the lower pole of the left kidney. Scattered renal hypodensities bilaterally are too small to fully characterize but likely represent additional simple cysts. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. Appendix contains air, has normal caliber without evidence of fat stranding. There is no evidence of mesenteric lymphadenopathy. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is heavy calcium burden in the abdominal aorta and great abdominal arteries. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Reproductive organs are within normal limits. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions. A small bowel containing hernia is noted in the anterior lower right abdominal wall (2:78) without evidence of upstream obstruction. Overall appearance is similar to the prior study from ___. IMPRESSION: 1. No acute intra-abdominal process. 2. Small bowel containing hernia adjacent to an area of surgical scarring in the right lower quadrant without evidence of obstruction.

10007795-RR-48

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2136-08-04 22:03:00

2136-08-05 06:15:00

HISTORY: PICC line with fevers. COMPARISON: ___. TECHNIQUE: PA and lateral chest radiograph, two views. FINDINGS: A right-sided PICC terminates in the low SVC, unchanged from prior examination. An upper enteric tube passes through the stomach and into the duodenum out of view. Cardiomediastinal silhouette and hilar contours are unremarkable. Plate-like atelectasis in the right middle lobe and lingula is unchanged compared to prior examination. Pleural surfaces are clear without effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary abnormality.

10007795-RR-49

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2136-08-06 16:38:00

2136-08-06 17:06:00

ABDOMEN INDICATION: Evaluation for gas pattern. COMPARISON: No comparison available at the time of dictation. FINDINGS: The supine film shows no evidence of free intra-abdominal air. No pathological calcifications. However, there is massive coiling of the nasogastric tube at the level of the stomach. The tip is in post-pyloric position. The mid and lower abdomen shows multiple air-fluid levels in bowel loops with borderline diameter, but without evidence of clear distention. No wall thickening, no pneumatosis. Minimal gas marking of the descending colon. Gas markings of the rectal ampulla. Known degenerative changes of the lumbar spine.

10007795-RR-50

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2136-08-09 17:20:00

2136-08-10 08:22:00

REASON FOR EXAMINATION: Evaluation of the patient with PICC line placement. Portable AP radiograph of the chest was reviewed in comparison to ___. The PICC line is coiled within the axillae and might be not in the vein or potentially in the tributaries of the axillary or cephalic vein and replacing is required. Bibasilar areas of atelectasis most likely in the right middle lobe and lingula are demonstrated. Small amount of pleural effusion cannot be excluded. There is no pneumothorax.

10007795-RR-51

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2136-08-10 16:03:00

2136-08-10 18:50:00

HISTORY: ___ female with bacteremia needing PICC for antibiotics. COMPARISON: Multiple prior exams, most recently chest radiograph of ___. OPERATORS: Dr. ___ (attending), Dr. ___ (fellow), Dr. ___ (resident). The attending was present and supervised throughout the procedure. FINDINGS: The procedure was explained to the patient. A time-out was performed per ___ protocol. Using sterile technique and local anesthesia, the patent right basilic vein was punctured under direct ultrasound guidance using a micropuncture set. Ultrasound images were obtained before and immediately after establishing intravenous access. The guidewire was unable to be passed into the right subclavian vein. A brief venogram was performed, which demonstrated non-opacification of the right subclavian vein and multiple moderately developed collaterals along the right chest wall. The guidewire was unable to be passed through the area of occlusion. The patent right brachial vein was then punctured under direct ultrasound guidance and again images were saved on PACS. A subsequent venogram demonstrated similar central occlusion with multiple collaterals. The patent left brachial vein was then punctured under sterile conditions using ultrasound guidance.Ultrasound images were stored before and after obtaining venous access. A needle venogram was performed of the left upper extremity veins, which demonstrated central stenosis of the left basilic vein but patency of the left brachial vein. After discussion with Dr ___, a resident of the primary surgical team, the decision was made to not place left brachial vein PICC given history of left mastectomy with lymph node dissection. No central catheter was placed. A total of approximately 20 cc of IV Optiray contrast was administered during the procedure. IMPRESSION: 1. No central catheter was placed. 2. Right upper extremity venogram demonstrating occlusion of the right subclavian vein, which is new since ___ when a right PICC was in position and likely represents thrombus. 3. Left upper extremity venogram via a 21G needle demonstrates stenosis of the left basilic vein and patency of the left brachial vein. This access would be suitable for central PICC placement if required in the future. Findings were communicated via phone call by Dr. ___ to Dr. ___ ___ on ___ at 18:40.

10007795-RR-52

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2136-08-10 19:20:00

2136-08-10 20:30:00

HISTORY: Inability to place a right-sided PICC line. TECHNIQUE: Grayscale, color Doppler, and spectral analysis of the venous system of the right upper extremity was performed. COMPARISON: None available FINDINGS: There is normal compression of the internal jugular vein. Nonocclusive thrombosis is seen in the subclavian vein. The axillary and central portion of the basilic veins are not compressible although there is flow suggesting nonocclusive thrombus extending into these veins as well. The distal basilic, paired brachials and cephalic veins show normal compressibility and wall to wall flow. The left subclavian vein is patent and normal with normal respiratory variation. IMPRESSION: Nonocclusive thrombus extending from the right subclavian vein into the axillary and central portion of the basilic vein. There is no DVT in the distal basilic vein, cephalic vein or paired brachial veins.

10007795-RR-54

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2136-09-22 19:59:00

2136-09-22 21:45:00

EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: History of laparoscopic drainage of pancreatic abscess with severe abdominal pain. ___. Frontal and lateral views of the chest were obtained. Left mid lung and right mid-to-lower lung plate-like atelectasis is seen. There is no focal consolidation, pleural effusion, or evidence of pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. No evidence of free air is seen beneath the diaphragms. IMPRESSION: Bilateral plate-like atelectasis, as above.

10007795-RR-55

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2136-09-22 19:50:00

2136-09-22 22:06:00

INDICATION: History of laparoscopic drainage of pancreatic abscess with severe abdominal pain and tachycardia. COMPARISON: CT ___ and ___. TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic symphysis were displayed with 5-mm slice thickness with oral and 130 mL Omnipaque intravenous contrast. Coronal and sagittal relations are displayed with 5-mm slice thickness. CT ABDOMEN: The visualized lung bases demonstrate bibasilar subsegmental atelectasis, slightly increased from ___. There is no pleural or pericardial effusion. The liver is unremarkable. There is no intra- or extra-hepatic bile duct dilation. The gallbladder is normal. A subtle peripheral wedge-shaped hypodensity in the inferior spleen is new compared to ___ and raises concern for a splenic infarction (601b:33). The pancreas enhances homogenously. Again seen are four well-positioned double-J transgastrostomy stents, unchanged in position from ___. There has been interval removal of the nasogastric tube. A fluid collection at the splenic hilum is 2.0 x 1.7 cm, previously 3.0 x 1.9 cm, smaller but with a new focus of air (2:22). No oral contrast is seen within it, but adjacent inflammatory change abuts the stomach and a small fistulous connection cannot be excluded. Just inferior to this, a peripancreatic collection is 3.7 x 1.8 cm, previously 4.8 x 2.2 cm, smaller, with similar tethering of adjacent bowel. A right posterolateral fluid collection has decreased, now measuring 4.1 x 1.3 cm, previously 6.0 x 2.1 cm. There has been interval removal of the drain within it. A hyperdensity within the subcutaneous tract of the drain is noted (2:47, 48). Gastric wall thickening along the lesser curvature is slightly increased compared to ___, nonspecific and may relate to distention. No new peripancreatic fluid collection is identified. The bilateral adrenal glands are normal, although the left adrenal gland abuts some inflammatory change. The kidneys enhance symmetrically and excrete contrast without hydronephrosis. There is no bowel obstruction. The patient is status post colostomy in the left lower quadrant. Diverticula are seen in the large bowel. Multiple injection granulomas are seen in the right anterior abdominal wall subcutaneous tissues. The abdominal aorta is of normal caliber throughout. The main portal vein and SMV are patent. The splenic vein is not opacified, unchanged. CT PELVIS: The rectum pouch is unremarkable. The sigmoid colon is absent. The bladder and uterus are unremarkable. There is no free fluid and no pelvic or inguinal lymphadenopathy. BONE WINDOWS: A 2.8 x 1.4cm right iliac lucency with possible cortical break through is more conspicuous than on ___ and ___. Compression deformity of T11 is unchanged. Degenerative changes, predominantly at L4-L5 and L5-S1 are similar to the prior study. IMPRESSION: 1. Interval decrease in size of peripancreatic fluid collections compared to ___. Superinfection of the collections cannot be excluded. The collection at the splenic hilum contains a new small focus of air. Although there is no oral contrast within it, a fistula to stomach or bowel cannot be excluded. 2. No new peripancreatic fluid collection. Homogenous enhancement of the pancreas. 3. Subtle wedge shaped hypodensity in the inferior spleen raises concern for a new splenic infarct. 4. High density in the subcutaneous tissues of the right posterolateral drain tract. Correlate with physical exam for retained catheter fragment. 5. Destructive appearing right iliac lucency, possibly with cortical breakthrough. Given the history of breast cancer, this is concerning for a metastatic focus. Updated findings, including impression #4 and #5, discussed with Dr. ___ ___ (surgery) at 11:12pm on ___.

10007920-RR-37

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2136-08-27 12:49:00

2136-08-27 15:36:00

INDICATION: ___ man with HIV, presenting with altered mental status. Evaluate for mass. COMPARISONS: Multiple prior head NECTs, most recently of ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large territorial infarction. The ventricles and sulci are normal in size and caliber. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. The visualized paranasal sinuses, middle ear cavities, and mastoid air cells are clear. IMPRESSION: No intracranial hemorrhage or mass effect.

10007920-RR-38

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2136-08-27 15:50:00

2136-08-27 17:09:00

CHEST, TWO VIEWS: ___ HISTORY: ___ male with altered mental status. Question pneumonia. FINDINGS: PA and lateral views of the chest are compared to previous exam from ___. As on prior, there are low lung volumes. There are calcified pulmonary nodules seen in the right upper lung stable dating back to ___. The lungs are clear of consolidation, effusion or pneumothorax. Cardiomediastinal silhouette is unchanged as are the osseous and soft tissue structures. IMPRESSION: No acute cardiopulmonary process.

10007928-RR-13

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2129-04-05 22:12:00

2129-04-05 23:31:00

INDICATION: ___ woman with upper GI bleeding, please assess NG tube placement. TECHNIQUE: Single portable radiograph of the chest was obtained. COMPARISON: There are no prior studies for comparison available. FINDINGS: The lung apices are not depicted. NG tube ends in the gastric antrum in appropriate position. The lungs are clear, the cardiomediastinal silhouette and hila are normal. There is no pleural effusion and no pneumothorax. Partially visualized abdomen shows normal bowel gas pattern. IMPRESSION: Appropriately placed NG tube.

10007928-RR-14

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2129-04-06 09:12:00

2129-04-06 11:38:00

AP CHEST, 9:25 A.M., ___ HISTORY: New hypoxia and fever with cough. Possible pneumonia. IMPRESSION: AP chest compared to ___, 10:08 p.m.: Lungs are essentially clear, heart size is normal, and there is no pleural abnormality.

10007928-RR-15

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2129-04-06 21:41:00

2129-04-07 10:13:00

HISTORY: ___ female with new hypoxia, evaluate for pulmonary embolus. COMPARISON: Portable chest performed ___ and ___. TECHNIQUE: Helical CT images were acquired of the chest before and after the administration of contrast, and reformatted into coronal, sagittal, and oblique planes. FINDINGS: Peribronchovascular ground-glass opacity is most pronounced centrally in the upper lungs, inferior to upper lobe regions with engorged lymphatics. Consolidation at both lung bases is more severe on the left. Trace non-serous bilateral pleural effusions are not accompanied by appreciable pleural enhancement. The airways are patent, but there is mild generalized wall thickening or peribronchial cuffing. There is no airway debris to suggest recent aspiration. The heart is normal in size and configuration. There is no pericardial effusion. The aorta is notable for a two-vessel configuration to the arch and atherosclerotic calcification of the arch. There is no evidence of aortic injury. The pulmonary arteries are well opacified, and patent to the subsegmental level. The mediastinal fat is diffusely infiltrated, with either high attenuation edema or edematous lymphadenopathy, and the esophageal is thickened in a similar fashion. There is no extraluminal gas or fluid collection to suggest esophageal perforation. While this exam is not tailored for the evaluation of infradiaphragmatic structures, no abnormality is seen. IMPRESSION: 1. No PE. 2. Mild pulmonary edema. 3. Upper lobe peribronchovascular airspace filling could be edema or a manifestation of more severe airspace abnormality in the lower lungs, mostly consolidation, partially atelectasis, due to aspiration, multifocal pneumonia, or less likely hemorrhage. In the setting of a recent transfusions, transfusion reaction may be contributory. 4. Esophageal wall thickening, with diffuse infiltration of the mediastinal fat which may reflect inflammatory change or confluent lymphadenopathy, though the progression from normal mediastinal contours on ___ favors a rapidly evolving inflammatory process. There is no finding to suggest esophageal perforation. Findings were discussed with Dr. ___ at 10:30am by phone.

10007928-RR-16

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2129-04-07 03:04:00

2129-04-07 08:53:00

CHEST RADIOGRAPH INDICATION: Hypoxic respiratory failure, multifocal pneumonia, evaluation for interval change. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, there is a massive increase in extent and severity of multifocal pneumonia. The resulting very widespread parenchymal opacities are more extensive on the right than on the left and show multiple air bronchograms. In addition, retrocardiac atelectasis has newly appeared, and there is a small right pleural effusion. The opacities are better displayed on the CTA examination, performed yesterday at 9:41 p.m. Moderate cardiomegaly. At the time of observation and dictation, 8:40 a.m., on ___, the referring physician, ___ was paged for notification and the findings were discussed over the telephone.

10007928-RR-17

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2129-04-08 03:22:00

2129-04-08 11:16:00

AP CHEST, 4:05 A.M., ___ HISTORY: ___ woman with hypoxemia and multifocal pneumonia. IMPRESSION: AP chest compared to ___: Moderately severe pulmonary edema has improved. Because of differences in patient positioning, I cannot say whether question right juxtahilar consolidation is also resolving. Moderate bilateral pleural effusion is stable. Heart size normal. No pneumothorax.

10009021-RR-22

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2132-04-11 10:28:00

2132-04-11 11:14:00

HISTORY: PICC. COMPARISON: None. FRONTAL CHEST RADIOGRAPH: A right upper extremity PICC extend 3.4 cm into the contralateral brachiocephalic vein and should be repositioned. Lungs are clear. No pleural effusion, pneumothorax or airspace consolidation. Heart size is normal. Mediastinum and hilar structures are unremarkable. Findings discussed with ___ from IV therapy by Dr. ___ at 11:00 on ___ by telephone at the time discovery.

10009021-RR-23

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2132-04-11 11:23:00

2132-04-11 11:52:00

HISTORY: Revised PICC placement. FINDINGS: In comparison with the earlier study of this date, the PICC line has been re-directed with the tip in the region of the mid portion of the SVC. This information was telephoned to Ping, one of the venous access nurses.

10009049-RR-20

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2174-05-26 05:10:00

2174-05-26 06:51:00

HISTORY: Cough and tachypnea. COMPARISON: Comparison is made with chest radiographs from ___. FINDINGS: PA and lateral images of the chest. There has been interval development of bibasilar opacities, which are concerning for a rapidly developing pneumonia versus alveolar hemorrhage. There appears to be a small left pleural effusion. There is no right pleural effusion or pneumothorax. The cardiomediastinal silhouette is unremarkable. IMPRESSION: Short interval development of bibasilar opacities, which are concerning for a rapidly developing pneumonia versus alveolar hemorrhage.

10009049-RR-21

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2174-05-27 07:21:00

2174-05-27 10:37:00

AP CHEST, 7:27 A.M., ___. HISTORY: ___ man with rapidly developing basilar opacities. IMPRESSION: AP chest compared to ___: Large scale consolidation in both lower lungs developed between ___, most likely severe pneumonia or pulmonary hemorrhage. Aspiration is most likely scenario. Mild-to-moderate cardiomegaly unchanged. Pulmonary vascular congestion is probably a function of volume resuscitation. Small left pleural effusion is larger, small right pleural effusion, presumed. No pneumothorax.

10009049-RR-22

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2174-05-26 18:18:00

2174-05-26 19:54:00

INDICATION: ___ year old man with pneumonia and distended abdomen, evaluate for intra-abdominal process TECHNIQUE: Single portable supine radiograph of the abdomen and pelvis was obtained. COMPARISON: None available. FINDINGS: There is mild gaseous distension of loops of small and large bowel with air seen within the rectum. No definite intraperitoneal free air is identified. Right basilar opacities partially imaged and better characterized on chest radiograph from the same day. IMPRESSION: Mild gaseous distention of loops of small and large bowel with air seen within the rectum. No evidence of obstruction.

10009049-RR-23

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2174-05-28 07:12:00

2174-05-28 13:39:00

PORTABLE CHEST FILM ___ AT 7:34. CLINICAL INDICATION: ___ with pneumonia, here for followup. Comparison to ___ at 7:27. A portable AP upright chest film ___ at 7:34 is submitted. IMPRESSION: There is persistent opacification within the left lower lobe and to a somewhat lesser extent at the right lung base. These findings would be consistent with aspiration or pneumonia. The heart remains enlarged. No pulmonary edema. Probable small layering left effusion. No evidence of pneumothorax. Marked thoracolumbar curvature.

10009049-RR-24

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2174-05-28 14:35:00

2174-05-28 15:55:00

INDICATION: ___ man with history of pneumonia and bacteremia. Evaluate for empyema. COMPARISON: No prior CT scan is available for comparison. Prior chest x-rays of ___ and ___ available for review. TECHNIQUE: Axial helical MDCT images were obtained of the chest after the administration of IV contrast. Multiplanar reformats were generated in the coronal and sagittal planes. DLP: 323 mGy-cm FINDINGS: There are bilateral pleural effusions, moderate on the left and small on the right. Loculated fluid is seen along the left major fissure. There is no enhancement of the pleural cavity to suggest an empyema. There is no pericardial effusion. The vessels of the mediastinum are patent. The main pulmonary artery is borderline in size, measuring 32 mm. There are multiple enlarged and prominent hilar and mediastinal lymph nodes. There is a 1 cm right paratracheal lymph node (series 3, image 19) and bilateral hilar lymph nodes measuring 9 mm on the right (series 3, image 26) and 9 mm on the left (series 3, image 28). These are likely reactive in nature. The trachea and proximal segmental bronchi are patent. There are bilateral patchy airspace and ground-glass opacities which are more predominant at the bases and most likely represent multifocal pneumonia and associated atelectasis. There is no pneumothorax. There is a non-obstructing 6 mm stone in the upper pole of the left kidney. The remainder of the visualized portion of the abdomen is unremarkable. No suspicious bony lesions. Dextroconvex thoracolumbar scoliosis. 14 mm rounded hyperdensity in the soft tissues of the back in the midline which may represent a sebaceous cyst (6b;115). IMPRESSION: 1. Bilateral pleural effusions, moderate on the left side without evidence of empyema. 2. Multifocal airspace disease which is predominant at the lung bases and is likely in keeping with multifocal pneumonia. Multiple mediastinal and hilar reactive lymph nodes are noted. 3. Incidental finding of a 6 mm non-obstructing stone in the upper pole of the left kidney.

10009203-RR-24

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2201-08-12 16:36:00

2201-08-12 18:18:00

INDICATION: ___ man with bloody bowel movements, fever and leukocytosis. COMPARISON: MRI of the pelvis ___. TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained after the administration of 130 mL of Omnipaque intravenous contrast. Sagittal and coronal reformations were performed and reviewed. FINDINGS: The imaged lung bases demonstrate mild dependent atelectasis. No suspicious pulmonary nodules are seen. There is no pleural or pericardial effusion. CT ABDOMEN: A subcentimeter hypodensity in the left hepatic lobe (2:9) is too small to characterize. The gallbladder, spleen and pancreas are normal. A 11-mm right and 7 mm left adrenal nodules are not characterized in this study. Both kidneys enhance and excrete contrast symmetrically without hydronephrosis. A subcentimeter hypodensity in the left kidney, too small to characterize. The abdominal aorta has mild atherosclerotic calcification, without aneurysmal dilation. No significant retroperitoneal or mesenteric lymphadenopathy is seen. The stomach and small bowel loops are normal in appearance. There is diffuse descending /sigmoid colonic wall thickening and surrounding fat stranding, consistent with acute colitis. The remainder of the colon is normal. The appendix is not visualized. There is no free fluid or air. CT PELVIS WITH INTRAVENOUS CONTRAST: The urinary bladder is normal. The prostate is enlarged measuring 7.0 x 5.8 cm. No pelvic lymphadenopathy or free fluid is seen. Sigmoid diverticulosis is noted. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. A sclerotic focus in the L5 vertebral body, may represent a bone island. Mild compression of T12 and T11 vertebral bodies is noted, acuity unknown. IMPRESSION: 1. Acute colitis involving the descending and sigmoid colon. Etiologies include infectious, inflammatory and less likely ischemic. 2. Enlarged prostate, correlate with PSA. 3. Bilateral small indeterminate adrenal nodules. 4. Mild compression of T11 and T12 vertebral bodies.

10009614-RR-20

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2188-09-16 16:21:00

2188-09-16 17:14:00

INDICATION: Right upper quadrant abdominal pain after eating a fatty meal. COMPARISONS: CT abdomen and pelvis ___. FINDINGS: The liver is normal in shape and contour. There is increased echogenicity, most consistent with fatty infiltration. There are no focal hepatic lesions. The portal vein is patent with normal hepatopetal flow. The gallbladder is mildly distended. There is no wall thickening or pericholecystic fluid. There is no sonographic ___ sign. There is no evidence of stones or sludge. There is no intra- or extra-hepatic biliary duct dilation. The common bile duct measures 4 mm. The spleen is mildly enlarged and measures 13.2 cm. Limited views of the right kidney are unremarkable without evidence of hydronephrosis. There is no ascites. IMPRESSION: 1. Normal gallbladder without evidence of cholecystitis or cholelithiasis. 2. Echogenic liver consistent with fatty infiltration; other forms of liver disease, including more significant hepatic fibrosis or cirrhosis cannot be excluded on the basis of this examination. 3. Mild splenomegaly.

10009657-RR-25

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2139-05-14 15:31:00

2139-05-14 18:57:00

INDICATION: ___ female with perianal tenderness and erythema, rule out perianal abscess. COMPARISON: CT abdomen and pelvis with contrast, ___. TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis with the administration of IV contrast. Oral contrast was also administered. Multiplanar reformats were generated and reviewed. CT OF THE ABDOMEN AND PELVIS: The visualized lung bases are clear. The visualized heart and pericardium are unremarkable. The liver, spleen, pancreas, gallbladder, bilateral adrenal glands and both kidneys appear unremarkable. Intra-abdominal loops of large and small bowel are within normal limits. There is no free air or free fluid within the abdomen. Retroperitoneal and mesenteric lymph nodes do not meet CT size criteria. Low density structure in the cul de sac may represent right adnexal cyst which is in an different position from the prior examination of ___ and measures 3.6 x 2.6 cm. Bladder, distal ureters and uterus appear unremarkable. Pelvic lymph nodes do not meet CT size criteria for pathology. Again noted is a multiloculated perianal fluid collection, which may represent either multiple adjacent collections or a single large collection with multiple compartments. Overall, these appear to measure approximately 3.9 x 2 cm consistent with an abscess. There is no evidence of extension of the fluid collections above the level of the levator ani. Visualized osseous structures show no focal lytic or sclerotic lesions suspicious for malignancy. IMPRESSION: 1. Large multilocular perianal collection, which may represent multiple adjacent collections or a single large collection with multiple compartments which is highly suspicious for abscess in the clinical setting, measuring approximately 3.9 x 2 cm. There is no evidence of extension of the fluid collections above the level of the levator ani. 2. Low density structure in the cul de sac may represent right ovary which is in an different position from the prior examination of ___.

10009657-RR-26

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2139-05-26 20:25:00

2139-05-26 23:42:00

INDICATION: ___ female with recent perirectal surgery, purulent diarrhea, abdominal pain, evaluate for perirectal abscess. COMPARISON: ___ and ___. TECHNIQUE: MDCT images were obtained through the abdomen and pelvis following the administration of IV and oral contrast. Coronal and sagittal reformations were performed. FINDINGS: Lung bases are clear. Visualized heart and pericardium are unremarkable. The liver enhances homogeneously and there is no focal liver lesion. Spleen is normal. The pancreas is normal. The adrenal glands are normal. The kidneys enhance and excrete contrast symmetrically. The stomach and small bowel are unremarkable. The colon is normal. There is no bowel wall thickening. The appendix is unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy. PELVIS: The gallbladder is unremarkable. Uterus is unremarkable. There is a hypoattenuating 4.7 x 3.8 cm cystic structure in the posterior pelvis with no surrounding fat stranding or rim enhancement and likely represents an ovarian or paraovarian cyst. This is slightly bigger than prior CT on ___ when it measured 3.6 x 2.6 cm and was also seen on CT scan on ___ but in a slightly different position. The left ovary is unremarkable. There is no free fluid in the pelvis. The bladder and terminal ureters are unremarkable. There is no pelvic or inguinal lymphadenopathy. The previously seen perirectal abscesses have almost entirely resolved. There is a trace amount of fluid in the area of the previously seen abscess posterior to the rectum, seen on series 2, image 76. Intra-abdominal vasculature is patent. BONES: Bones are unremarkable. IMPRESSION: 1. Near complete resolution of the perirectal abscesses. 2. Cystic structure in the cul-de-sac potentially an ovarian or paraovarian cyst on the right. This is slightly bigger than prior CT on ___. Pelvic ultrasound suggested to further characterize.

10009657-RR-27

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2139-05-27 08:30:00

2139-05-27 09:18:00

INDICATION: ___ woman with nausea, vomiting, and diarrhea. Abdominal pain, found to have enlarging right ovarian cyst on CT scan from ___. LMP: ___. COMPARISON: CT, ___. TECHNIQUE: Transabdominal and transvaginal ultrasound images of the pelvis were obtained. Transvaginal images are obtained for further evaluation of the uterus and adnexa. FINDINGS: Transabdominal ultrasound demonstrates an anteverted uterus measuring 9.1 x 3.5 x 5 cm. By transvaginal technique, the endometrium measures 5 mm. The left ovary is normal. There is a simple right ovarian cyst measuring 4.6 x 5.2 x 3.3 cm. There is no evidence of hypervascularity. There is no pelvic free fluid. IMPRESSION: Simple right ovarian cyst measuring up to 5.2 cm in maximum dimension. Ultrasound followup in one year is recommended.

10010058-RR-21

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2145-10-02 15:23:00

2145-10-02 15:45:00

EXAMINATION: CHEST (AP upright AND LAT) INDICATION: ___ with increased lethargy// eval pnuemonia COMPARISON: Prior exam from ___ FINDINGS: AP upright and lateral views of the chest provided. Left chest wall AICD is again seen with leads extending to the region of the coronary sinus and right ventricle. The heart remains top-normal in size. The mediastinal contour is stable. There is a linear density again seen in the right midlung likely focus of scarring. Nipple shadows are noted bilaterally. There is no focal consolidation concerning for pneumonia. No large effusion or pneumothorax. No evidence of edema. Bony structures are intact. IMPRESSION: No acute findings.

10010058-RR-22

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2145-10-02 15:06:00

2145-10-02 15:35:00

EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ with increased lethargy on eliquis// eval bleed TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute large territorial infarction, hemorrhage, edema, or mass. Hypodensities in the bilateral thalami are probably Virchow ___ spaces or old lacunar infarcts. Prominence of the ventricles and sulci is compatible with age-related involutional changes. Confluent periventricular and subcortical white matter hypodensities are nonspecific but likely represent sequelae of chronic small vessel ischemic disease. Calcification of the carotid siphons is noted. No osseous abnormalities seen. Minimal mucosal thickening of the left maxillary sinus and anterior ethmoid air cells. The mastoid air cells, and middle ear cavities are clear. Patient is status post bilateral lens replacements.. IMPRESSION: No acute intracranial process.

10010058-RR-23

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2145-10-03 12:58:00

2145-10-03 16:51:00

EXAMINATION: CT abdomen and pelvis without contrast INDICATION: ___ year old man with n/v weight loss, inability to tolerate PO, has CKD/ARF, PO contrast ok, IV not ok// please eval for cause to n/v/inability to tolerate PO, weight loss. PO contrast ok. TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired without intravenous contrast. Non-contrast scan has several limitations in detecting vascular and parenchymal organ abnormalities, including tumor detection. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 286 mGy-cm. COMPARISON: CT abdomen and pelvis without contrast ___ and CT abdomen with and without contrast ___. FINDINGS: LOWER CHEST: Bibasilar atelectasis left greater than right. Partial visualization of 2 pacemaker leads terminating in the region of the coronary sinus and in the right ventricular wall. Mild to moderate cardiomegaly with at least right atrial enlargement, possibly biatrial enlargement. Stable left ventricular aneurysm with increased interval calcification. Coronary artery calcifications. Too 2 mm pulmonary micro nodules in the right lung base (3:5 and 03:19. These were not clearly seen on prior imaging. No pericardial or pleural effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. Stable hepatic cysts or biliary hamartomas on ___:21 and 03:17. Hepatic cyst or biliary hamartoma on ___:20 was not seen on prior studies. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or evidence of inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There are bilateral renal cysts. A subcentimeter hyperdense structure arising from the medial lower pole of the right kidney most likely represents a hemorrhagic cyst (05:31). There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: Evaluation of the hollow organs is limited by poor intake of oral contrast the stomach is unremarkable. Small bowel loops demonstrate normal caliber and wall thickness throughout. Diverticulosis of the sigmoid colon is noted, without evidence of wall thickening and fat stranding. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is fusiform and saccular aneurysmal dilatation of the infrarenal abdominal aorta measuring up to 3.9 cm (05:15) extending into both common iliac arteries measuring 1.6 cm on the right and 1.9 cm on the left. Linear areas of calcification within the aneurysm sac at the level of the third portion of the duodenum (03:35) is suspicious for dissection. The aneurysm sac exerts mass effect on the third portion of the duodenum which is decompressed. There is no upstream dilatation of the duodenum. The distance between the anterior aspect of the aortic aneurysm to the anterior wall peritoneal is approximately 1.5 cm. There is also aneurysmal dilatation of the right external iliac artery measuring up to 1.4 cm. There are scattered areas of severe atherosclerotic calcification associated with the areas of aneurysmal dilatation. BONES: No suspicious lytic or blastic osseous lesions are seen. There is asymmetric sclerosis and narrowing of the right SI joint, likely reflecting prior sacroiliitis. There is a stable bone island in the right iliac bone on 3:66. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Fusiform and saccular aneurysmal dilatation of the infrarenal abdominal aorta measuring up to 3.9 cm extending into both common iliac arteries and the right external iliac artery. Linear areas of calcification within the aneurysm sac at the level of the third portion of the duodenum is suspicious for dissection which is limited in the absence of intravenous contrast. The aneurysm sac exerts mass effect on the third portion of the duodenum which is decompressed. There is no upstream dilatation of the duodenum to suggest obstruction. The distance between the anterior aspect of the aortic aneurysm to the anterior wall peritoneal is approximately 1.5 cm. 2. Colonic diverticulosis without CT evidence of acute diverticulitis. 3. Cholelithiasis without CT evidence of acute cholecystitis. 4. Asymmetric sclerosis and narrowing of the right SI joint likely reflecting prior sacroiliitis. 5. Mild-to-moderate cardiomegaly with at least right and possibly biatrial enlargement. Stable size of a known left ventricular aneurysm with increased interval calcifications since ___. 6. Two 2 mm pulmonary micro nodules in the right lung base. In a patient with no known risk factors for lung cancer, these are presumed to be benign and no follow-up is recommended. In a patient with risk factors for lung cancer, ___ year follow-up is recommended.

10010058-RR-24

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2146-12-27 05:10:00

2146-12-27 05:26:00

INDICATION: History: ___ with acute onset chest/abdominal pain// eval for PTX or dissection TECHNIQUE: Chest PA and lateral COMPARISON: ___ chest radiograph FINDINGS: There is increased opacities in the left retrocardiac and right lung base obscuring the hemidiaphragms. Linear opacity in the right midlung likely represents chronic scarring, unchanged since ___. The heart is moderately enlarged and there is prominence of the pulmonary vasculature bilaterally consistent with mild interstitial pulmonary edema. Blunting of the right and left costophrenic angle suggests small bilateral pleural effusions. There is no evidence of pneumothorax. There is no acute osseous abnormality. The left chest wall pacer device is noted in situ. The terminal leads remain in unchanged position projecting over the IMPRESSION: 1. Increased perihilar opacities particularly in the right and left lung base with prominence of the pulmonary vasculature suggests mild pulmonary edema. 2. Small bilateral pleural effusions. 3. Cardiomegaly. No evidence of pneumothorax.

10010058-RR-25

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2146-12-27 06:38:00

2146-12-27 09:56:00

INDICATION: History: ___ with acute onset chest/abdominal pain// eval for PTX or dissection TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast in the arterial phase. Then, imaging was obtained through the abdomen and pelvis in the portal venous phase. Reformatted coronal and sagittal images through the chest, abdomen, and pelvis, and oblique maximal intensity projection images of the chest were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 27.3 mGy (Body) DLP = 13.7 mGy-cm. 2) Spiral Acquisition 4.5 s, 35.1 cm; CTDIvol = 5.0 mGy (Body) DLP = 174.1 mGy-cm. 3) Stationary Acquisition 9.0 s, 0.5 cm; CTDIvol = 54.6 mGy (Body) DLP = 27.3 mGy-cm. 4) Spiral Acquisition 3.6 s, 28.6 cm; CTDIvol = 4.5 mGy (Body) DLP = 129.2 mGy-cm. 5) Spiral Acquisition 6.1 s, 48.1 cm; CTDIvol = 8.0 mGy (Body) DLP = 386.6 mGy-cm. 6) Spiral Acquisition 1.3 s, 10.1 cm; CTDIvol = 7.7 mGy (Body) DLP = 77.7 mGy-cm. Total DLP (Body) = 809 mGy-cm. COMPARISON: CT abdomen pelvis without contrast ___ FINDINGS: CHEST: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The ascending aorta is mildly aneurysmal and measures up to 4.3 cm. Short segment of focal dissection in the mid aortic arch, 2 cm in AP dimension (6:34 and 607:24), with calcification on the edges likely chronic. A 7 mm outpouching focus of IV contrast is seen within a soft plaque (6:27, 607: 29, 608:43). Moderate to severe cardiomegaly and small pericardial effusion. There is reflux of the IV contrast into the IVC and hepatic veins indicate poor cardiac output. Calcification and aneurysmal dilation of the left ventricular apex is sequela of prior infarct. Three lead pacemaker in place. AXILLA, HILA, AND MEDIASTINUM: The subcarinal lymphadenopathy. No mediastinal mass. PLEURAL SPACES: Bilateral small pleural effusions, larger on the right. LUNGS/AIRWAYS: Bilateral ground-glass opacities particularly at the bases the without focal consolidations. Subsegmental atelectasis in both bases of the lungs. Calcified granulomas in the lingula and right upper lobe. The airways are patent to the level of the segmental bronchi bilaterally. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Multiple hypodensities are unchanged since prior, the largest measures 1.1 cm in the left hepatic lobe likely represent cysts. There is cholelithiasis. Large gallbladder wall thickening and edema. There is no gallbladder distension or fat stranding. PANCREAS: Pancreas appears atrophic without evidence of focal lesions or pancreatic duct dilation. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. Multiple hypodense CT is bilaterally measure up to 1 cm in the right lower pole, too small to characterized on CT. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. The urinary bladder appears within normal limits. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The mild edema surrounding the ascending colon, otherwise colon and rectum are within normal limits. The appendix is normal. There is small amount of pelvic fluid. REPRODUCTIVE ORGANS: The prostate is enlarged. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Multiple areas of aneurysmal dilation seen the infrarenal aorta to the iliac bifurcation and left common iliac appear unchanged since prior CT. Despite not having intravenous contrast on prior CT the wall calcifications and diameters of the aorta are unchanged, for instance in the abdominal aorta 3 x 3.2 cm (08:40); 2.6 x 3.2 cm (04:45); 3.3 x 3.7 cm (849), 2.8 x 2.7 cm (08:56). The left common iliac measures up to 1.7 cm. BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or acute fracture. The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. 7 mm penetrating plaque in the distal portion of the aortic arch, without prior imaging for 2 studies acuity. A short-segment focal dissection in the mid aortic arch, appears chronic. 2. Signs of heart failure with cardiomegaly, pulmonary edema, bilateral pleural effusions greater on the right, as well as gallbladder-wall edema. 3. Infrarenal aortic aneurysm and left common iliac aneurysm. Please note that the prior study was done without IV contrast however based on wall calcifications in overall diameter it is grossly unchanged.

10010058-RR-26

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2147-01-04 14:25:00

2147-01-04 14:55:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT INDICATION: ___ year old man with ongoing LFT abnormalities and gallbladder congestion on CT at time of presentation// eval of ongoing LFT abnormality, mild gallbladder congestion on CT TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There are simple cysts in the left lobe of the liver that measure up to 1.3 cm.. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. CHD: 4 mm GALLBLADDER: Gallbladder contains numerous small gallstones. There is mild gallbladder wall thickening measuring 3 mm likely reflecting mild gallbladder wall edema, significantly improved compared to recent CT. IMPRESSION: 1. Cholelithiasis. 2. Mild gallbladder wall edema is significantly improved compared to recent CT from ___. No other evidence of cholecystitis.

10010231-RR-13

RR

2118-04-14 13:31:00

2118-04-14 15:06:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with fever, on chemo // Please eval for pna Please eval for pna IMPRESSION: In comparison with the study of ___, there is little change and no evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. Little change in the appearance of the Port-A-Cath.

10010231-RR-14

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2118-04-14 14:53:00

2118-04-14 15:52:00

EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK INDICATION: ___ year old man with neutropenia, fever, tender abscess-like mass in submandibular area // Please eval for abscess TECHNIQUE: Imaging was performed after administration intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.8 s, 29.4 cm; CTDIvol = 15.4 mGy (Body) DLP = 453.5 mGy-cm. Total DLP (Body) = 453 mGy-cm. COMPARISON: None. FINDINGS: The salivary glands enhance normally and are without mass or adjacent fat stranding. The thyroid gland appears normal.There are few prominent, though nonenlarged, cervical lymph nodes. None are enlarged by CT criteria.There is mild soft tissue stranding in the subcutaneous tissues inferior to the chin (602 B/ ___). The neck vessels are patent. There is a partially visualized right port catheter. The imaged portion of the lung apices are clear and there are no concerning pulmonary nodules. There are no osseous lesions. There is moderate mucosal thickening of the left maxillary sinus. There is a mucous retention cyst in the right maxillary sinus. Otherwise, the paranasal sinuses, middle ears and mastoid air cells are clear. IMPRESSION: 1. There are a few prominent, though nonenlarged, cervical lymph nodes. 1 of which may correspond to the clinical area of concern, but is not pathologically enlarged or necrotic. No mass or abscess is identified. 2. Mild, nonspecific soft tissue stranding in the subcutaneous tissues inferior to the chin. 3. Moderate mucosal thickening in the left maxillary sinus.

10010231-RR-15

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2118-04-17 14:31:00

2118-04-17 16:44:00

EXAMINATION: CT NECK W/CONTRAST INDICATION: ___ year old man with neutropenic MSSA bacteremia from skin source in the submandibular area and pain when swallowing, now with persistent fevers of several days duration. Evaluate for fluid collections or abscesses. TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque350 intravenous contrast material. MDCT acquired helical axial images were obtained from the thoracic inlet through the skull base. Coronal and sagittal multiplanar reformats were then produced and reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.4 s, 35.0 cm; CTDIvol = 7.1 mGy (Body) DLP = 242.4 mGy-cm. Total DLP (Body) = 242 mGy-cm. COMPARISON: ___ CT neck with contrast. FINDINGS: Again seen is edema and stranding in the left greater than right submental subcutaneous soft tissues, increased compared to 3 days earlier. There is no evidence for free fluid or organized drainable fluid collection. Nonenlarged enhancing bilateral level 1a lymph nodes are unchanged and likely reactive. There are no enlarged cervical lymph nodes. Evaluation of the aerodigestive tract demonstrates no mass and no areas of focal mass effect. The salivary glands appear unremarkable. The thyroid gland appears unremarkable. The major cervical vessels are patent. Note is made of a diminutive non-dominant right vertebral artery, likely congenital. There is a partially visualized right Port-A-Cath. Multiple small lung nodules in the visualized right upper lobe are new new compared to 3 days earlier: 4 mm subpleural nodule, image 4:96 3 mm peripheral nodule, image 4:93 3 mm peripheral nodule, image 4:82 5 mm peripheral nodule, image 4:80 3 mm subpleural nodule, image 4:78 3 mm peripheral nodule, image 4:66 The maxilla is partially edentulous, which limits counting of the teeth. There is a small periapical lucency of the left maxillary molar, either ___ 14 or 15. There are also periodontal lucencies of the left maxillary molars. There is moderate mucosal thickening in the left maxillary sinus with occlusion of the left ostiomeatal unit. A mucous retention cyst is seen in the right maxillary sinus. There is mild mucosal thickening in the ethmoid sinuses. The middle ears and the mastoid air cells are clear. There are no suspicious osseous lesions. Mild deformities of the left nasal bone (4:18) and the lateral wall of the left maxillary sinus (4:20) suggest prior fractures. IMPRESSION: 1. Left greater than right submental subcutaneous edema, consistent with known cellulitis in this area, demonstrates mild progression compared to 3 days earlier on ___. No free fluid or abscess. 2. Multiple small right upper lobe lung nodules measuring up to 5 mm are new compared ___. In the setting of bacteremia, these may represent septic emboli. Atypical infection may also be considered as the patient is neutropenic (Nocardia, etc). 3. Moderate polypoid mucosal thickening in the left maxillary sinus with occlusion of the left ostiomeatal unit and a mucous retention cyst in the right maxillary sinus, similar to prior. Given the small periapical lucency involving ___ 14 or 15, as detailed above, please correlate clinically whether there may be odontogenic etiology of sinus disease. RECOMMENDATION(S): Full extent of pulmonary abnormalities may be assessed by chest CT, if clinically warranted NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:24 ___, 5 minutes after discovery of the findings.

10010231-RR-16

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2118-04-17 13:56:00

2118-04-17 16:44:00

EXAMINATION: UNILAT LOWER EXT VEINS RIGHT INDICATION: ___ year old man with new onset right calf pain this morning in the setting of malignancy and neutropenic MSSA bacteremia // Evaluate for right DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the right lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the right common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins.

10010231-RR-17

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2118-04-18 15:17:00

2118-04-18 16:39:00

EXAMINATION: CT CHEST WANDW/O C INDICATION: ___ man with febrile neutropenia and lung nodiules found incidentally on neck CT presenting for further evaluation of pulmonary nodules. TECHNIQUE: Multidetector helical scanning of the chest was performed without intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. DOSE: Total DLP (Body) = 420 mGy-cm. COMPARISON: No prior chest CT is available on PACS at the time of this dictation. Reference is made to a CT neck dated ___. FINDINGS: Detailed evaluation of the solid organs, soft tissues, and vessels is limited without the use of intravenous contrast. Within this limitation: The thoracic aorta is normal in caliber without evidence of atherosclerotic calcified disease. The main, left, and right pulmonary arteries are normal in caliber. The heart appears normal in size. Hypoattenuation of the cardiac blood pool on this unenhanced exam indicates anemia. No evidence of a pericardial effusion. The right Port-A-Cath tip ends in the proximal right atrium. No axillary, supraclavicular, mediastinal, or hilar lymphadenopathy. Numerous, small bilateral pulmonary nodules and are nonspecific favor infectious in etiology since some of the nodules in the previously imaged upper lungs appear new in the short interval and given the patient's history of neutropenia and fever. A right lower lobe pulmonary nodule measures 10 mm (series 4, image 25). A lingular subpleural nodule measures 7 mm (series 4, image 222). A calcified granuloma in the left lower lobe measures 5 mm (series 4, image 283). The airways are patent to at least the subsegmental level. No evidence of bronchiectasis or significant peribronchiolar wall thickening. No pneumothorax or pleural effusion. No cavitary lesions. The thyroid gland is normal in size without evidence of focal mass. No osseous lesions in the chest cage concerning for malignancy. Degenerative changes in the upper thoracic spine are mild. No evidence of acute fracture. This exam is not dedicated for imaging of the upper abdomen. Within this limitation: The spleen appears normal in size. Diverticulosis of the partially imaged transverse colon in the upper abdomen is mild. Partially imaged small bowel loops in the left upper abdomen containing small amount of fluid but are normal in caliber. IMPRESSION: 1. Numerous bilateral pulmonary nodules appear increased in number at least in the upper lobes since the prior neck CT and favor infectious etiology, likely fungal in the setting of febrile neutropenia. Correlate with clinical assessment. If the patient's symptoms persist despite treatment, consider repeat Chest CT in ___ weeks to reevaluate. 2. Anemia. 3. Minimal colonic diverticulosis. RECOMMENDATION(S): If the patient's symptoms persist despite treatment, consider repeat Chest CT in ___ weeks to reevaluate. NOTIFICATION: The findings, impression, and recommendation were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 4:39 ___, 20 minutes after discovery of the findings.

10010231-RR-18

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2118-04-18 17:16:00

2118-04-19 14:41:00

EXAMINATION: MANDIBLE (PANOREX ONLY) INDICATION: ___ year old man with febrile neutropenia and submandibular source with likely MSSA and some concern for possible dental abscessess // Evaluate for dental abscessess Evaluate for dental abscessess TECHNIQUE: Panorex radiograph of the teeth. COMPARISON: CT of the neck dated ___. FINDINGS: No periapical lucencies are identified. No mandibular fracture. There has been apparent previous extraction of multiple mandibular and maxillary teeth. IMPRESSION: No periapical lucency.

10010231-RR-19

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2118-04-20 08:45:00

2118-04-20 12:16:00

EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT INDICATION: ___ year old man with febrile neutropenia, mssa bacteremia, and cellulitis under chin // evaluate for abscess under chin TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the submental area. COMPARISON: None provided. FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the bilateral submental area. There is moderate skin thickening and subcutaneous edema, consistent with known cellulitis. No discrete fluid collection or abnormal lymph nodes identified. IMPRESSION: 1. No drainable fluid collection. No abnormal lymph nodes. 2. Mild skin thickening and subcutaneous edema of the submental area, consistent with patient's known cellulitis.

10010231-RR-20

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2118-04-21 09:24:00

2118-04-21 11:26:00

INDICATION: ___ year old man with AML s/p hiDAC cycle 4 (completed infusions) here with febrile neutropenia found to have MSSA bacteremia and needs port removed. ___ aware. // please remove port, likely date would be ___ waiting for counts to recover COMPARISON: NONE TECHNIQUE: OPERATORS: Dr. ___ radiology attending) performed the procedure. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 9 min during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl, midazolam, lidocaine with and without epinephrine CONTRAST: None FLUOROSCOPY TIME AND DOSE: 0.1 min, 0 mGy PROCEDURE: 1. Right chest Port-a-Cath removal. PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The upper chest was prepped and draped in the usual sterile fashion. After a scout image, the port site was incised along the suture line down to the subcutaneous fat. Blunt dissection was used to free the port. The port was then removed. The subcutaneous pocket was closed in layers with ___ interrupted and ___ subcuticular continuous Vicryl sutures. Steri-Strips were applied over the sutures. Final spot fluoroscopic image was obtained. The port was sent to microbiology for culture. FINDINGS: Final fluoroscopic image showing complete removal of the port. IMPRESSION: Successful removal of a right upper chest port.

10010231-RR-21

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2118-04-23 14:29:00

2118-04-23 17:01:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with new transaminitis // r/o obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___ FINDINGS: LIVER: The liver is diffusely echogenic. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The imaged portion of the pancreas appears within normal limits, without masses or pancreatic ductal dilation, with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 10.3 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on this examination. Unchanged from prior.

10010231-RR-22

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2118-05-06 17:30:00

2118-05-06 20:28:00

EXAMINATION: CT chest without contrast INDICATION: Mr. ___ us a ___ year old male with history of AML on HiDAC C4D1 (___) who initially presented with febrile neutropenia and associated worsening cellulitis under the L mandible found to have MSSA bacteremia now s/p port removal on cefazolin// please eval for pulm nodules TECHNIQUE: Contiguous axial images were obtained through the chest without intravenous contrast. Coronal and sagittal reformats were obtained. COMPARISON: Chest CT ___ FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart, pericardium, and great vessels are within normal limits based on an unenhanced scan. No pericardial effusion is seen. There has been interval removal of Port-A-Cath since comparisons study. AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: There are multiple scattered pulmonary nodules in both lungs, most of which are mildly decreased in size as compared to chest CT ___. For example, a left upper lobe nodule now measures 3 mm (5:67), previously 4 mm. A sub solid nodule in the Left upper lobe measures 6 mm (5:117), previously 7 mm. A Left major perifissural nodule measures 6 mm (5:200) previously 7 mm. A spiculated nodule in the superior segment of the right lower lobe measures 5 mm (5:169), previously 10 mm. Another right lower lobe nodule measures 3 mm (5:190), previously 6 mm. A right upper lobe nodule measures 3 mm (5:73), previously 6 mm. There is no evidence of new pulmonary nodules or nodules that are increasing in size. No focal consolidation. The airways are patent to the level of the segmental bronchi bilaterally. There is no bronchiectasis. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: There is mild diverticulosis of the partially visualized colon without evidence of diverticulitis. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: Multiple scattered pulmonary nodules are minimally decreased in size as compared to chest CT ___. No new pulmonary nodules identified.

10010393-RR-9

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2136-07-01 10:24:00

2136-07-01 15:34:00

EXAMINATION: SECOND OPINION CT NEURO PSO1 CT INDICATION: ___ year old woman with acute low back pain and tenderness around intrathecal catheter site // Please evaluate CT-L spine from ___ for evidence of infection around intrathecal catheter TECHNIQUE: Outside CT with contrast was presented for interpretation. DOSE: Found no primary dose record and no dose record stored with the sibling of a split exam. !If this Fluency report was activated before the completion of the dose transmission, please reinsert the token called CT DLP Dose to load new data. COMPARISON: None. FINDINGS: There is normal alignment of the lumbar spine. Mild ligamentum flavum thickening is seen at L3-4, L4-5 and L5-S1. No significant spinal canal or neural foraminal stenosis is seen. There is no acute fracture or malalignment. There is an intrathecal catheter which courses from the pump, which is not visualized, through the left subcutaneous soft tissues of the back, between the L2-3 spinous process and into the thecal sac. Two linear hyperdensities are noted within the soft tissues at the level of the L3 spinous process, consistent with surgical sutures. Minimal stranding is noted within the posterior soft tissues, at the level of the L3 spinous process, likely secondary to postsurgical changes. No fluid collection or soft tissue mass is identified along the course of the catheter. The catheter extends from the through the T11- L2 spinal canal. No discontinuity is noted in the visualized catheter. A fluid-filled distended bladder is seen. Multiple sub cm hypodensities are noted in the kidneys, which are too small to characterize and likely represent simple cysts. IMPRESSION: 1. Minimal soft tissue stranding in the posterior soft tissues of the back, at the L2-3 level, consistent with postsurgical changes. No fluid collection or abscess identified along the course of the visualized catheter.

10010440-RR-20

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2173-08-08 09:06:00

2173-08-08 12:03:00

INDICATION: ___ year-old woman with T12 lytic lesion extending to the spinal canal. Assess for the degree of spinal canal stenosis and/or cord compression. The patient is status post intracranial aneurysmal clip, which is incompatible with MRI. PROCEDURE: Lumbar spinal myelography, followed by CT thoracic and lumbar myelography (dictated separately). CLINICIANS: Dr. ___ (attending), Dr. ___ (neuroradiology fellow). ANESTHESIA: Local anesthesia was achieved using 1% lidocaine. PROCEDURAL DETAILS: Prior to the procedure, written informed consent was obtained from the patient's healthcare proxy ___, patient's son), and both the patient and the healthcare proxy showed good understanding of the indications, risks, benefits and alternatives. A pre-procedural timeout was performed upon arrival in the angiography suite, using name, date of birth and medical record number as identifiers. The patient was placed in a prone position on the angiography table and his lower back was prepped and draped in the typical sterile fashion. The skin was anesthetized using 1% lidocaine. The patient had severe multilevel lumbar stenosis, and there were not good window for the placement of the spinal needle from L2-3 to the remainder lower lumbar spine. Thereafter, a 20-gauge spinal needle was advanced into the spinal canal at the L1-2 level, under careful fluoroscopic observation. CSF flow flashback was noted through the spinal needle. 12 cc of Isovue-M 200 iodinated contrast was then carefully hand-injected into the spinal canal. After injection of the contrast, the spinal needle stylet was replaced, and then removed in conjunction with the spinal access needle. The patient was then imaged fluoroscopically, as the contrast bolus disseminated superiorly and inferiorly from the lumbar intrathecal space to the thoracic and upper sacral intrathecal spaces. AP, lateral oblique fluoroscopic spot images were captured and saved. The patient was transferred from the angiography suite to the CT scanner. Overall, there were no complications and the patient tolerated this procedure well. FINDINGS: Spot fluoroscopic images taken in frontal, lateral and oblique projections of the lumbar spine following the instillation of contrast. The old L1 anterior wedge compression fracture is noted. IMPRESSION: Uncomplicated lumbar myelogram, with intrathecal injection of 12 cc of Isovue-M 200 iodinated contrast at L1-2. The patient tolerated the procedure well without immediate complications. Please refer to the separately dictated report of the CT thoracic and lumbar myelogram.

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2173-08-08 09:21:00

2173-08-08 12:35:00

HISTORY: ___ woman, with back pain and lower extremity weakness. Outside CT shows progression of a lytic lesion at T12, with significant encroachment of the spinal canal. Assess for the severity of cord compression. TECHNIQUE: The patient received intrathecal iodinated contrast via a fluoroscopic-guided L1-2 level injection in the angiographic suite. The patient was subsequently transferred to the CT scanner. MDCT images were acquired through the thoracic and lumbar spine without IV administration of contrast. Multiplanar reformatted images were obtained for evaluation. COMPARISON: Outside CT lumbar spine on ___. CT abdomen and pelvis on ___. FINDINGS: CT THORACIC SPINE: At T12, there is a large lytic lesion predominantly involving the right aspect of the vertebral body, with significant bony destruction extending to the right pedicle. The left pedicle and bilateral lamina appear intact. There is extensive posterior soft tissue extension into the bony spinal canal, compressing and displacing the spinal cord to the left. At T12, the deformed spinal cord measures 7 mm TV x 3 mm AP, compared to 9 mm x 8 mm at the upper L1 level, and 7 mm x 6 mm at the T11 level. A thin rim of intrathecal contrast remains at the most severely stenotic point at T12. There is severe right T12-L1 neural foraminal narrowing, but no significant left T12-L1 neural foraminal narrowing. Despite the severe spinal canal stenosis at T12, intrathecal contrast has reached the upper thoracic spinal canal up to the cervicothoracic junction. At the remaining levels of the thoracic spine, there are multilevel small-to-moderate disc bulges, most significantly affecting T8-9, T9-10, T10-11 levels with mild indentation the anterior thecal sac and in contact with the anterior spinal cord, but without significant cord deformity. There is no evidence of acute thoracic spinal alignment. CT LUMBAR SPINE: There is intrathecal contrast throughout the lumbar spinal canal, with the contrast reaching the sacral spinal canal. There is an old L1 anterior wedge deformity, with approximately 40% of vertebral height loss, unchanged from the prior CT abdomen pelvis study on ___. There is no evidence of acute vertebral height loss in the lumbar spine. Small fat-containing foci are again noted scattered in the vertebral bodies, with the most prominent one at the lower L1 vertebral body, unchanged from the CT abdomen and pelvis, and likely representing focal fat depositions. No acute lumbar malalignment is noted. The conus medullaris terminates at L1-2. At L1-2, there is a diffuse disc bulge with extension into neural foramina, resulting in mild bilateral neural foraminal narrowing but no significant spinal canal stenosis. At L2-3, there is a diffuse disc bulge with extension into neural foramina. In combination with ligamentum flavum thickening and bilateral facet arthropathy, there is moderate bilateral neural foraminal narrowing, mild-to-moderate bilateral subarticular zone narrowing, and mild spinal canal narrowing. At L3-4, there is a diffuse disc bulge with extension into neural foramina. In combination with ligamentum flavum thickening and facet arthropathy, there is moderate spinal canal stenosis and mild bilateral neural foraminal narrowing. At L4-5, there is a diffuse disc bulge with ligamentum flavum thickening and facet arthropathy, resulting in moderate spinal canal stenosis and mild bilateral neural foraminal narrowing. At L5-S1, there is a small disc protrusion, but no significant spinal canal or neural foraminal narrowing. Significant atherosclerotic disease is noted at the distending aorta and its major branches. The patient is status post a VP shunt with the tip terminating in the intra-abdominal cavity. IMPRESSION: 1. Large expansile lytic lesion at the right aspect of the T12 vertebral body and extending the right pedicle. Significant soft tissue extension into the right-sided spinal canal, resulting in severe spinal canal stenosis, compression and deformity of the T12 spinal cord. The spinal canal remains patent, as intrathecal has reached the upper thoracic spinal canal. Severe right T12-L1 neural foraminal narrowing. No significant left T12-L1 neural foraminal narrowing. 2. Old L1 anterior wedge deformity, unchanged. Moderate lumbar spondylosis.

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2173-08-08 12:58:00

2173-08-08 17:46:00

STUDY: Left foot, ___. CLINICAL HISTORY: ___ woman with a history of stroke ___ years ago. Status post fall with fourth and fifth digit fracture. FINDINGS: Comparison is made to the prior radiographs from ___ at outside hospital. There is a fracture involving the base of the fifth proximal phalanx with extension to the fifth MTP joint. The rest of the bony structures appear intact. Lisfranc interval is preserved. Mineralization is normal.

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2173-08-08 17:40:00

2173-08-09 08:57:00

PORTABLE CHEST ___ COMPARISON: Scout image from a CT abdomen of ___. FINDINGS: Cardiac silhouette is mildly enlarged allowing for accentuation by low lung volumes and portable technique. This factor also accentuates the pulmonary vascularity. With this in mind, there is no evidence of congestive heart failure. No focal areas of consolidation are present within the lungs, and there are no pleural effusions or pneumothoraces. Ventriculoperitoneal shunt catheter is noted.

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2173-08-09 15:22:00

2173-08-10 09:27:00

STUDY: Lumbar spine intraoperative study, ___. CLINICAL HISTORY: The patient with posterior lumbar surgery and fusion. FINDINGS: Several views of the lumbar spine from the operating room demonstrates placement of pedicle screws in T10, T11, L1 and L2. Please refer to the operative note for additional details. There is wedging of the L1 vertebral body. Loss of intervertebral disc height and spurring is seen at several levels. Please refer to the operative note for additional details.

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2173-08-09 09:46:00

2173-08-09 11:47:00

HISTORY: Status post fall, now with right foot pain. Evaluation for fracture. COMPARISON: None available. TECHNIQUE: Right foot, three views. FINDINGS: There is no evidence of acute fracture or dislocation within the right foot. Calcaneal spurring is noted, representing mild degenerative changes. Otherwise, no lytic or sclerotic lesion is identified. On the oblique view, there is question of an old healed medial malleolar fracture which is not well seen on the other views. Enthesopathy is noted at the insertion point of the Achilles tendon. No radiopaque foreign body is identified. IMPRESSION: No acute fracture or dislocation within the right foot. Mild degenerative changes.

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2173-08-09 17:12:00

2173-08-10 08:40:00

HISTORY: Intraoperative evaluation for T10 through L2 posterior spinal fusion. TECHNIQUE: Five intraoperative radiographic examinations of the lumbar spine. COMPARISON: Intraoperative radiographs performed ___. FINDINGS: There are pedicle screws in place at the T10, T11, L1, and L2 levels. These pedicle screws appear intact. There is an intervertebral spacer device placed at the fractured T12 level. A previously noted chronic appearing compression fracture at the L1 level is not well visualized on this current examination. IMPRESSION: 1. Intraoperative radiographic examination was provided for placement of pedicle screws at the T10, T11, L1, and L2 levels. 2. Intervertebral spacer device plaed at the L1 level. 3. Surgical hardware appears intact. Please refer to the operative report for further evaluation.

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2173-08-11 16:13:00

2173-08-11 17:53:00

INDICATION: Spinal mass with right foot pain, evaluate for ankle fracture. COMPARISON: ___ foot radiograph. THREE VIEWS, RIGHT ANKLE There are moderate degenerative changes of the tibiotalar joint with narrowing and subchondral sclerosis. There is evidence of prior avulsive injury arising off the medial malleolus and likely the lateral malleolus as well. There is chronic deformity of the lateral malleolus. No acute fracture is identified. There is calcaneal enthesopathy. Soft tissue swelling is noted. IMPRESSION: Moderate tibiotalar joint degenerative change. No acute fracture appreciated.

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2173-08-12 08:54:00

2173-08-12 10:29:00

INDICATION: ___ male status post placement of a left PICC. Assess position. COMPARISON: Chest radiograph from ___ PORTABLE SEMI-UPRIGHT FRONTAL CHEST RADIOGRAPH: A left approach PICC is malpositioned. The catheter runs across the left subclavian vein, left brachiocephalic vein and then courses cephalad, terminating in the region of the left internal jugular vein at the thoracic inlet. Re-positioning is recommended. A presumed ventriculoperitoneal shunt is in unchanged expected position. Lung volumes are low resulting in bronchovascular crowding. There is no consolidation or overt interstitial edema. No large pleural effusions are identified. Mediastinal and hilar contours are within normal limits. Mild cardiomegaly is unchanged. Thoracolumbar spinal hardware is partially imaged and is new in the interval, though incompletely evaluated. IMPRESSION: 1. Malpositioned left PICC terminating in the mid right internal jugular vein. 2. Interval placement of thoracolumbar spinal fusion hardware, incompletely evaluated on this portable semi-upright frontal chest radiograph. Dr. ___ communicated the above results to IV RN, ___ ___, at 10:04 a.m. on ___ by telephone immediately after discovery.

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2173-08-12 10:15:00

2173-08-12 12:10:00

PICC LINE EXCHANGE/REPOSITIONING INDICATION: Malposition of indwelling PICC line. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Dr. ___, radiology resident, Dr. ___, ___ fellow and Dr. ___, ___ attending, performed the procedure. TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was advanced through the indwelling left arm PICC line, and subsequently into the SVC under fluoroscopic guidance. The old PICC line was then removed and a peel-away sheath was then placed over the guidewire. A new double lumen PICC line measuring 47.5 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new 5 ___ double lumen PICC line. Final internal length is 47.5 cm, with the tip positioned in the SVC. The line is ready to use.

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2173-08-12 14:18:00

2173-08-12 16:25:00

HISTORY: UNDERLYING MEDICAL CONDITION: ___ year old woman with hx of SAH with aneurysmal clip now with Hct drop, worsening mental status, and headache. REASON FOR THIS EXAMINATION: Evaluate for intracerebral bleed. COMPARISON: Outside non contrast head CT performed at ___ on ___. TECHNIQUE: Multi detector CT axial imaging of the head was obtained without intravenous contrast. FINDINGS: The patient is status post right frontal craniotomy and clipping of a ruptured cerebral aneurysm. An aneurysm clip is noted in the suprasellar region. A right parietal approach ventriculostomy catheter is unchanged in position with the tip terminating in the midline along the septum pellucidum. The ventricles and sulci are unchanged in size and configuration from the only prior study available for comparison. There is no evidence of intracranial hemorrhage. Bifrontal cystic encephalomalacia is unchanged. There is relative ___ of the left posterior cerebral hemisphere, which does not correspond to a particular vascular territory and could conceivably represent retained contrast related to the patient's recent myelogram. Elsewhere, the gray-white matter interface is preserved. The orbits and globes are unremarkable. The visualized paranasal sinuses, middle ear cavities and mastoid air cells are well pneumatized bilaterally. IMPRESSION: 1. No acute intracranial hemorrhage status post right craniotomy and aneurysm clipping. 2. ___ of the left posterior cerebral hemisphere not corresponding to vascular territory could conceivably represent retained contrast related to the patient's recent myelogram. Attention on followup is recommended. 3. Stable bifrontal encephalomalacia. 4. Unchanged position of a right parietal ventriculostomy catheter.

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2173-08-13 14:05:00

2173-08-13 17:58:00

RADIOGRAPHS OF THE THORACIC AND LUMBAR SPINES HISTORY: T12 lesion status post T10 through L2 fusion, T12 corpectomy and new difficulties with pain control and falling hematocrit. COMPARISONS: CT from ___ and lumbar spine radiographs from ___. TECHNIQUE: Thoracolumbar spine, five views. FINDINGS: The patient is status post posterior fusion from T10 through L2 with a T12 corpectomy including placement of a vertical fusion spacer. Moderate-to-severe degenerative changes are incompletely characterized, but suspected, along the facet joints along the mid through lower lumbar spine. Small anterior osteophytes are present along the lower thoracic spine. There is no evidence for hardware loosening. A PICC line terminates in the upper right atrium. A ventriculoperitoneal shunt is also noted. IMPRESSION: Unremarkable post-operative appearance.

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2173-08-13 16:46:00

2173-08-14 09:37:00

HISTORY: Multiple myeloma status post T12 corpectomy and T10-L2 fusion now with increasing pain and hematocrit drop. TECHNIQUE: Sagittal imaging was performed with T2, T1, and T2 weighted ideal technique. Axial T1 and T2 weighted imaging was performed through select levels. Ten cc of Gadavist intravenous contrast were administered. Sagittal and post contrast T1 weighted imaging also was performed. COMPARISON: No prior MR examinations are available for comparison. Comparison to a myelogram and CT myelogram ___. FINDINGS: Again seen is distortion of the thecal sac with leftward displacement of the sac at the T12 level. The patient is now status post laminectomy with posterior fusion from T10-L2, and interbody fusion after corpectomy T11-L1. The material posterior and right lateral to the thecal sac appears to be a fluid collection. There is no enhancement of the substance of this material after contrast administration. There is no enhancement of the periphery. Alignment of the spine appears normal. There is markedly heterogeneous signal intensity of the vertebral bodies at every level of spine. This may reflect diffuse involvement by myeloma. There are no findings to suggest neoplastic encroachment on the spinal canal. There are changes of degenerative disc disease in the cervical and lumbar spines that encroach on the spinal canal and thecal sac. In the cervical spine, this is most prominent at C5-6 where intervertebral osteophytes slightly flattening the anterior surface of the spinal cord. In the lumbar spine bulging of the intervertebral disc, thickening of the ligamentum flavum, and facet osteophytes produce moderate to severe spinal stenosis at L3-4 and L4-5. Disc bulging into the neural foramina also produces bilateral foraminal narrowing at both levels. Mild bulging of the L5-S1 intervertebral disc does not encroach on the thecal sac. There is mild bilateral neural foraminal narrowing. IMPRESSION: Status post T12 corpectomy and T10-L2 fusion. Posterior and right-sided intraspinal fluid collection communicates through the laminectomy defect and causes anterior and left lateral displacement of the thecal sac. This leads to severe encroachment on the distal spinal cord. There are no findings to suggest tumor in this location. The signal intensity characteristics are typical of simple fluid, rather than hemorrhage. These findings were discussed by telephone by Dr. ___ with Dr. ___ at 9:30 am, ___.

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2173-10-22 19:50:00

2173-10-22 20:26:00

HISTORY: ___ female with altered mental status. COMPARISON: ___. FINDINGS: AP view of the chest. There is asymmetric left basilar opacity. Given lower lung volumes this could be due to atelectasis. Elsewhere, the lungs are grossly unchanged. Cardiomediastinal silhouette has not definitely changed although exact evaluation is difficult given rotation. Posterior spinal fixation hardware seen in the lower thoracic spine. Ventriculoperitoneal shunt catheter projects over the right anterior chest wall. IMPRESSION: Left basilar opacity potentially atelectasis given low ___ ___ ng volumes however infection cannot be excluded.

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2173-10-22 19:14:00

2173-10-22 20:26:00

HISTORY: History of subarachnoid hemorrhage on heparin now with altered mental status. COMPARISON: Comparison is made with head CT from ___. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Reformatted coronal and sagittal and thin section bone algorithm reconstructed images were acquired. FINDINGS: The patient is status post right frontal craniotomy. A right parietal approach VP shunt is seen terminating in the area of the septum pellucidum, unchanged from prior exam. An aneurysm clip is again seen in the suprasellar region. There is no evidence of acute hemorrhage, edema, mass effect, or infarction. Foci of encephalomalacia are again seen in the bifrontal and left temporoparietal areas. The ventricles and sulci are unchanged in configuration from prior exam. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. The basal cisterns appear patent and there is preservation of gray-white matter differentiation. No fracture is identified. Visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial process. No change from prior.

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2173-10-24 19:52:00

2173-10-25 10:01:00

INDICATION: ___ woman with multiple myeloma and history of ruptured cerebral aneurysm, presenting with subacute altered mental status. COMPARISON: Non-contrast head CT from ___. FINDINGS/IMPRESSION: A localizer sequence was obtained. Two attempts at sagittal T1-weighted images were made, both degraded by patient's motion. The exam was subsequently discontinued because the patient was trying to climb off the table. No diagnostic information was obtained.

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2150-10-05 02:36:00

2150-10-05 06:21:00

INDICATION: ___ with rash, ___ edema, DOE, evaluate for acute cardiopulmonary process. TECHNIQUE: Chest PA and lateral COMPARISON: None available. FINDINGS: The lungs are well inflated and clear. The cardiomediastinal silhouette, hila contours, and pleural surfaces are normal. There is no pleural effusion or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary process.

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2139-04-28 14:44:00

2139-04-28 15:09:00

EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT INDICATION: History: ___ with R index finger infection s/p cyst removal on ___// ? osteo ? osteo TECHNIQUE: Frontal, oblique, and lateral view radiographs of right hand COMPARISON: Hand radiograph ___ FINDINGS: No acute fracture or dislocation is seen. There are mild degenerative changes, including at the interphalangeal joints, first CMC, and triscaphe joint.. No bone erosion or periostitis is identified. No suspicious lytic or sclerotic lesion is identified. IMPRESSION: No acute fracture or dislocation. No cortical destruction to suggest acute osteomyelitis radiographically.

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2155-11-20 12:26:00

2155-11-20 12:50:00

HISTORY: ___ male with abdominal pain and fever. COMPARISON: Multiple prior exams, most recently ___. FINDINGS: Frontal and lateral views of the chest. The heart size and cardiomediastinal contours are normal. Small biapical scarring is unchanged. The lungs are otherwise clear without focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: No acute cardiopulmonary process.