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19982539-RR-55

RR

2175-05-29 12:51:00

2175-05-29 13:35:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with EVD, decreased output, confirm placement. Evaluate for drain placement and hydrocephalus. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: CT head ___. FINDINGS: Status post left craniectomy with unchanged extent of parenchymal herniation is present through the craniectomy site. Extra-axial fluid collection in the craniectomy site has substantially decreased, with new small foci of air within this collection. Subacute left MCA territory infarct is again seen. No acute hemorrhage. No evidence for new parenchymal edema. A right frontal approach ventriculostomy catheter terminates near the left foramen ___ in unchanged position. Mild hypodensity along the right frontal path of the catheter has increased compared to ___. Frontal horns and bodies of the lateral ventricles have slightly decreased in size. Asymmetric enlargement of the atrium and temporal horn of the left lateral ventricle persist. The third ventricle has slightly decreased in size. The fourth ventricle is stable. Basal cisterns are stable in size. The left mastoid is underpneumatized and partially opacified, similar to prior. Small mucous retention cyst in the right posterior ethmoid. Mild mucosal thickening and mild aerosolized secretions in the partially visualized right maxillary sinus. IMPRESSION: 1. The right frontal approach ventriculostomy catheter terminate near the left foramina of ___, unchanged. Slightly decreased horns of the frontal horns and bodies of the lateral ventricles, and of the third ventricle, compared to ___. 2. Subacute left MCA infarct is again demonstrated. 3. Status post left craniectomy with stable herniation of the brain parenchyma through the defect. Decreased in the size of the left extra-axial collection. Unchanged herniation of the brain parenchyma through the defect.

19982539-RR-56

RR

2175-06-01 08:57:00

2175-06-01 09:15:00

EXAMINATION: CT HEAD WITHOUT CONTRAST INDICATION: ___ s/p placement of R VPS on ___. Head CT without contrast to be performed on ___ at 0600 to evaluate ventricle size. TECHNIQUE: Axial images of the head were obtained without contrast . DOSE: Acquisition sequence: 1) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 47.4 mGy (Head) DLP = 829.0 mGy-cm. Total DLP (Head) = 843 mGy-cm. COMPARISON: ___. FINDINGS: Brain ectomy is identified in the left cerebral hemisphere. A large hypodensity seen in the region of left parietal lobe. The overall protrusion of brain parenchyma through the craniectomy site has slightly decreased. A ventricular drain is seen neck tearing from the right frontal region with the tip in the left anterior horn. No acute hemorrhage is identified. IMPRESSION: Left-sided craniectomy is identified with hypodensity in the left parietal lobe with decreasing mass effect compared to the previous CT of ___. No acute hemorrhage. Unchanged ventricular size. No hydrocephalus.

19982541-RR-12

RR

2148-11-30 10:50:00

2148-11-30 16:12:00

EXAMINATION: Ultrasound-guided cholecystostomy insertion INDICATION: ___ year old man with scute cholecystitis with intra-hepatic abscess // please place percutaneous cholecystostomy tube COMPARISON: CT from ___ PROCEDURE: Ultrasound-guided cholecystostomy insertion OPERATORS: Dr. ___, radiology trainee and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agree with the trainee's findings. TECHNIQUE: The risks, benefits, and alternatives of the procedure were explained to the patient. After a detailed discussion, informed written consent was obtained. A pre-procedure timeout using three patient identifiers was performed per ___ protocol. The patient was placed in a supine position on the US scan table. Limited preprocedure ultrasound was performed to localize the collection. Based on the ultrasound findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Local anesthesia was administered with 1% Lidocaine solution. Using continuous sonographic guidance, ___ Exodus drainage catheter was advanced via trocar technique into the collection. A sample of fluid was aspirated, confirming catheter position within the collection. The pigtail was deployed. The position of the pigtail was confirmed within the collection via ultrasound. Approximately 50 cc of purulent fluid was drained with a sample sent for microbiology evaluation. The catheter was secured by a StatLock. The catheter was attached to bag. Sterile dressing was applied. The procedure was tolerated well, and there were no immediate post-procedural complications. SEDATION: Moderate sedation was provided by administering divided doses of 2 mg Versed and 100 mcg fentanyl throughout the total intra-service time of 18 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Distended gallbladder with focal hypodense region in the adjacent liver compatible with the findings at CT. Images demonstrate the needle within the gallbladder lumen and subsequently complete decompression of the gallbladder and adjacent liver collection. IMPRESSION: Successful US-guided placement of ___ pigtail catheter into the gallbladder. Samples was sent for microbiology evaluation.

19982872-RR-40

RR

2156-12-12 06:53:00

2156-12-12 09:57:00

INDICATION: ___ female with right sided/epigastric pain. Question appendagitis or diverticulitis. COMPARISON: ___. TECHNIQUE: MDCT images were acquired from the lung bases through the pubic symphysis following administration of intravenous contrast. Multiplanar reformations were generated. CT ABDOMEN: The lung bases are clear. There is no pleural effusion. The heart is normal in size without pericardial effusion. No focal liver lesion is demonstrated. The gallbladder contains multiple gallstones without evidence of acute inflammation. The bile ducts are normal and there is no intrabiliary air, nor any air within the gallbladder. A tiny subcentimeter splenic lesion (601B, 36) is too small to fully characterize but unchanged since ___, and could represent a small hemangioma or cyst. The pancreas, adrenal glands, and kidneys are within normal limits. A tiny lower pole right renal cyst is also unchanged. The stomach, small and large bowel loops are normal in caliber. A duodenal diverticulum is noted. Patient is status post appendectomy. There is no frank free air or free fluid. Within the mid anterior abdomen, along the transverse mesocolon is a 1.6 cm rounded density measuring 150 Hounsfield units with significant subjacent inflammatory changes. This is new since ___ and could represent diverticulitis or appendagitis with a fecalith eroding through the colon with microperforation, or less likely an enhancing mass given similar density to the blood pool, which is difficult to exclude on this contrast-enhanced study. There is no frank free air. The great vessels are patent. There are mild atherosclerotic calcifications involving the great vessel origins without significant stenosis. There is no intra-abdominal adenopathy. There is no free fluid. CT PELVIS: The bladder, distal ureters, uterus, adnexa, and rectum appear within normal limits. There is no inguinal or pelvic sidewall adenopathy. No free fluid in the pelvis. BONE WINDOW: No focal concerning lesion. Mild multilevel thoracic and lumbar degenerative changes are present. Facet arthropathy is worst at L4-5 and L5-S1. Subchondral cystic formation is present in the right sacral ala. IMPRESSION: 1. 1.6 cm high-density rounded structure along transverse mesocolon with significant surrounding inflammatory changes, new since ___, in similar location to a previously seen transverse colonic diverticulum, suggestive of diverticulitis or appendagitis with an eroding fecalith with possible microperforation. An enhancing mass is felt less likely but cannot be excluded on this contrast-enhanced study, and could be further assessed with a limited non-contrast CT through this region in a few hours. 2. Cholelithiasis without evidence to suggest cholecystitis. Findings reported to Dr. ___ phone and Dr. ___ in person at respectively 7:50 and 8:30 a.m. on ___.

19982872-RR-41

RR

2156-12-12 11:17:00

2156-12-12 11:59:00

INDICATION: Evaluation of patient with epigastric pain with recent CT demonstrating a hyperdense focus in the transverse mesocolon, for further evaluation. COMPARISON: CT abdomen and pelvis with contrast from ___. CT abdomen and pelvis with contrast from ___. TECHNIQUE: MDCT-acquired axial images were obtained through limited area of the abdomen in the region of interest without the administration of IV contrast. Multiplanar reformatted images were prepared. FINDINGS: Limited abdominal CT without contrast: Again demonstrated is a 1.6 x 1.6 cm hyperdense focus measuring 150 Hounsfield units in the mid anterior abdomen along the transverse mesocolon (2:19). This focus appears unchanged in comparison to prior study from earlier the same day and is new compared to prior study from ___. Given the hyperdensity of this focus with surrounding inflammatory changes and focus of microperforation (2:20) on this non-contrast scan, this focus is thought to represent a fecalith eroding through the colon with microperforation causing diverticulitis. The limited portions of the gallbladder demonstrate cholelithiasis without evidence of cholecystitis. The kidneys are within normal limits. No free air or free fluid throughout the abdomen. OSSEOUS STRUCTURES: Degenerative changes are again noted throughout the thoracolumbar spine on the limited scan. IMPRESSION: 1. 1.6 cm high-density rounded structure along the transverse mesocolon with significant surrounding inflammatory changes and evidence of microperforation appears stable in comparison to prior study from earlier the same day and new compared to prior study from ___. This focus is in the similar location as a previously seen transverse colon diverticulum in ___ suggesting diverticulitis due to an eroding fecalith with microperforation. Given the density of this mass on this non-contrast scan, an enhancing mass is essentially excluded. 2. Cholelithiasis without evidence of cholecystitis.

19982896-RR-17

RR

2157-07-25 17:00:00

2157-07-25 18:18:00

INDICATION: Known stones in the cystic duct with worsening pain. COMPARISONS: None. TECHNIQUE: Grayscale and Doppler ultrasound images were acquired through the right upper quadrant. FINDINGS: The liver is normal in shape and contour. It appears slightly coarsened, although the echogenicity is normal. There are no focal hepatic lesions. The main portal vein is patent with normal direction of flow. The patient is status post a cholecystectomy. A fluid-filled structure in the gallbladder fossa is likely residual gallbladder neck. There is a 13-mm stone within the fluid structure, and possibly some small amount of sludge. The cystic structure does not demonstrate wall edema or surrounding fluid. The cystic duct is not definitely identified by ultrasound. There is no intrahepatic biliary duct dilation. The common bile duct at the hepatic hilum measures 6 mm. No filling defects are identified. The distal common bile duct is somewhat obscured by overlying bowel gas. The spleen is normal in size. Limited views of the kidneys are normal without evidence of hydronephrosis. The visualized portions of the pancreas are normal. The tail is obscured by overlying bowel gas. There is no intra-abdominal ascites. IMPRESSION: 13 mm stone in what appears to be a remnant gallbladder neck. There is no intrahepatic biliary duct dilation. The common bile duct is normal in size without evidence of stones, though the distal portions are obscured by overlying bowel gas.

19982896-RR-20

RR

2157-07-26 21:39:00

2157-07-27 10:04:00

INDICATION: Cholecystectomy ___ years ago, abdominal pain, found to have stone in the cystic duct remnant/gallbladder neck. COMPARISON: Abdominal ultrasound on ___. TECHNIQUE: MDCT images were obtained through the abdomen first without IV contrast, and subsequently following the administration of IV contrast in the arterial and portal venous phases. Coronal and sagittal reformats were performed. FINDINGS: There is mild bibasilar dependent atelectasis. Visualized heart and pericardium are unremarkable. The liver is normal in contour and there are no focal hepatic lesions. There is no intrahepatic biliary duct dilatation. A clip is seen either within a seroma in the gallbladder fossa or in the remnant cystic duct which would be dilated. There is mild fat stranding adjacent to the gallbladder fossa. The pancreas is normal. The spleen is normal. The adrenal glands are normal. The kidneys are normal. No hydronephrosis. The visualized portions of the small and large bowel are unremarkable. The appendix is visualized and unremarkable. There is no free air. There is no mesenteric or retroperitoneal lymphadenopathy. CTA: The celiac artery and its major branches are patent. The SMA and its major branches are patent. The origin of the ___ is patent. The portal vein is patent. The aorta is normal in caliber. BONES: There is a hemangioma in the T12 vertebral body. There are mild-to-moderate degenerative changes of thoracolumbar spine. No suspicious osseous lesions. IMPRESSION: Findings consistent with inflammation of either a chronic seroma or remnant cystic duct with a surgical clip within the lumen of the structure. No stones are identified in the CBD.

19982989-RR-31

RR

2150-12-17 09:54:00

2150-12-17 10:52:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with CHF, dyspnea// SOB TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: Lungs are low volume with increase in volume of bilateral pleural effusions right greater than left. Pulmonary edema has worsened. Consolidative opacities in both lower lobes right greater than left have also worsened. No pneumothorax. There is worsening pulmonary vascular congestion

19982989-RR-32

RR

2150-12-18 12:04:00

2150-12-18 15:04:00

EXAMINATION: RENAL U.S. INDICATION: ___ year old man with HFpEF, dementia, T2DM, BPH who presents with dyspnea and + UA concerning for pneumonia and acute complicated UTI with rising Cr in the setting of diuresis and volume overload. Evaluation for hydronephrosis. TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: No relevant prior imaging for comparison. FINDINGS: There is no hydronephrosis or stones bilaterally. There is a complex cystic structure at the left upper renal pole measuring 1.9 x 1.5 x 1.4 cm, without evidence of internal vascularity. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 11.8 cm Left kidney: 10.4 cm The bladder is only minimally distended and can not be fully assessed on the current study. IMPRESSION: 1. No evidence of stones or hydronephrosis. 2. Complex cystic structure at the left upper renal pole measuring 1.9 cm without evidence of internal vascularity, possibly representing a complex cyst but cannot exclude the possibility of an abscess. Reccomend follow-up with dedicated CT or MRI with contrast for further characterization.

19982989-RR-33

RR

2150-12-19 12:55:00

2150-12-19 16:32:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with HFpEF, COPD (no home O2) and baseline dementia presenting with UTI and HF exacerbation.// Assess for interval changes in pulm edema, pleural effusions, and presence of focal consolidations given persistent hypoxemia. TECHNIQUE: Chest PA and lateral COMPARISON: Multiple chest radiographs from ___, most recent ___. FINDINGS: Bilateral pulmonary edema is mildly decreased. The pleural effusion with associated bibasilar atelectasis is unchanged, a superimposed focal consolidation cannot be excluded. Cardiomediastinal silhouette is stable. There is no pneumothorax. IMPRESSION: Mildly decreased bilateral pulmonary edema..

19982989-RR-37

RR

2151-01-31 10:19:00

2151-01-31 11:24:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with sob// eval for pulm edema/ptx COMPARISON: Prior exam from ___ FINDINGS: AP portable upright view of the chest. There is a moderate size right pleural effusion with associated collapse of the right middle and lower lobes. There is pulmonary vascular congestion with likely mild edema. Mild haziness at the left lung base raises concern for a small left effusion. No pneumothorax is seen. Heart size cannot be reliably assessed. Mediastinal contour is stable. Bony structures are intact. IMPRESSION: Moderate right and probable small left pleural effusion. Significant atelectasis in the right middle and lower lobes. Congestion with probable mild edema.

19982989-RR-38

RR

2151-02-01 07:43:00

2151-02-01 11:17:00

EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: ___ year old man with HFpEF// interval change in pulm edema interval change in pulm edema IMPRESSION: Compared to chest radiographs since ___ most recently ___ and ___. Moderate pulmonary edema worsened slightly since ___. Moderate right pleural effusion is changed in distribution, but probably not in overall volume. Moderate cardiomegaly unchanged. No pneumothorax.

19982989-RR-39

RR

2151-02-04 13:58:00

2151-02-04 14:56:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with ams/delerium// increased delerium increased delerium IMPRESSION: Cardiomegaly is severe, unchanged. Patient continues to be in interstitial pulmonary edema. Bilateral pleural effusion, large on the right and moderate on the left is unchanged. No pneumothorax.

19982989-RR-40

RR

2151-02-05 13:43:00

2151-02-05 14:21:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ y/o M w/ HFpEF (HFpEF, EF 50% ___, possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from ___ (discharge weight 70.2 kg (154.76 lb)) who presented from his nursing facility with SOB d/t pulmonary edema initially requiring BiPAP who is admitted for acute on chronic HFpEF now with AMS, any evidence of head bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. 2) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 186.9 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: MRI brain dated ___ and CT head dated ___. FINDINGS: There is no evidence of infarction or hemorrhage. There is redemonstration of a hypodense extra-axial mass in the floor of the anterior cranial fossa with mild associated vasogenic edema measuring 3.7 x 3.2 cm, previously measuring 3.7 x 3.2 cm on prior study dated ___. There are bilateral periventricular and subcortical white matter hypodensities, nonspecific but compatible with sequelae of chronic small vessel ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. There is mild mucosal thickening of the left ethmoid air cells. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Stable olfactory groove meningioma, unchanged in size from prior study dated ___.

19982989-RR-41

RR

2151-02-05 13:21:00

2151-02-05 13:43:00

EXAMINATION: RENAL U.S. PORT INDICATION: ___ y/o M w/ HFpEF (HFpEF, EF 50% ___, possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from ___ (discharge weight 70.2 kg (154.76 lb)) who presented from his nursing facility with SOB d/t pulmonary edema initially requiring BiPAP who is admitted for acute on chronic HFpEF// any evidence of abscess or hydronephrosis TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: Renal ultrasound ___ FINDINGS: There is no hydronephrosis or stones bilaterally. Again seen within the upper pole of the left kidney is a 1.4 x 1.1 x 1.1 cm cystic structure with thin avascular septations, likely a minimally complex cyst, which previously measured 1.9 x 1.5 x 1.4 cm. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 10.5 cm Left kidney: 9.1 cm The bladder is moderately well distended and normal in appearance. IMPRESSION: 1. No evidence of stones or hydronephrosis. 2. 1.4 cm cystic structure with thin avascular septations in the upper pole of the left kidney has decreased in size compared to prior, previously 1.9 cm. This likely represents a minimally complex cyst which requires no further follow-up, and is unlikely an abscess.

19983009-RR-14

RR

2143-06-11 18:02:00

2143-06-11 19:02:00

INDICATION: ___ year old man with pancreatic cancer, worsening distension and now vomiting. Recent history of SBO// r/o obstruction, ileus TECHNIQUE: Supine and left lateral decubitus views of the abdomen were obtained COMPARISON: CT abdomen and pelvis dated ___ FINDINGS: There are multiple dilated air-filled loops of large and small bowel seen predominantly within the left hemiabdomen. Fecal material is seen within the rectum and projecting over the descending colon. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Dilated air-filled loops of large and small bowel may reflect ileus or early/partial obstruction. Fecal material is visualized within the rectum and is noted to project over the descending colon as well.

19983009-RR-4

RR

2142-09-05 13:47:00

2142-09-05 15:59:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old man with elevated ALT/AST// assess for liver or GB pathology TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT from an outside hospital ___.. 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. There is pneumobilia noted throughout the right left hepatic lobes. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm. GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 9.6 cm. A heterogeneously hyperechoic ill-defined Mass is identified within the left upper quadrant adjacent to the spleen and does not demonstrate flow on color Doppler imaging. This is of unclear etiology and could represent a heterogeneous Mass or fluid collection. KIDNEYS: Limited views of the right kidney shows moderate hydronephrosis. There is no obstructing stone identified. Limited views of the left kidney are within normal limits, no hydronephrosis is identified. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Pneumobilia without intrahepatic or extrahepatic biliary dilatation. 2. The patient is status post cholecystectomy. 3. Mild right-sided hydronephrosis, stable when compared to the CT from an outside facility on ___. 4. A heterogeneously hyperechoic ill-defined Mass is identified within the left upper quadrant adjacent to the spleen and does not demonstrate flow on color Doppler imaging. This is of unclear etiology and could represent a heterogeneous mass, hematoma or fluid collection. Further evaluation with contrast-enhanced imaging such as a multiphasic CT is recommended. RECOMMENDATION(S): Multiphasic CT of the abdomen.

19983009-RR-5

RR

2142-09-05 18:43:00

2142-09-05 20:00:00

EXAMINATION: CT chest abdomen pelvis INDICATION: ___ year old man with metastatic pancreatic ca, rising LFTs// assess for interval change in disease 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. Postcontrast images of the chest were also obtained Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 67.2 cm; CTDIvol = 6.5 mGy (Body) DLP = 437.7 mGy-cm. 2) Spiral Acquisition 2.0 s, 32.2 cm; CTDIvol = 5.9 mGy (Body) DLP = 191.0 mGy-cm. 3) Stationary Acquisition 8.7 s, 0.5 cm; CTDIvol = 43.7 mGy (Body) DLP = 21.8 mGy-cm. Total DLP (Body) = 651 mGy-cm.; Acquisition sequence: 1) Spiral Acquisition 4.2 s, 67.2 cm; CTDIvol = 6.5 mGy (Body) DLP = 437.7 mGy-cm. 2) Spiral Acquisition 2.0 s, 32.2 cm; CTDIvol = 5.9 mGy (Body) DLP = 191.0 mGy-cm. 3) Stationary Acquisition 8.7 s, 0.5 cm; CTDIvol = 43.7 mGy (Body) DLP = 21.8 mGy-cm. Total DLP (Body) = 651 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: CT from ___ and from ___ FINDINGS: Visualized lower neck is normal. There is a right chest wall port, tip terminates at the cavoatrial junction. Heart size is normal. No pericardial effusion. No pleural effusion. No pneumothorax. Airways are patent throughout. There is a 3 mm left lower lobe pulmonary nodule and a 6 mm left lower lobe pulmonary nodule both unchanged from ___. There is scarring at the right lung apex from prior wedge resection. There is nodular peripheral left medial midlung airspace opacities which may be atelectasis. There is no mediastinal mass. There is no significant hilar or mediastinal adenopathy. ABDOMEN: HEPATOBILIARY: Status post Whipple procedure. The liver demonstrates homogenous attenuation. There is a 1.5 cm hypodense lesion with internal calcification along the anterior surface of the liver in hepatic segment 4A. This appears increased in size since prior. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is absent. There is pneumobilia. The left lateral segment of the liver show scalloping due to extensive peritoneal masses. PANCREAS: Not well seen. SPLEEN: There are numerous new and enlarged subcapsular masses in the spleen consistent with metastatic disease. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with delayed right nephrogram. There is moderate right hydronephrosis and hydroureter, similar to prior. There is no perinephric abnormality. GASTROINTESTINAL: There is mass effect on the stomach, multiple loops of small bowel, and large bowel from peritoneal and mesenteric soft tissue masses which are increased from prior. Rectum is distended with an air-fluid level. There are multiple surgical clips associated with the small bowel. There is a dilated loop of small bowel in the midabdomen which may be postsurgical in nature, as it appears unchanged since prior. There is no definite evidence of obstruction and oral contrast is able to transit through the small bowel. PELVIS: The urinary bladder is unremarkable. Large soft tissue peritoneal and mesenteric masses are seen in the pelvis causing local mass effect, increased from prior REPRODUCTIVE ORGANS: Not well evaluated. LYMPH NODES: Bulky mesenteric and peritoneal masses which are increased in size from prior predominantly involving the pelvis and left lateral abdomen. VASCULAR: There is no abdominal aortic aneurysm. 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 intrahepatic or extrahepatic biliary duct dilation. There is pneumobilia. 2. Interval increase in the size and mass effect related to bulky soft tissue peritoneal and mesenteric masses from metastatic disease representing progression of metastatic carcinomatosis. 3. There are multiple new subcapsular splenic lesions and increase in size of the previously seen splenic lesions, due to progression of to metastatic disease. 4. Moderate right hydronephrosis and proximal to mid hydroureter with a delayed nephrogram. Hydronephrosis is not significantly changed from prior and is due to extrinsic mass effect on the ureter in the pelvis.

19983009-RR-6

RR

2142-09-05 18:44:00

2142-09-05 20:00:00

EXAMINATION: CT chest abdomen pelvis INDICATION: ___ year old man with metastatic pancreatic ca, rising LFTs// assess for interval change in disease 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. Postcontrast images of the chest were also obtained Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.2 s, 67.2 cm; CTDIvol = 6.5 mGy (Body) DLP = 437.7 mGy-cm. 2) Spiral Acquisition 2.0 s, 32.2 cm; CTDIvol = 5.9 mGy (Body) DLP = 191.0 mGy-cm. 3) Stationary Acquisition 8.7 s, 0.5 cm; CTDIvol = 43.7 mGy (Body) DLP = 21.8 mGy-cm. Total DLP (Body) = 651 mGy-cm.; Acquisition sequence: 1) Spiral Acquisition 4.2 s, 67.2 cm; CTDIvol = 6.5 mGy (Body) DLP = 437.7 mGy-cm. 2) Spiral Acquisition 2.0 s, 32.2 cm; CTDIvol = 5.9 mGy (Body) DLP = 191.0 mGy-cm. 3) Stationary Acquisition 8.7 s, 0.5 cm; CTDIvol = 43.7 mGy (Body) DLP = 21.8 mGy-cm. Total DLP (Body) = 651 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: CT from ___ and from ___ FINDINGS: Visualized lower neck is normal. There is a right chest wall port, tip terminates at the cavoatrial junction. Heart size is normal. No pericardial effusion. No pleural effusion. No pneumothorax. Airways are patent throughout. There is a 3 mm left lower lobe pulmonary nodule and a 6 mm left lower lobe pulmonary nodule both unchanged from ___. There is scarring at the right lung apex from prior wedge resection. There is nodular peripheral left medial midlung airspace opacities which may be atelectasis. There is no mediastinal mass. There is no significant hilar or mediastinal adenopathy. ABDOMEN: HEPATOBILIARY: Status post Whipple procedure. The liver demonstrates homogenous attenuation. There is a 1.5 cm hypodense lesion with internal calcification along the anterior surface of the liver in hepatic segment 4A. This appears increased in size since prior. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is absent. There is pneumobilia. The left lateral segment of the liver show scalloping due to extensive peritoneal masses. PANCREAS: Not well seen. SPLEEN: There are numerous new and enlarged subcapsular masses in the spleen consistent with metastatic disease. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with delayed right nephrogram. There is moderate right hydronephrosis and hydroureter, similar to prior. There is no perinephric abnormality. GASTROINTESTINAL: There is mass effect on the stomach, multiple loops of small bowel, and large bowel from peritoneal and mesenteric soft tissue masses which are increased from prior. Rectum is distended with an air-fluid level. There are multiple surgical clips associated with the small bowel. There is a dilated loop of small bowel in the midabdomen which may be postsurgical in nature, as it appears unchanged since prior. There is no definite evidence of obstruction and oral contrast is able to transit through the small bowel. PELVIS: The urinary bladder is unremarkable. Large soft tissue peritoneal and mesenteric masses are seen in the pelvis causing local mass effect, increased from prior REPRODUCTIVE ORGANS: Not well evaluated. LYMPH NODES: Bulky mesenteric and peritoneal masses which are increased in size from prior predominantly involving the pelvis and left lateral abdomen. VASCULAR: There is no abdominal aortic aneurysm. 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 intrahepatic or extrahepatic biliary duct dilation. There is pneumobilia. 2. Interval increase in the size and mass effect related to bulky soft tissue peritoneal and mesenteric masses from metastatic disease representing progression of metastatic carcinomatosis. 3. There are multiple new subcapsular splenic lesions and increase in size of the previously seen splenic lesions, due to progression of to metastatic disease. 4. Moderate right hydronephrosis and proximal to mid hydroureter with a delayed nephrogram. Hydronephrosis is not significantly changed from prior and is due to extrinsic mass effect on the ureter in the pelvis.

19983512-RR-16

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2141-08-19 16:59:00

2141-08-19 17:39:00

EXAM: Left foot, three views. CLINICAL INFORMATION: sweet syndrome and ulceration of left second toe, question osteomyelitis. COMPARISON: None. FINDINGS: AP, oblique, lateral views of the left foot were obtained. No acute fracture or dislocation is seen. No definite soft tissue ulceration is seen radiographically. No definite cortical destruction is seen. There is soft tissue swelling overlying the mid and distal foot. No concerning osteoblastic or lytic lesion seen. IMPRESSION: Soft tissue swelling without underlying acute fracture. No definite cortical destruction seen to suggest acute osteomyelitis. If clinical concern is high, MRI or nuclear medicine scan is more sensitive.

19983512-RR-17

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2141-12-22 11:32:00

2141-12-22 12:06:00

EXAMINATION: TIB/FIB (AP AND LAT) RIGHT INDICATION: ___ female with right leg wound. TECHNIQUE: Two-view COMPARISON: None available. FINDINGS: Two views of the right leg were obtained. No fracture or dislocation is identified. Screws are identified within the distal femur and tibial plateau. A soft tissue defect is identified adjacent to the lateral malleolus with no underlying osseous abnormality identified. A posterior calcaneal enthesophyte is identified. Enthesophytes are also identified at the insertion site at the quadriceps tendon at the proximal tibia as well as its origin at the inferior pole of the patella. A lucency within the patellar osteophyte is suggestive of fracture, this appears well corticated and is likely chronic. Degenerative changes about the tibial femoral joint with osteophytosis, predominately along the medial joint space is seen. IMPRESSION: Soft tissue defect lateral to the distal fibular with no underlying osseous abnormality. Limited views of the knee demonstrate well corticated fracture through an enthesophyte extending inferior to the patella at the origin of the patellar tendon. Clinical correlation for pain at the site of abnormality is recommended and if warranted dedicated knee radiographs recommended.

19983512-RR-23

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2142-03-05 12:00:00

2142-03-05 12:33:00

EXAMINATION: ULTRASOUND ABDOMEN INDICATION: ___ female with epigastric pain, increased LFTs, 6 weeks status post laparoscopic cholecystectomy. TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None available. FINDINGS: The liver is normal in echotexture, without focal lesions or intrahepatic biliary ductal dilatation. Main portal vein is patent with hepatopetal flow. The CBD measures 6 mm. The patient is status post cholecystectomy. 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. The spleen measures 12.2 cm, and is normal in echogenicity. The right kidney measures 10.7 cm. The left kidney measures 11.6 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones or hydronephrosis in the kidneys. Visualized portions of aorta and IVC are within normal limits. There is no ascites. IMPRESSION: Unremarkable abdominal ultrasonographic examination in this patient with prior cholecystectomy.

19983512-RR-24

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2142-03-06 19:14:00

2142-03-07 08:37:00

EXAMINATION: MRCP. INDICATION: ___ year old woman s/p lap chole in ___, now with climbing transaminases, nl bili // ?remnant stone, stricture, other anatomical abnlty TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired within a 1.5 T magnet, including 3D dynamic sequences obtained prior to, during, and following the administration of 12 cc of Gadavist intravenous contrast. The patient also received oral contrast of 1 cc of Gadavist diluted in 50 cc of water. COMPARISON: Ultrasound from ___, and MRI examination from ___. FINDINGS: MRCP WITH AND WITHOUT IV CONTRAST: Included views of the lung bases are clear. There is no pericardial pleural effusion. The heart size is normal. The liver parenchyma demonstrates mild heterogeneous on T1 weighted out of phase images in comparison to in phase sequences, denoting steatosis (series 12, image 13). Again seen arising from the caudate lobe is a well-circumscribed 14 mm lesion demonstrating high internal signal intensity on T2 weighted sequences, with peripheral nodular enhancement and centripedal enhancement on delayed sequences, most compatible with a hemangioma (series 4, image 18). A 4 mm segment III hepatic cyst is present (series 4, image 20). No concerning hepatic mass is detected. There is no intra or extrahepatic bile duct dilation. No peribiliary enhancement is detected. The patient is post cholecystectomy. The pancreas demonstrates normal signal intensity and bulk. A 3 mm cystic lesion within the pancreatic head is again seen, likely a tiny side branch IPMN (series 4, image 34). No concerning pancreatic lesion is detected. Pancreatic duct is normal in caliber. The spleen, adrenal glands, stomach, and intra-abdominal loops of small and large bowel are within normal limits. Arising from the posterior interpolar aspect of the left kidney is a well-circumscribed 6 mm hemorrhagic or proteinaceous cyst, denoted by a high internal signal intensity on T2 weighted sequences, intermediate signal intensity on T1 weighted precontrast images, without appreciable internal contrast enhancement (series 4, image 60, series 18, image 61). No concerning renal mass is detected. There is no collecting system obstruction. There is no mesenteric or retroperitoneal lymphadenopathy, and no free fluid. The abdominal aorta, celiac trunk, SMA, and renal arteries are patent and normal in caliber. A replaced left hepatic artery arises from the left gastric (series 16, image 31). There are no osseous lesions concerning for malignancy or infection. IMPRESSION: 1. No intra or extrahepatic bile duct dilation. No ductal stones. Post cholecystectomy. 2. Mild heterogeneous hepatic steatosis. 3. 3 mm cystic lesion within the pancreatic head is unchanged, likely a tiny side branch IPMN. ___ year followup recommended. 4. 14 mm caudate lobe hemangioma and 3 mm segment III hepatic cyst. No concerning hepatic mass.

19984491-RR-16

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2163-03-02 14:56:00

2163-03-02 16:38:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ s/p fall with small SDH, on Coumadin for AVR unclear if bioprosthetic or mechanical // characterize aortic valve replacement COMPARISON: None FINDINGS: PA and lateral views of the chest provided. Sternotomy wires are noted. Linear opacities in the bilateral lower lobes likely represent bibasilar atelectasis versus scarring. There are atherosclerotic calcifications involving the aortic arch and descending thoracic aorta. No radiopaque cardiac valve is seen. S-shaped curvature of the thoracolumbar spine is noted. IMPRESSION: 1. No radio opaque cardiac valve is seen. 2. Bibasilar atelectasis.

19984491-RR-17

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2163-03-02 21:20:00

2163-03-02 23:00:00

EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT INDICATION: ___ year old woman s/p fall // evaluate for fracture TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and frog-leg lateral views of the right hip COMPARISON: None available FINDINGS: The patient is status post bilateral total hip arthroplasties with evidence of revision on the right. There is no acute fracture or dislocation identified. Evaluation the sacrum is however obscured by overlying bowel. There are no gross degenerative changes. There is no suspicious lytic or sclerotic lesion. Vascular calcification is present as are calcifications over the right gluteal region likely reflective of injection granulomas. IMPRESSION: Status post bilateral total hip arthroplasties. No evidence of an acute fracture of the pelvis or right hip.

19984491-RR-18

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2163-03-02 21:20:00

2163-03-02 22:57:00

EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT INDICATION: ___ year old woman with R ankle pain after fall. // evaluate for fracture TECHNIQUE: Frontal, oblique, and lateral view portable radiographs of the right ankle COMPARISON: None available FINDINGS: No fracture, dislocation, or degenerative change is detected. The mortise is congruent on this non stress view. The tibial talar joint space is preserved and no talar dome osteochondral lesion is identified. No suspicious lytic or sclerotic lesion is identified. No soft tissue calcification or radiopaque foreign body is identified. IMPRESSION: No acute fracture or dislocation of the right ankle.

19984573-RR-10

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2113-02-14 00:45:00

2113-02-14 01:46:00

INDICATION: High-speed motor vehicle crash; unrestrained driver. COMPARISONS: None. TECHNIQUE: Helical axial MDCT images were obtained through the cervical spine without the administration of IV contrast. Sagittal and coronal reformatted images were obtained and reviewed. FINDINGS: There is no fracture, subluxation, or thickening of the prevertebral soft tissues. Disc space heights are preserved. There are small central disc protrusions at C3-4 and C4-5, without evidence of significant spinal canal narrowing, though resolution of intraspinal detail on CT is limited. A small calcification is present in the nuchal ligament at C5. Numerous non-enlarged cervical lymph nodes are within normal limits in a patient of this age. There is mild pleural/parenchymal scarring at the imaged lung apices. IMPRESSION: No fracture or malalignment.

19984573-RR-11

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2113-02-14 00:46:00

2113-02-14 02:19:00

INDICATION: High-speed unrestrained motor vehicle crash. COMPARISONS: None. TECHNIQUE: 64-row MDCT images were obtained through the torso after the administration of IV contrast only. Sagittal and coronal reformatted images were obtained and reviewed. FINDINGS: CHEST: The thyroid is unremarkable. There is no axillary, mediastinal, or hilar lymphadenopathy. The heart is normal in size. There is no pericardial effusion. The thoracic aorta is normal in caliber. There is no evidence of dissection or aortic injury. In the right lower lobe, there is a 5-mm pulmonary nodule (2, 37). No other pulmonary nodules are identified. At the left base, there is a small ground-glass opacity (2, 53), which measures 11 mm. This may be a small focal area of atelectasis or contusion. The lungs are otherwise clear. There is no pleural effusion. There is no pneumothorax. ABDOMEN: The liver is normal in shape and contour. There are no focal hepatic lesions. There is no evidence of hepatic injury. There is no perihepatic fluid. The portal vein is patent. There is no intra- or extra-hepatic biliary duct dilation. The gallbladder is not distended and unremarkable. In the spleen, there is approximately a 2-cm hypodense laceration (2, 56). There is some scattered heterogeneity of the right side of the spleen in the region of the laceration, likely from splenic hematoma. There is no perisplenic fluid. There is no definite evidence of active extravasation. The pancreas is normal. The adrenal glands are unremarkable. The kidneys are normal without evidence of injury. There is no perinephric fluid. The kidneys enhance and excrete contrast symmetrically. The ureters are intact without evidence of extraluminal contrast. Bilateral ureteral jets are present. The stomach is filled with food and fluid. It is otherwise unremarkable. The small bowel is normal, without evidence of surrounding inflammatory changes. There is no definite mesenteric stranding, although the patient is thin without a lot of fat. There is no mesenteric, abdominal, or retroperitoneal lymphadenopathy. The abdominal vasculature is normal in course and caliber. There is no evidence of vascular injury. There is no free fluid in the abdomen. There is no free air. PELVIS: The large bowel is unremarkable without evidence of injury or surrounding inflammatory changes. There is no evidence of obstruction. The appendix is visualized and normal. The bladder and prostate are normal. There is no pelvic or inguinal lymphadenopathy. The pelvic vasculature is normal in course and caliber. OSSEOUS STRUCTURES: No fracture is identified. There are no concerning lytic or sclerotic osseous lesions. There are no significant degenerative changes of the spine. IMPRESSION: 1. Grade 2 splenic laceration measuring 2 cm. Surrounding heterogeneity of the splenic parenchyma likely represents some additional parenchymal hematoma. There is no evidence of a subcapsular hematoma or perisplenic fluid. 2. Rounded opacity at the left base adjacent to the spleen is likely due to a tiny pulmonary contusion or a small focal region of atelectasis. 3. 5-mm right lower lobe pulmonary nodule. In the absence of specific risk factors, a followup CT is recommended at 12 months. If factors such as smoking exist, recommend a followup CT in 6 to 12 months.

19984573-RR-12

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2113-02-14 02:10:00

2113-02-14 08:40:00

HISTORY: Left knee pain. TECHNIQUE: 3 views of the left knee ___. COMPARISON: None. FINDINGS: Unremarkable soft tissues. Small to moderate joint effusion. No acute fracture or dislocation. No significant degenerative changes. A small bone island is seen within the lateral tibial plateau. A small oval sclerotic focus is seen along the lateral cortex of the proximal tibial diaphysis, which may represent an additional bone island or possibly a small involuted nonossifying fibroma. IMPRESSION: Small to moderate joint effusion.

19984573-RR-8

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2113-02-14 00:39:00

2113-02-14 05:03:00

INDICATION: Trauma. COMPARISONS: None. FINDINGS: A single frontal supine image of the chest demonstrates no consolidation or pulmonary edema. There is no pleural effusion. Within the limitations of a supine exam, there is no evidence of pneumothorax. The cardiomediastinal silhouette is normal. Subtle loss of height in a mid thoracic vertebral body can be better evaluated on the trauma torso CT. IMPRESSION: No acute cardiopulmonary process.

19984573-RR-9

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2113-02-14 00:46:00

2113-02-14 01:44:00

INDICATION: Unrestrained driver in a high-speed motor vehicle accident. Evaluate for acute injury. COMPARISONS: None. TECHNIQUE: Contiguous axial MDCT images were acquired through the brain without the administration of IV contrast. Sagittal, coronal, and thin-section bone reformats were obtained and reviewed. FINDINGS: A portion of the scan was repeated (series 7) due to motion on the initial acquisition. There is no acute hemorrhage, edema, mass effect, or pathologic extraaxial collection. The ventricles, sulci and basal cisterns are normal in size and configuration. There is preservation of gray-white matter differentiation. No fracture is identified. There is a small mucous retention cyst in the left maxillary sinus. The remainder of the visualized paranasal sinuses, mastoid air cells, and middle ear cavities is clear. IMPRESSION: No evidence of an acute intracranial injury. No fracture.

19984710-RR-22

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2179-03-15 12:43:00

2179-03-15 14:06:00

INDICATION: ___ year old woman with cough and fever but no hypoxia or SOB// evaluate for possible pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: None IMPRESSION: Lungs are low volume with an ill-defined parenchymal opacity in the lingula concerning for pneumonia and posterior segment of the left upper lobe. Heart size is normal. Cardiomediastinal silhouette is unremarkable. There is no pleural effusion. No pneumothorax is seen

19984710-RR-23

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2179-03-16 12:21:00

2179-03-16 14:54:00

EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE INDICATION: ___ year old woman with active IVDU with new mid low back and mid thoracic back pain // evaluate for osteomyelitis evaluate for osteomyelitis evaluate for osteomyelitis TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of 6 mL of Gadavist contrast agent. COMPARISON: None. FINDINGS: THORACIC SPINE: Alignment is normal. Vertebral body and intervertebral disc signal intensity appear normal. The spinal cord appears normal in caliber and configuration. There is no evidence of spinal canal or neural foraminal narrowing. There is no evidence of infection or neoplasm. LUMBAR SPINE: Alignment is normal. Vertebral body and intervertebral disc signal is normal. The spinal cord is normal in configuration and terminates at L1/L2. There is no evidence of spinal cord edema or abnormal enhancement. Degenerative changes of the lumbar spine are mild as follows: From T12-L3, there is no significant spinal canal or neural foraminal narrowing. At L4-5, a small posterior disc bulge does not cause significant spinal canal narrowing, and mild bilateral neural foraminal narrowing. At L5-S1, a posterior disc bulge does not cause significant spinal canal narrowing, and mild bilateral neural foraminal narrowing. There is no prevertebral or paravertebral edema. IMPRESSION: 1. No evidence of infection orspinal cord compression in the thoracic or lumbar spine. 2. Minimal degenerative changes of the lumbar spine as described above.

19984781-RR-66

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2165-06-01 19:51:00

2165-06-01 20:23:00

INDICATION: ___ with fever, cough// eval for pna TECHNIQUE: Frontal and lateral views the chest. COMPARISON: Chest x-ray from ___. FINDINGS: The lungs are clear besides mild biapical scarring. Pectus deformity mimics a right middle lobe consolidation. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process.

19984781-RR-67

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2165-06-01 19:52:00

2165-06-01 20:43:00

EXAMINATION: CT abdomen pelvis with contrast INDICATION: ___ with LLQ abd pain, feverNO_PO contrast// eval for diverticulitis, other 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 not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 614 mGy-cm. COMPARISON: None available. 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 a 2.0 cm posterior right hepatic lobe hypodensity likely represents a hepatic cyst. Additional subcentimeter hypodensities are visualized, too small to characterize and likely represent hepatic cysts versus biliary hamartomas. 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: A small hiatal hernia is visualized otherwise the stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. There is a extensive stool burden throughout the colon and rectum which is otherwise 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: Probable uterine fibroid is noted. No adnexal abnormalities. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. There is narrowing of the proximal celiac axis potentially due to the diaphragmatic crus with mild poststenotic dilatation. Mild atherosclerotic disease is noted. BONES: Degenerative changes are seen in the lumbar spine. Total right hip arthroplasty is visualized and appears to be in proper alignment. Degenerative changes noted at the left hip. SOFT TISSUES: The abdominal and pelvic wall is within normal limits besides a small fat containing umbilical hernia. IMPRESSION: 1. No acute intra-abdominal or pelvic findings to correlate with patient's symptoms. 2. Extensive stool burden is visualized throughout the colon and rectum. 3. Narrowing of the proximal celiac axis which can be normal variant or potentially seen in median arcuate ligament syndrome, to be correlated clinically.

19984781-RR-68

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2165-06-02 09:59:00

2165-06-02 13:13:00

EXAMINATION: PELVIS U.S., TRANSVAGINAL INDICATION: ___ year old woman with fever, abdominal pain and newly sexually active. negative ct scan// eval for PID TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with transabdominal approach followed by transvaginal approach for further delineation of uterine and ovarian anatomy. COMPARISON: CT abdomen pelvis of ___. FINDINGS: The uterus is retroverted and measures 4.5 x 2.7 x 2.9 cm. The endometrium is homogenous and measures 3-4 mm. Small degenerative fibroids are present, measuring up to 0.8 cm. The ovaries are not visualized. There is no free fluid. IMPRESSION: No free pelvic fluid. The ovaries are not visualized.

19984781-RR-69

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2165-06-04 14:04:00

2165-06-04 14:32:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ year old woman with cold agglutinin disease and transaminitis// eval for etiology of transaminitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: CT abdomen pelvis from ___ 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 no intrahepatic biliary dilation. The CHD measures 4 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 12.3 cm. KIDNEYS: The right kidney measures 9.2 cm. The left kidney measures 9.8 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Normal abdominal ultrasound with no focal findings to correlate with recent findings of transaminitis.

19984875-RR-20

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2118-01-05 01:35:00

2118-01-08 14:53:00

EXAMINATION: CT torso INDICATION: History: ___ with new brain tumor, status post fall.// CT found tumor, please evaluate further. Please eval torso for mets TECHNIQUE: MDCT axial images were acquired through the chest, 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) = 707 mGy-cm. COMPARISON: None. FINDINGS: CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without evidence of acute injury. The heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass or hematoma. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Diffuse moderate centrilobular emphysema. No areas of parenchymal opacification or masses seen. Status post partial right lower lobectomy with suture material and postoperative scarring/atelectasis noted (e.g. 02:30). The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Numerous hypoenhancing nodules seen throughout the thyroid gland measuring up to 0.7 cm in left lobe of the thyroid the warrant additional imaging follow-up per ACR criteria. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. Subcentimeter hypodensities in segment 6 (2:62) and in segment 2 (02:41) are too small to characterize, but likely represent simple cysts or biliary hamartomas. 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 lesion or laceration. 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. Large periampullary duodenal diverticulum is noted. Pain colonic diverticulitis. The appendix is normal. There is no free fluid or free air in the abdomen. PELVIS: Evaluation limited by artifact from bilateral hip prostheses. The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The endometrium appears thickened. An exophytic calcified fibroid is also noted. No adnexal lesions are seen. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Moderate atherosclerotic disease is noted. BONES: Compression deformity of the T4 vertebral body does not appear pathologic and is of indeterminate age. No focal suspicious osseous abnormality. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. No evidence of malignancy or lymphadenopathy in the abdomen or pelvis. 2. Severe emphysema with postsurgical changes from prior partial right lower lobectomy noted. No definite evidence of recurrence in this location. 3. Apparent endometrial thickening. Recommend further evaluation with pelvic ultrasound. 4. Compression deformity of the T4 vertebral body of indeterminate age. Correlate with focal tenderness at this location. RECOMMENDATION(S): Pelvic ultrasound for endometrial thickening

19984875-RR-22

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2118-01-06 05:38:00

2118-01-06 09:43:00

EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: ___ year old woman with seizure in setting of new parietal mass, history of lung CA// Evaluate parietal mass TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique. After administration of Gadavist intravenous contrast, T1 axial and coronal images obtained. Examination is limited by motion particularly the post gadolinium images. COMPARISON: CT ___. FINDINGS: There is a 3.3 x 3.1 cm rim enhancing mass in the left posterior temporal region with surrounding edema and chronic associated blood products. The mass demonstrates intrinsic low signal intensities on T2 and FLAIR images. Increased signal along the periphery seen on the diffusion images with decreased ADC. Small focus of hyperintensity on diffusion images in the right frontal lobe (04:17) has corresponding subtle FLAIR abnormality but no definite enhancement is identified. Given significant motion on postcontrast images assessment of other subtle areas of enhancement is limited. There is no midline shift or hydrocephalus. IMPRESSION: Approximately 3.5 cm left temporal rim enhancing lesion with chronic blood products and surrounding edema suggestive of metastatic disease. E no other definite lesions are seen but valuation is limited due to motion on postcontrast images.

19984875-RR-23

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2118-01-07 17:30:00

2118-01-07 18:56:00

EXAMINATION: PRE-SURGICAL WAND OR THERAPY PLANNING ___ MR HEAD INDICATION: ___ year old woman with left parietal brain lesion.// Please evaluate for preop planning. TECHNIQUE: After administration of 6 mL of Gadavist intravenous contrast, axial imaging was performed with MPRAGE and T1 technique. Sagittal and coronal orientation reformatted images of the MPRAGE acquisition was then produced. COMPARISON: MRI brain with without contrast of ___. FINDINGS: Heterogeneously enhancing 3.5 x 3.0 cm (AP, TRV) left temporal parietal mass, with prominent surrounding edema pattern resulting in effacement of the left lateral ventricle trigone is unchanged. In addition, there is a right frontal subtly enhancing 4 mm lesion (series 3, image 81; series 10, image 17) corresponding to diffusion-weighted hyperintense signal, better seen on the current exam compared to the prior. No additional enhancing lesions are identified. No evidence of acute infarct. There is scattered opacification of right sided ethmoid air cells. Mild mucosal thickening of the remainder the paranasal sinuses is noted. The dural venous sinuses are patent. No definite osseous lesions. IMPRESSION: 1. Unchanged 3.5 cm left temporal parietal mass with associated edema pattern. 2. Unchanged 4 mm enhancing lesion of the right frontal lobe. 3. No other definite enhancing lesions are identified. 4. No interval change from prior examination on pre-surgical planning examination.

19984875-RR-25

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2118-01-08 16:02:00

2118-01-08 16:46:00

EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with L parietal lesion s/p crani for rsxn// L parietal lesion s/p crani for rsxn TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: MRI dated ___ FINDINGS: The patient is status post left parietal craniotomy with resection of a left parietal lesion. Post surgical changes including pneumocephalus and blood products is visualized within the surgical bed. Edema within the left temporoparietal lobes is similar to the prior MRIs. There is no midline shift or mass effect. The basal cisterns are patent. A known 4 mm right frontal lesion was better evaluated with MRI. No osseous abnormalities seen apart from the postsurgical changes in the left parietal bone. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: Postsurgical changes in the left cerebral hemisphere as described above following a left parietal craniotomy and resection of a left parietal lesion.

19984875-RR-26

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2118-01-09 13:55:00

2118-01-09 15:01:00

EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with L parietal lesion s/p crani for rsxn// L parietal lesion s/p crani for rsxn TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CT head from ___ and MR head from ___ FINDINGS: Patient is status post left parietal craniotomy for resection of left parietal lesion with postsurgical changes visualized in the resection cavity including blood products with adjacent diffuse parietal lobe edema with an area of focal slowed diffusion surrounding the resection cavity. Expected thin rim of peripheral enhancement in the resection cavity, compatible with breakdown of blood brain barrier is identified without nodularity or masslike enhancement. Expected left hemispheric dural thickening and enhancement. No midline shift. There is minimally increased effacement of the occipital horn of the left lateral ventricle, secondary to postoperative edema. There is no evidence for acute infarct.. The ventricles and sulci are otherwise stable in caliber and configuration. Unchanged 4 mm enhancing focus of the right frontal lobe, concerning for an additional lesion. No other definite abnormal enhancement visualized. The major vascular flow voids are preserved. The dural venous sinuses are patent. There is a small right maxillary mucous retention cyst otherwise the imaged paranasal sinuses and mastoid air cells are clear. The orbits are unremarkable IMPRESSION: 1. Status post left parietal craniotomy for resection of left parietal lesion with postsurgical changes in the resection cavity, as described above, without clear evidence of residual lesion within the resection cavity. 2. Unchanged 4 mm enhancing focus of the right frontal lobe concerning for an additional lesion. 3. Additional findings described above.

19984875-RR-27

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2118-01-11 14:51:00

2118-01-11 15:50:00

EXAMINATION: UNILAT LOWER EXT VEINS LEFT INDICATION: ___ year old woman with left leg pain, tenderness in calf// r/o clot TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left 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 left lower extremity veins.

19984875-RR-29

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2118-02-04 22:03:00

2118-02-05 10:31:00

EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD. INDICATION: History: ___ with concern for brain mass//mass. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 6 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: Comparison is made to multiple prior brain CT and MRI studies dating back to ___. FINDINGS: The patient is status post left parietal craniotomy for resection of left temporoparietal lesion, with postsurgical changes visualized in the resection cavity including blood products with an area of restricted diffusion surrounding the resection cavity, both appearing slightly improved compared to most recent MRI done ___. There is persistent fairly diffuse temporal and parietal edema with unchanged thick, irregular enhancement about the resection cavity. The enhancement abuts the left temporal lobe. Small overlying extra-axial/subdural collection measuring 3 mm in diameter is also decreased in size compared to prior (previously 5 mm). Previously noted ring enhancing lesion in the right frontal lobe is again visualized, and appears slightly larger and more conspicuous, measuring approximately 5 mm in transverse dimension (image 17, series 14), previously 3.5 mm in ___, suspicious for an additional metastatic lesion, no midline shift or significant mass effect is seen adjacent to this lesion. The pituitary appears normal. The craniocervical junction appears normal. The orbits appear normal. The paranasal sinuses are essentially clear. The intracranial arteries demonstrate normal T2 flow voids. IMPRESSION: 1. The patient is status post left parietal craniotomy for resection of a left temporoparietal lesion. 2. Compared to most recent MRI done ___ the postsurgical changes in the form of blood in the resection cavity as well as restricted diffusion surrounding the resection cavity both appear slightly improved. However there is persistent fairly diffuse temporal and parietal edema with unchanged thick irregular enhancement about the resection cavity which is concerning for residual disease. 3. Also compared to MRI done ___ the restricted diffusion and enhancement about the resection cavity is increased concerning for residual disease/disease progression. 4. Overlying extra-axial/subdural collection is slightly decreased in size currently measuring 3 mm. 5. Unchanged ring enhancing lesion in the right frontal lobe, which is also suspicious for metastatic disease. No new lesions are identified.

19985000-RR-27

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2169-07-13 12:51:00

2169-07-13 18:20:00

INDICATION: History of Crohn's disease and recent C. diff infection. Presenting with worsening diarrhea. Please evaluate for small bowel inflammation or signs of active Crohn's disease. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5 Tesla magnet including dynamic 3D imaging obtained prior to, during, and after the uneventful intravenous administration of 5 mL of Gadavist. The patient also received 900 mL of VoLumen p.o. and 0.75 mg of glucagon IM. FINDINGS: MR ENTEROGRAPHY: The ileum appears diffusely thick-walled with transmural enhancement post-contrast and prominence of the vasa recta (se 901 im 58). However, no focal areas of abnormality are identified and the enhancement pattern is not the stratified pattern usually associated with Crohn's disease. Multiple subcentimeter mesenteric lymph nodes are also identified. No strictures. No masses. The colon is unremarkable. Normal haustral pattern. MR ABDOMEN AND PELVIS: The liver is within normal limits. The portal and hepatic veins are patent. No intra- or extra-hepatic duct dilatation. The gallbladder is normal. The kidneys are within normal limits. There are single renal arteries bilaterally. The adrenals, pancreas and spleen are within normal limits. No retroperitoneal adenopathy. There is a small amount of free fluid within the pelvis. The uterus and ovaries are within normal limits. The bladder is within normal limits. No pelvic adenopathy. Bone marrow signal is normal. No destructive osseous lesions. IMPRESSION: 1. Diffusely abnormal ileum with wall thickening and transmural enhancement. The features are not typical for active Crohn's disease and are more suggestive of infectious enteritis. 2. Normal appearing colon.

19985259-RR-3

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2129-12-19 20:19:00

2129-12-19 21:40:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with chest pain // eval for pna COMPARISON: None FINDINGS: AP portable upright view of the chest. Overlying EKG leads are present somewhat limiting assessment. The heart appears top-normal in size. Interstitial opacities are noted bilaterally which could reflect chronic lung disease i.e. fibrosis and/or interstitial pulmonary edema. Please correlate clinically. No large effusion or pneumothorax. No focal opacity concerning for pneumonia. Bony structures are intact IMPRESSION: Interstitial opacities noted bilaterally which could reflect chronic lung disease and/or pulmonary interstitial edema. Please correlate clinically.

19985259-RR-4

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2129-12-21 11:33:00

2129-12-22 13:03:00

INDICATION: ___ year old man with HTN, HLD, dilated CMY, CAD presenting with sustained VT thought to be secondary to ischemic scar. // eval for evidence of scar, focus of VT TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology. IMPRESSION: Please note that this report only pertains to extracardiac findings. There are no extracardiac findings. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports.

19985259-RR-5

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2129-12-23 08:35:00

2129-12-23 13:28:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man s/p dual chamber ICD // Assess leads placement and r/o PTx. Assess leads placement and r/o PTx. IMPRESSION: In comparison with study of ___, there has been placement of a left subclavian pacer with leads extending to the right atrium and apex of the right ventricle. No postprocedure pneumothorax. The cardiac silhouette is again enlarged without definite vascular congestion or evidence of acute focal pneumonia.

19985293-RR-38

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2184-08-19 16:48:00

2184-08-19 17:19:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with GNR bacteremia// any evidence of pneumonia? TECHNIQUE: Semi-upright AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Lung volumes are low. Heart size remains mildly enlarged. The aorta is tortuous. Mediastinal and contours are otherwise unchanged. Crowding of bronchovascular structures is present with possible mild pulmonary vascular congestion. Patchy and linear bibasilar opacities may reflect atelectasis. No large pleural effusion or pneumothorax is seen. Extensive degenerative changes are noted within the right glenohumeral joint. Metallic biliary stent is seen within the right upper of the abdomen. IMPRESSION: Patchy bibasilar opacities likely reflect atelectasis.

19985293-RR-39

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2184-08-19 20:30:00

2184-08-19 22:28:00

INDICATION: History: ___ with history pancreatic cancer, biliary stenting, with GNR bacteremia. Reasonably asymptomatic.//any evidence of intraabdominal source of GNR bacteremia? 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: Acquisition sequence: 1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP = 13.2 mGy-cm. 2) Spiral Acquisition 4.5 s, 49.5 cm; CTDIvol = 10.3 mGy (Body) DLP = 510.6 mGy-cm. Total DLP (Body) = 524 mGy-cm. COMPARISON: CT abdomen pelvis dated ___ and ___ FINDINGS: LOWER CHEST: Left basilar atelectasis is slightly improved from prior. No pleural or pericardial effusion. Diffuse coronary artery and aortic valvular calcifications are re-demonstrated. ABDOMEN: HEPATOBILIARY: There has been interval removal of the previously seen right-sided PTBD. A metallic CBD stent remains in place. Over the interval, the patient has developed mild or slightly increased right-sided intrahepatic biliary ductal dilatation. Left-sided pneumobilia is again seen. A 2.1 x 1 cm hypodense collection within segment 6 appears slightly decreased in size as compared to ___, when it measured 2.8 x 0.8 cm. The gallbladder is markedly distended, similar in appearance to prior, and contains multiple layering gallstones. There is a small amount of pericholecystic fluid, which appears new. There is trace perihepatic fluid. PANCREAS: Known infiltrative pancreatic head mass abutting the portal vein, SMV, and infiltrating the gastroduodenal artery is better assessed on a multiphasic CT dated ___. As before, the remainder of the pancreas appears atrophic, and there is persistent pancreatic ductal dilatation. The degree of soft tissue stranding surrounding the pancreatic head mass has increased compared to the prior study. There is a new approximately 3.3 x 4.1 cm collection containing gas and low-density fluid anterior to the common hepatic artery, along the lesser sac of the stomach (02:27, 601:23). This likely represents a contained perforation/abscess from the stomach/duodenum, in the region of the pancreatic mass invasion of the proximal duodenum. 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: Patient is status post gastrojejunostomy with intact anastomosis. There is circumferential wall edema involving the antropyloric region of the stomach and proximal duodenum. 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 a small amount of pelvic free fluid. REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal limits. LYMPH NODES: Numerous prominent although not technically enlarged retroperitoneal and mesenteric lymph nodes are present. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Degenerative changes are seen in the lower lumbar spine with mild grade 1 L1 on L2 retrolisthesis and L4 on L5 anterolisthesis. SOFT TISSUES: Several adjacent rounded areas of hyperattenuation and soft tissue density within the left rectus abdominus muscles appear to have increased in size slightly as compared to the prior study, measuring approximately 3.9 x 1.8 cm in conglomeration, previously 3.6 x 1.5 cm (601:13, 602:48). IMPRESSION: 1. Interval development of an approximately 3.3 x 4.1 cm air and fluid collection anterior to the common hepatic artery within the lesser sac of the stomach, which likely represents a contained perforation/abscess originating from the stomach/duodenum, where the pancreatic mass is invading. 2. Chronically obstructed and distended gallbladder containing multiple small gallstones and sludge. New pericholecystic fluid is nonspecific and may be reactive to the adjacent inflammatory process. 3. Interval removal of right-sided PTBD, with mild right intrahepatic biliary ductal dilatation. Trace perihepatic fluid. 4. Interval increase in size of nonspecific hyperattenuating and soft tissue density rounded areas in the left rectus abdominus muscle possibly hematomas. metastatic implants would be unusual in this location, but cannot be completely excluded and attention to this region on follow-up imaging is recommended. 5. Small amount of pelvic free fluid.

19985293-RR-40

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2184-08-20 01:41:00

2184-08-20 03:55:00

INDICATION: History: ___ with sepsis// line placement TECHNIQUE: AP portable chest radiograph COMPARISON: Chest radiograph dated ___. FINDINGS: AP portable chest radiograph demonstrates interval placement of a right internal jugular central venous catheter, its tip which terminates in the approximate location of the right atrium. Lung volumes are low with associated atelectasis at the bases bilaterally. Cardiomediastinal and hilar contours are stable. Crowding of the bronchovascular structures is present with possible mild vascular congestion. Biliary stent is noted projecting over the right upper quadrant. Moderately severe degenerative changes are noted involving the right glenohumeral joint. There is no pneumothorax. IMPRESSION: 1. Low lung volumes with bibasilar atelectasis. Mild vascular congestion. 2. Interval placement of right internal jugular central venous line, its tip which projects over the right atrium. No evidence of pneumothorax.

19985293-RR-41

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2184-08-20 05:21:00

2184-08-20 11:11:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ y.o F with sepsis secondary to bowel perforation now with desaturations// evidence of pulmonary edema or something evidence of pulmonary edema or something IMPRESSION: Right internal jugular line tip is at the level of lower SVC. Heart size and mediastinum are stable. Bibasal areas of atelectasis are unchanged. There is evidence of extensive degenerative disease in the right shoulder. There is no pneumothorax.

19985293-RR-42

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2184-08-23 15:10:00

2184-08-23 16:50:00

EXAMINATION: CT abdomen and pelvis with contrast INDICATION: ___ year old woman with ___ female with history of lap gastrojejunostomy in ___ for duodenal stricture causing gastric outlet obstruction, nonresectable pancreatic cancer, s/p duodenal, weaned off pressors// assess for continued extravasation 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 4.5 s, 0.2 cm; CTDIvol = 76.8 mGy (Body) DLP = 15.4 mGy-cm. 3) Spiral Acquisition 9.4 s, 60.9 cm; CTDIvol = 8.0 mGy (Body) DLP = 479.5 mGy-cm. Total DLP (Body) = 497 mGy-cm. COMPARISON: CT abdomen and pelvis dated ___ FINDINGS: LOWER CHEST: There are new trace bilateral nonhemorrhagic pleural effusions with adjacent atelectasis. ABDOMEN: HEPATOBILIARY: There is stable pneumobilia in the left hepatic lobe. Unchanged mild biliary ductal dilatation is again seen in the right hepatic lobe. A common bile duct stent is in stable position terminating in the duodenum. Heterogeneous enhancement of the right hepatic lobe is probably a perfusion defect. The gallbladder is chronically obstructed and contains stones and sludge. There remains trace high perihepatic ascites. PANCREAS: A locally advanced pancreatic head mass abutting the portal vein and surrounding the a gastroduodenal artery is better evaluated on CT dated ___. The remainder of the pancreas is atrophic and there remains ductal dilation. The degree of stranding surrounding the pancreatic head appears reduced compared to ___. A fluid collection anterior to the common hepatic artery with locule of air measures 4.3 x 2.4 cm, previously 4.2 x 2.8 cm (05:48). 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 patient is status post gastrojejunostomy with a patent anastomosis. There is persistent circumferential wall edema in the stomach antrum to the second portion of the duodenum. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus and adnexae 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. Moderate atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. There is diffuse osseous demineralization. Degenerative changes of the lumbar spine are again noted. SOFT TISSUES: Soft tissue density with areas of hyperdensity in the left rectus abdominal muscle measures up to 2.8 x 1.5 cm, and is grossly unchanged (5:65). IMPRESSION: 1. No significant change in the size of the 4.2 x 2.8 cm air and fluid collection anterior to the common hepatic artery, which may represent a perforation/abscess arising from the stomach or duodenum. 2. Interval stability in the size of the nonspecific hyperattenuating and soft tissue density in the left rectus abdominal muscle, which may represent a metastatic implant. 3. Stable left hepatic lobe pneumobilia and mild right intrahepatic biliary dilation. 4. Chronically obstructed and distended gallbladder with gallstones and sludge is grossly unchanged. 5. Known pancreatic head mass abutting the portal vein and gastroduodenal artery is better evaluated on CT from ___. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:41 pm, 10 minutes after discovery of the findings.

19985293-RR-43

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2184-08-23 15:10:00

2184-08-23 17:03:00

EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year female with history of lab gastrojejunostomy in ___ for duodenal stricture causing gastric outlet obstruction and nonresectable pancreatic cancer. Evaluate for continued extravasation. TECHNIQUE: MD CT axial images of the chest were obtained after administration of intravenous contrast. Multiplanar reformats, coronal, sagittal and axial maximal intensity projection images were obtained and reviewed on PACs. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9 mGy-cm. 2) Stationary Acquisition 4.5 s, 0.2 cm; CTDIvol = 76.8 mGy (Body) DLP = 15.4 mGy-cm. 3) Spiral Acquisition 9.4 s, 60.9 cm; CTDIvol = 8.0 mGy (Body) DLP = 479.5 mGy-cm. Total DLP (Body) = 497 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Chest CT from ___. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid again demonstrate punctate calcifications at the isthmus and the right lobe. There is no supraclavicular adenopathy by CT size criteria. Scattered axillary lymph nodes are not pathologic by CT size criteria. The breast parenchyma is suboptimally evaluated on the current modality. The remaining chest wall is unremarkable. The thoracic esophagus is mildly patulous, containing hyperdense material, likely ingested oral contrast. Right internal jugular central venous catheter tip terminates UPPER ABDOMEN: Please refer to the dedicated CT abdomen and pelvis report from the same day for details on subdiaphragmatic findings. MEDIASTINUM: There is no mediastinal lymphadenopathy by CT size criteria. HILA: There is no hilar lymphadenopathy by CT size criteria. HEART and PERICARDIUM: The heart is normal in size. There is no pericardial effusion. Moderate aortic and mitral vascular calcifications, and moderate to severe 3 vessel coronary artery calcifications are unchanged from prior exam. PLEURA: Trace right greater than left pleural effusion is new since ___. There is no pneumothorax. LUNG: 1. PARENCHYMA: There is minimal bibasilar atelectasis and non characteristics scarring at the bases. There are no suspicious nodules. 2. AIRWAYS: The airways are patent to the subsegmental levels. 3. VESSELS: The ascending and descending aorta are normal in caliber. The main pulmonary artery is top normal in size. While this exam is not tailored for the evaluation of pulmonary embolism, no incidental filling defects are noted. CHEST CAGE: There are no worrisome osseous lesions for malignancy or infection. Severe degenerative changes of the bilateral glenohumeral joints are seen with subchondral cysts and sclerosis, right worse than left. IMPRESSION: Minimal bibasilar atelectasis and non characteristic scarring at the bases. No suspicious nodules.

19985293-RR-44

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2184-08-23 17:06:00

2184-08-23 17:30:00

INDICATION: ___ year old woman with picc// r dl picc 41cm iv ping ___ Contact name: ping, ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the right internal jugular central venous catheter projects over the right atrium. The new right PICC line tip projects over the cavoatrial junction. Low bilateral lung volumes and bibasilar atelectasis. No pleural effusion or pneumothorax identified. The size of the cardiac silhouette is within normal limits. Marked degenerative changes of the right greater than left glenohumeral joints. IMPRESSION: The tip of a new right PICC line projects over the cavoatrial junction. No pneumothorax identified.

19985545-RR-162

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2144-07-22 15:44:00

2144-07-22 16:37:00

EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old man with multiple myeloma with recent disease progression now with acute onset altered mental status. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. Contrast was not administered due to the patient's new renal impairment. COMPARISON: 1. CT head ___. 2. CTA head and neck/CT perfusion ___. 3. MR head ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, mass, or mass effect. The ventricles and sulci are prominent, compatible with global parenchymal volume loss. Bilateral periventricular and deep white matter foci of T2/FLAIR signal hyperintensity are nonspecific but compatible with mild changes of chronic white matter microangiopathy, similar to prior exam of ___. The visualized paranasal sinuses and mastoids appear clear. The globes and orbits are unremarkable. Major intracranial vascular flow voids are preserved. Hypointense right frontal calvarial 10 mm focus (08:19) is unchanged since ___, nonspecific, likely benign given stability and lack of enhancement on the prior study, possibly a bone island. IMPRESSION: 1. No acute intracranial abnormality. 2. Chronic findings include global parenchymal volume loss and mild changes of chronic white matter microangiopathy.

19985545-RR-163

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2144-07-22 13:30:00

2144-07-22 15:17:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ with h/o multiple myeloma c/b recent spinal lesions s/p radiation with recent initiation of clinical trial drug regimen now with AMS, ? code stroke// interval change, acute event TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP = 940.0 mGy-cm. Total DLP (Head) = 940 mGy-cm. COMPARISON: CT CTA head and neck ___ FINDINGS: There is no evidence of large territorial infarction,hemorrhage,edema, or mass. The ventricles and sulci are normal in size and configuration. There are bilateral periventricular subcortical hypodensities that are non specific most likely related to chronic small vessel ischemia. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. Bilateral periventricular and subcortical hypodensities that are most likely related to chronic small vessel ischemia.

19985545-RR-164

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2144-07-24 08:10:00

2144-07-25 08:50:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with multiple myeloma, admitted for acute onset AMS.// Please evaluate for infectious etiology. TECHNIQUE: 3 frontal views of the chest COMPARISON: Chest x-ray ___ and chest CTA ___ FINDINGS: Mild bronchial wall thickening at the lung bases suggesting mild bronchitis again noted. Hazy opacity left lung base, corresponding to pneumonia on prior chest CT, appears slightly improved. No new focal infiltrate The cardio-mediastinal silhouette is unremarkable. No significant pleural effusion or pneumothorax. IMPRESSION: Probable mild bronchitis lung bases again noted. Hazy opacity left lung base appears slightly improved.

19985545-RR-165

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2144-07-29 13:32:00

2144-07-29 15:25:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with MM, here for AMS, now hypotensive.// Hypotensive, please evaluate for pulmonary infectious source. TECHNIQUE: Chest AP COMPARISON: Multiple chest x-rays dated ___ and most recent dated ___ FINDINGS: Lungs are well expanded. Cardiomediastinal and hilar contours are unremarkable. No evidence of pneumonia or pulmonary edema. No evidence of effusion or pneumothorax. Right IJ central venous catheter terminates at the cavoatrial junction. IMPRESSION: No evidence of pneumonia or pleural effusion.

19985545-RR-166

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2144-07-31 03:56:00

2144-07-31 05:33:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old man with multiple myeloma and altered mental status. Evaluate for acute process or bleed. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP = 855.5 mGy-cm. Total DLP (Head) = 856 mGy-cm. COMPARISON: MR head performed ___. CT head performed ___. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Periventricular and subcortical white matter hypodensities are likely secondary to chronic microvascular ischemic disease. Atherosclerotic vascular calcifications are noted of bilateral cavernous portions of internal carotid arteries. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. Please note MRI of the brain is more sensitive for the detection of acute infarct. 2. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described.

19985545-RR-169

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2144-08-03 17:10:00

2144-08-03 17:53:00

EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old man with MM on chronic opiates found unresponsive.// Unresponsive, please evaluate for neurologic etiology. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP = 855.5 mGy-cm. 2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9 mGy-cm. 3) Stationary Acquisition 6.2 s, 0.2 cm; CTDIvol = 99.5 mGy (Head) DLP = 19.9 mGy-cm. 4) Spiral Acquisition 7.1 s, 46.3 cm; CTDIvol = 32.9 mGy (Head) DLP = 1,503.1 mGy-cm. Total DLP (Head) = 2,381 mGy-cm. COMPARISON: ___ brain MRI, ___ noncontrast head CT, ___ brain MRI, ___ and ___ chest radiographs FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of infarction,hemorrhage,edema,ormass. Periventricular and subcortical white matter hypodensities are nonspecific but likely sequelae of chronic small vessel ischemic disease. The ventricles and sulci are slightly prominent, indicative of chronic involutional change. The visualized portion of the paranasal sinuses, mastoid air cells,and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The left transverse sinus is hypoplastic. The dural venous sinuses are patent. CTA NECK: The carotidandvertebral arteries and their major branches appear without evidence of significant stenosis or occlusion. There is moderate carotid bifurcation calcification. There is no evidence of internal carotid stenosis by NASCET criteria. OTHER: There is an air-fluid level in the oropharynx in the setting of intubation. The endotracheal tube terminates 4.1 cm proximal to the carina. A left lower lobe superior segment consolidation is partially imaged, new since ___ chest CTA, unchanged and probably reflecting left lower lobe collapse given the immediately preceding chest radiograph. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. No evidence of mass, hemorrhage or infarction. 2. The major arteries the head and neck are patent. 3. Partially imaged left lower lobe collapse. Difficult to exclude pneumonia in the appropriate clinical setting. Please see report for subsequent chest radiograph dated ___.

19985545-RR-170

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2144-08-03 15:08:00

2144-08-03 16:28:00

EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM INDICATION: ___ year old man with myeloma and altered mental status// Placement of new RIJ CVL Contact name: W ___: ___ TECHNIQUE: Chest AP COMPARISON: Comparison to multiple prior radiographs dating from ___ to ___. FINDINGS: Interval placement of a right IJ central venous line with tip terminating at the mid SVC. No pneumothorax. Interval placement of an endotracheal tube with tip terminating approximately 5 cm above the level the carina. Cardiomediastinal silhouette is within normal limits and unchanged. No focal consolidation. There is loss of the left hemidiaphragm with opacification of the left mid and lower lung consistent with layering effusion. No right pleural effusion. IMPRESSION: 1. Right IJ central venous line with tip terminating in the mid SVC. No pneumothorax. 2. Interval development of a small left layering pleural effusion.

19985545-RR-171

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2144-08-03 21:01:00

2144-08-03 22:21:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with new OG tube placement// OG tube placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The tip of the enteric tube projects over the stomach and the tip of a central venous catheter projects over the mid to distal SVC. There is a small left pleural effusion and subjacent atelectasis. Pulmonary vascular congestion is mild. No right pleural effusion. The lung apices were not included on these radiographs. The size of the cardiomediastinal silhouette is within normal limits. IMPRESSION: The tip of the enteric tube extends to the stomach. Small left pleural effusion with subjacent atelectasis.

19985545-RR-172

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2144-08-04 05:42:00

2144-08-04 11:36:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man intubated for respiratory compromise// ETT advanced ETT advanced IMPRESSION: Compared to chest radiographs ___. Left lower lobe collapse was new on ___, somewhat improved. However the heterogeneous consolidation now seen could be developing pneumonia. Sequence events points to previous aspiration or mucous plugging. Radiographic follow-up advised. Heart size normal. Right lung grossly clear. Small left pleural effusion is likely, probably incidental to previous collapse. Indwelling cardiopulmonary support devices in standard placements.

19985545-RR-173

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2144-08-04 11:43:00

2144-08-04 13:56:00

EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD INDICATION: ___ with history of multiple myeloma complicated by recent spinal lesions s/p radiation, now with altered mental status and concern for stroke. CTA head without evidence for infarct or hemorrhage. TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON ___ CTA head and neck ___ brain MRI FINDINGS: There is no evidence of acute infarction, edema, mass effect, or intracranial blood products.. Mild periventricular and subcortical white matter T2/FLAIR hyperintensities are again seen, nonspecific but likely sequelae of chronic small vessel ischemic disease. The ventricles and sulci are mildly prominent, indicative of chronic involutional change. Evaluation of the bilateral supraclinoid internal carotid flow voids, and of the right cavernous carotid and proximal middle cerebral artery flow voids, is limited by volume averaging artifact. However, the intracranial arteries are better assessed on the ___ CTA. There is a persistent air-fluid level in the nasopharynx, likely secondary to the endotracheal intubation. IMPRESSION: No acute infarction or evidence of other acute intracranial abnormalities.

19985545-RR-174

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2144-08-06 15:33:00

2144-08-07 10:58:00

EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE INDICATION: ___ year old man with multiple myeloma and altered mental status of unclear etiology. Concern for infection vs. myeloma CNS infiltration. Evaluate for myeloma progression. TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of ___ contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: MRI lumbar spine without contrast dated ___. MRI cervical spine dated ___. CT chest, abdomen and pelvis dated ___. FINDINGS: CERVICAL: The cervical vertebral body heights and alignment are grossly maintained. Cervical bone marrow signal intensity appears normal. There are multilevel disc bulges in the cervical spine from C3-C4 through C6-C7, most pronounced at C4-C5 with moderate spinal canal narrowing. There is no evidence of abnormal contrast enhancement. THORACIC: The thoracic vertebral body heights and alignment are maintained. There are multiple T2 hyperintense, T1 hypointense lesions throughout the thoracic spine which demonstrate enhancement. The largest measures 3 cm AP x 2 cm TV x 1.8 cm SI in the left aspect of the T8 vertebral body. The lesions are consistent with the clinical history of multiple myeloma. The spinal cord appears normal in caliber and configuration without evidence of edema. There is no evidence of spinal canal or neural foraminal narrowing. LUMBAR: There are 5 non-rib-bearing lumbar type vertebral bodies. There is grade 1 anterolisthesis of L4 on L5. Otherwise, sagittal alignment of the lumbar spine is maintained. There are T2 hyperintense, T1 hypointense lesions in the left pedicle at L1 posterior, posterior L3 vertebral body, and right iliac bone, which demonstrate heterogeneous enhancement. The lesion in the posterior L3 vertebral body appear smaller in size compared to prior exam and currently measures 2.2 x 2.1 cm (image 11 of series 4), previously 2.7 x 2.3 cm. Previously, there was a soft tissue component of the L3 vertebral body lesion, which appears to have resolved. Additionally, a lesion in the L3 spinous process appears decreased in size compared to prior exam. The visualized spinal cord is normal in caliber and configuration with no evidence of edema. The conus medullaris terminates at the level of L1. Sagittal postcontrast images demonstrate linear areas of subtle enhancement of the cauda equina nerve roots on the left at the level of L2, new compared to prior exam. This is much less conspicuous on the axial T1 postcontrast images. From T12-L1 through L2-L3, there are mild disc bulges without significant spinal canal or neural foraminal narrowing. There is minimal nonspecific facet joint fluid on the left at T12-L1, bilaterally at L1-L2, and left greater than right at L2-L3. L3-L4: There is mild diffuse disc bulge and ligamentum flavum thickening resulting in moderate spinal canal narrowing. Moderate right and mild left neural foraminal narrowing due to facet osteophytes. Mild nonspecific facet joint fluid is present. L4-L5: There is mild disc bulge and ligamentum flavum thickening without significant spinal canal narrowing. There is mild bilateral neural foraminal narrowing with the L4 exiting nerve root contacting the disc. Mild nonspecific left facet joint fluid is present. L5-S1: There is minimal disc bulge without significant spinal canal narrowing. There is mild bilateral neural foraminal narrowing. Minimal nonspecific right facet joint fluid is present. OTHER: There are small bilateral pleural effusions. There are consolidations in the dependent portions of the visualized lungs, which have increased compared to CT chest dated ___. IMPRESSION: 1. Multiple T2 hyperintense, T1 hypointense enhancing lesions throughout the thoracic and lumbar spine are consistent with clinical history of multiple myeloma. Dominant lesion in the L3 vertebral body has slightly decreased in size compared to prior exam with resolution of the soft tissue component. 2. Subtle enhancement of the cauda equina nerve roots on the left at the level of L2 are new compared to prior exam concerning for leptomeningeal metastatic infiltration. 3. Multilevel degenerative disc disease in the cervical spine, most pronounced at C4-C5 with moderate spinal canal narrowing. 4. Multilevel degenerative disc disease in the lumbar spine, most pronounced at L3-L4 with moderate spinal canal narrowing and moderate right spinal canal narrowing. 5. Small bilateral pleural effusions with consolidations in the dependent portions of the lungs are consistent with worsening pleural-parenchymal disease.

19985545-RR-175

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2144-08-08 17:47:00

2144-08-09 07:34:00

EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE INDICATION: ___ with history of multiple myeloma c/b recent spinal lesions s/p radiation now with AMS concerning for myelomatous involvement of the CNS.// ?myelomatous involvement of the CNS TECHNIQUE: After informed consent was obtained from the patient explaining the risks, benefits, and alternatives to the procedure, the patient was laid in prone position on the fluoroscopic table. A pre-procedure time-out was performed confirming the patient's identity, relevant history, procedure to be performed and labs. Puncture was attempted at L4-L5, L5-S1 and L3-L4. Approximately 5 cc of 1% lidocaine was administered for local anesthesia. Under fluoroscopic guidance, a 20 gauge, 3.5 inch spinal needle was inserted into the thecal sac. However, there was barely any CSF return. 1 mL of blood-tinged CSF was collected in 1 tubes and sent for requested analysis. COMPARISON: MRI of the entire spine from ___ FINDINGS: Puncture was attempted at L4-L5, L5-S1 and L3-L4. However, there was barely any CSF return at either of these Level despite proper needle positioning on the radiographic images. 1 mL of blood-tinged CSF were collected in 1 tubes. The patient tolerated the procedure well without complication. IMPRESSION: 1. Difficult lumbar puncture with attempts at L4-L5, L5-S1 and subsequently L3-L4 which yielded only 1 mL of blood tinged CSF. 2. The sample was submitted to the laboratory for as much analysis as possible. I, Dr. ___ supervised the trainee during the key components of the above procedure and I reviewed and agree with the trainee's findings and dictation. RECOMMENDATION(S): Difficulty of the procedure and minimal amount of CSF obtained was discussed with Dr. ___ by Dr. ___ (neuroradiology fellow) via telephone on ___ at 19:45 pm.

19985545-RR-176

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2144-08-13 10:06:00

2144-08-13 11:45:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with multiple myeloma, prior unresponsive/hypoxic episode requiring intubation, now extubated.// Follow-up left lower lobe consolidation seen ___. Follow-up left lower lobe consolidation seen ___. IMPRESSION: Comparison to ___. Resolution of a pre-existing left pleural effusion. Stable normal size of the cardiac silhouette. No pulmonary edema, no pneumonia, no pleural effusions. Stable correct position of a right internal jugular vein catheter. A previous left lower lobe consolidation is still visualized. The consolidation shows air inclusion and could correspond to the hiatal hernia, documented on the CT examination from ___. No pleural effusions. No pulmonary edema.

19985545-RR-177

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2144-08-18 19:21:00

2144-08-19 09:53:00

EXAMINATION: MR ___ AND W/O CONTRAST ___ MR SPINE INDICATION: ___ year old man with multiple myeloma, orthostatic hypotension likely ___ autonomic dysregulation. Re-evaluate enhancement seen on prior MRI ___. TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique, followed by axial T2 imaging. This was followed by sagittal and axial T1 images obtained after the uneventful intravenous administration of Gadavist contrast agent. COMPARISON: Multiple prior MRI scans of the lumbar spine, most recent dated ___ and ___. FINDINGS: There are 5 non-rib-bearing lumbar type vertebral bodies. Grade 1 anterolisthesis of L4 on L5 persists. Otherwise, the sagittal alignment of the lumbar vertebral bodies is maintained. Multiple T2 hyperintense, T1 hypointense lesions throughout the lumbar spine and right iliac bone are again identified, which demonstrate heterogeneous enhancement. The largest lesion is located in the posterior L3 vertebral body and measures 2.2 x 2.1 cm, unchanged. The visualized spinal cord is normal in caliber and configuration. The conus medullaris terminates at the level of L1. In comparison to prior exams, there is increasing subtle enhancement of the cauda equina nerve roots. Moderate to severe spinal canal narrowing at L3-L4 appears minimally progressed compared to prior exam. Mild-to-moderate bilateral neural foraminal narrowing persists at L3-L4 and mild at L4-L5 and L5-S1. There is redemonstration of small facet joint effusions from L1-L2 through L5-S1, unchanged compared to prior exam. Small posteriorly projecting synovial cysts are seen at L3-L4 and L4-L5. The paraspinal and paravertebral muscles are unremarkable. IMPRESSION: 1. Multiple T2 hyperintense, T1 hypointense enhancing lesions throughout the lumbar spine are consistent with clinical history of multiple myeloma, similar compared to prior exam. 2. Increasing subtle enhancement of the cauda equina nerve roots are concerning for worsening leptomeningeal metastatic infiltration. 3. Moderate to severe spinal canal narrowing at L3-L4 appears minimally progressed.

19985545-RR-188

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2144-10-06 11:45:00

2144-10-06 12:09:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with fall and SOB// evaluate for PNA COMPARISON: Prior dated ___ FINDINGS: PA and lateral views of the chest provided. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process.

19985545-RR-189

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2144-10-06 12:09:00

2144-10-06 12:39:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with multiple myeloma with falls x2// evaluate for intracranial bleed vs mets TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Total DLP (Head) = 803 mGy-cm. COMPARISON: ___ CT head FINDINGS: There is no evidence of infarction, hemorrhage, edema,or discrete mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Minimal periventricular and subcortical white matter hypodensities are nonspecific, but likely reflect sequelae of chronic small vessel ischemic disease. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial process. No fracture.

19985545-RR-190

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2144-10-06 23:01:00

2144-10-07 00:53:00

EXAMINATION: CT chest abdomen pelvis. INDICATION: ___ year old man with multiple myeloma presents with progressive dyspnea. Evaluate for pulmonary embolism. 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4 mGy-cm. 2) Stationary Acquisition 1.9 s, 0.2 cm; CTDIvol = 16.8 mGy (Body) DLP = 3.4 mGy-cm. 3) Spiral Acquisition 6.0 s, 38.9 cm; CTDIvol = 4.7 mGy (Body) DLP = 181.2 mGy-cm. 4) Spiral Acquisition 8.4 s, 54.4 cm; CTDIvol = 9.7 mGy (Body) DLP = 521.4 mGy-cm. Total DLP (Body) = 707 mGy-cm. COMPARISON: CTA chest abdomen pelvis performed ___. PET-CT dated ___. CT abdomen pelvis performed ___. FINDINGS: CHEST: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the subsegmental level without filling defect to indicate a pulmonary embolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. There are mild coronary artery and aortic arch calcifications. Otherwise, the heart, pericardium, and great vessels are within normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: No pleural effusion or pneumothorax. LUNGS/AIRWAYS: Previously seen ground-glass opacifications within the bilateral lower lobes has improved compared to ___, now with mild residual atelectasis/scarring. The lungs are otherwise clear without evidence of masses or areas of parenchymal opacification. No suspicious pulmonary nodules are identified. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. No supraclavicular lymphadenopathy. 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: There is mild fatty atrophy of the pancreas without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: Spleen is enlarged up to 13.6 cm similar to prior exam. No focal splenic lesions are identified. 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: Small hiatal hernia. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. Appendix is not visualized. 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.A 1.4 cm rim calcified lesion within the right pelvis is unchanged compared to at least ___, and likely reflects the sequelae of prior epiploic appendagitis (12:68). REPRODUCTIVE ORGANS: The prostate and seminal vesicles 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. Extensive atherosclerotic disease is noted. BONES AND SOFT TISSUES: Apparent increased lucency along the anterior right humerus is artifactual in nature secondary to contrast streaking (06:22). Mild lucency about the T1 vertebral body is not seen on the axial or coronal reformats and is likely artifactual in nature secondary to the anterior chest wall leads(09:37). Known myelomatous osseous lesions in the T and L-spine are better evaluated on lumbar spine MR dated ___. Coarse calcification about the superficial right anterior thigh is unchanged compared to at least ___. No concerning soft tissue lesions are identified. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic injury. 2. Known myelomatous osseous lesions are better evaluated on prior MR ___ and L-spine dated ___. 3. No acute findings in the abdomen or pelvis.

19985545-RR-191

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2144-10-09 12:37:00

2144-10-09 15:23:00

EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE INDICATION: ___ year old man with MM presenting with falls and urinary retention. TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: ___, and ___ contrast thoracic and lumbar spine MRIs. FINDINGS: Study is moderately degraded by motion. Within these confines: Levels were established by counting down from the C2 level using series 3, image 4. THORACIC: Alignment is normal. No evidence of fracture. Multiple T1 hypointense, T2 hyperintense, enhancing vertebral body and posterior element lesions are unchanged since less than 1 month prior. Dominant lesions at T2 and T8 measure 1.4 and 2.8 cm, respectively. No evidence of extension into the spinal canal. The spinal cord is normal in caliber and signal intensity. There is mild multilevel intervertebral disc height loss and desiccation and T6 superior endplate and T8 inferior endplate Schmorl's nodes. A small disc bulge at T6-T7 and small right subarticular disc protrusion at T11-T12 result in mild spinal canal narrowing. LUMBAR: Grade 1 anterolisthesis of L4 on L5 is unchanged. No evidence of fracture. Multiple T1 hypointense, T2 hyperintense, enhancing lesions are unchanged since less than 1 month prior. A dominant lesion at L3 measures 2.2 cm. No evidence of extension into the spinal canal. The spinal cord is normal in caliber and signal intensity. Previously seen enhancement of the cauda equina nerve roots is less conspicuous. T12-L1: A small disc bulge and ligamentum flavum thickening result in mild spinal canal narrowing. L1-L2: A small disc bulge and ligamentum flavum thickening result in mild spinal canal narrowing. L2-L3: A disc bulge and ligamentum flavum thickening result in mild spinal canal narrowing and mild right and moderate left neural foraminal narrowing. L3-L4: A disc bulge, ligamentum flavum thickening, and facet hypertrophy result in mild-to-moderate spinal canal narrowing, moderate left neural foraminal narrowing, and severe right neural foraminal narrowing with abutment of the exiting right L3 nerve roots. Nonspecific bilateral facet joint fluid is noted. L4-L5: Grade 1 anterolisthesis, a disc bulge, and ligamentum flavum thickening result in mild spinal canal narrowing and mild left and moderate right neural foraminal narrowing. L5-S1: A disc bulge results in mild spinal canal and bilateral neural foraminal narrowing. OTHER: A T1 hypointense, T2 hyperintense, enhancing lesion in the right iliac bone is unchanged and measures 1.6 cm. Limited imaging of the lungs suggests bilateral scarring and probable dependent atelectasis. IMPRESSION: 1. Study is moderately degraded by motion. 2. No definite evidence of fracture. 3. Scattered myelomatous lesions are unchanged. 4. Within limits of study, no definite new or enlarging myomatous lesions identified. 5. Previously seen enhancement of the cauda equina nerve roots is less conspicuous. 6. Grossly stable multilevel thoracic and lumbar spondylosis compared to 3 weeks prior thoracic and lumbar spine contrast MRI as described, again most pronounced at L3-4 where there is mild-to-moderate vertebral canal, moderate left and severe right neural foraminal narrowing. 7. Limited imaging of the lungs suggests bilateral scarring and probable dependent atelectasis. If concern for lung opacities, consider dedicated chest imaging for further evaluation.

19985545-RR-192

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2144-10-09 15:49:00

2144-10-09 16:54:00

EXAMINATION: CHEST FLUORO INDICATION: ___ year old man with MM p/w dyspnea, falls, malnutrition// sniff nasal inspiratory pressure under fluoro c/f diaphragmatic motion abnormalities TECHNIQUE: AP fluoroscopic images were obtained during respiration and sniffing while patient is upright. Total for rescue 00:02 minutes. Air kerma 14.38 mGy. COMPARISON: None. FINDINGS: Both may diaphragm move simultaneously during respiration. No evidence of diaphragmatic paralysis or paradoxical motion. IMPRESSION: No evidence of diaphragmatic paralysis.

19985545-RR-193

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2144-10-12 14:18:00

2144-10-12 15:33:00

EXAMINATION: SCROTAL U.S. INDICATION: ___ year old man with MM, orthostatic hypotension, urinary retention has L testicular pain. Evaluate for testicular pain. TECHNIQUE: Grayscale with color and spectral Doppler ultrasound of the scrotum was performed with a linear transducer. COMPARISON: None. FINDINGS: The right testicle measures: 2.3 x 1.9 x 3.2 cm The left testicle measures: 2.4 x 2.1 x 3.7 cm. The right testicle demonstrates heterogeneous echogenicity without evidence of focal mass or increased vascularity. The left testicle demonstrates homogeneous echogenicity with a small avascular 0.2 x 0.2 x 0.4 cm cystic lesion with central punctate focus of echogenicity seen superiorly. This lesion demonstrates no concerning features. Bilateral epididymal cysts measure up to 0.4 cm on the right and 0.3 cm on the left. Vascularity is normal and symmetric in the testes and epididymides. IMPRESSION: 1. Heterogeneous echotexture of the right testis without evidence of focal mass or abnormal vascularity. Findings may reflect sequelae of prior injury. 2. Otherwise normal scrotal ultrasound.

19985545-RR-199

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2145-07-11 07:51:00

2145-07-11 08:32:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with RUQ abdominal pain // eval for cholecystitsi TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: MR enterography from ___. 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 no intrahepatic biliary dilation. CHD: 3 mm GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. Negative sonographic ___ sign. 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. Spleen length: 12.2 cm KIDNEYS: Limited views of the kidneys show no hydronephrosis. RETROPERITONEUM: There are atherosclerotic calcifications of the abdominal aorta, without aneurysmal dilatation. Visualized portions of the IVC are unremarkable.. IMPRESSION: No cholelithiasis or evidence of acute cholecystitis. No biliary ductal dilatation.

19985545-RR-200

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2145-07-11 09:31:00

2145-07-11 10:09:00

EXAMINATION: CT ABD AND PELVIS W/O CONTRAST INDICATION: ___ with multiple myeloma w epigastric and RUQ pain. Eval pancreatitis, abscess, cancer progression 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 not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 11.5 mGy (Body) DLP = 561.8 mGy-cm. Total DLP (Body) = 562 mGy-cm. COMPARISON: MRE dated ___ and MR ___ from ___ FINDINGS: LOWER CHEST: Mild bibasilar atelectasis is noted. Coronary artery calcifications and dense mitral annular calcifications noted. Hypoattenuation of the blood pool relative to the myocardium is consistent anemia. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. There is no evidence of overt lesions within the limitations of an unenhanced scan. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: There is mild diffuse atrophy of the pancreas. There is no main ductal dilatation. There is no peripancreatic stranding or fluid collection. SPLEEN: The spleen is mildly enlarged, measuring 13.7 cm in length, previously 12.1 cm on MRI of the abdomen from ___. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size. There is no suspicious renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: There is a moderate size hiatal hernia. Small bowel loops are normal in caliber. There is a small rim calcified sigmoid diverticulum. The colon is otherwise unremarkable. The appendix is not visualized however there are no secondary signs of appendicitis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: No abdominopelvic lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic disease is noted. BONES: Known myelomatous osseous lesions are better evaluated on prior MR of the thoracic and lumbar spine from ___. There is no acute fracture. There is mild anterolisthesis of L4 on L5. SOFT TISSUES: Bilateral fat containing inguinal hernias. IMPRESSION: 1. No acute intra-abdominal pathology to account for patient's symptoms, within the limitations of this unenhanced scan.

19985545-RR-201

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2145-07-11 18:05:00

2145-07-11 19:13:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with neutropenia, chills, SOB. Evidence of infection or reasons for dyspnea? TECHNIQUE: AP radiograph of the chest. COMPARISON: Chest radiograph ___. FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities are identified. IMPRESSION: No pneumonia or acute cardiopulmonary process.

19985545-RR-202

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2145-07-12 11:46:00

2145-07-12 14:45:00

EXAMINATION: CT CHEST W/O CONTRAST Q411 INDICATION: ___ year old man with history myeloma admitted with SOB, n/v/d, ___ and pancytopenia now with + blood culture (GNR). abd/pelvis CT done ___. // any source of infection TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as 5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Contrast agent was not administered. All images were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.6 s, 36.4 cm; CTDIvol = 8.0 mGy (Body) DLP = 284.7 mGy-cm. Total DLP (Body) = 285 mGy-cm. COMPARISON: Chest CT from ___. FINDINGS: NECK, THORACIC INLET, AXILLAE AND CHEST WALL: Thyroid is unremarkable. Stable small axillary and thoracic inlet lymph nodes. No chest wall abnormalities. Moderate atherosclerotic calcifications in the head and neck arteries, specially in the proximal left subclavian artery. MEDIASTINUM AND HILA: Esophagus is patulous, most likely associated to a large hiatal hernia, unchanged. Small mediastinal lymph nodes, none enlarged by CT size criteria and stable from prior studies. Hilar contours show no evidence of enlarged lymph nodes. HEART, PERICARDIUM AND VASCULATURE: The heart is normal in size and shape. No pericardial effusion. Heavy atherosclerotic calcification of the coronary arteries and mitral annulus, moderate in the aortic valve leaflets. Aorta and pulmonary artery normal in caliber throughout. LUNGS, AIRWAYS, AND PLEURA: The airways are patent to the subsegmental levels. Moderate bronchial wall thickening, no bronchiectasis or mucus plugging. Stable right upper lobe 4 mm nodule (5:34). No focal consolidation. No pleural effusion or thickening. Mild biapical pleuroparenchymal scarring. CHEST CAGE: Striated pattern of osteopenia is stable since ___ with no evidence of compressive or pathologic fractures. No acute fractures. Moderate dorsal spondylosis. No lytic or sclerotic bone lesions worrisome for malignancy. A sclerotic focus in the lateral aspect of the right seventh rib, stable since ___ is most likely a bone island. UPPER ABDOMEN: The limited sections of the upper abdomen show no focal hepatic or splenic lesions. Adrenals unremarkable. IMPRESSION: No evidence of pneumonia in the present examination. Stable right upper lobe 4 mm nodule (5:34). Moderate bronchial wall thickening reflecting chronic bronchitis. Severe coronary artery atherosclerotic disease. Severe mitral annulus calcification.

19985545-RR-203

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2145-07-13 13:04:00

2145-07-13 16:31:00

INDICATION: ___ year old man with GNR bacteremia with abd pain. CT without acute abnormalites on ___. KUB to r/o obstruction. // r/o obstruction TECHNIQUE: Portable supine and upright abdominal radiographs were obtained. COMPARISON: CT of the abdomen from ___ FINDINGS: There are no abnormally dilated loops of large or small bowel. Mild colonic stool burden. There is no free intraperitoneal air. Osseous structures show degenerative changes of the lumbar spine. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No evidence of bowel obstruction or ileus..

19985545-RR-204

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2145-07-16 13:36:00

2145-07-16 13:53:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with multiple myeloma w/ chest pain // evaluate for PNA TECHNIQUE: Chest PA and lateral COMPARISON: ___ IMPRESSION: Lungs are clear. Heart size is normal. There is no pleural effusion. No pneumothorax is seen. No evidence of pneumonia there are healing right-sided rib fractures.

19985545-RR-205

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2145-07-18 14:52:00

2145-07-18 18:41:00

EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ year old man with multiple myeloma with progressive DOE/SOB with minimal activity // Evaluate for PE TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8 mGy-cm. 2) Stationary Acquisition 5.0 s, 0.2 cm; CTDIvol = 84.4 mGy (Body) DLP = 16.9 mGy-cm. 3) Spiral Acquisition 5.9 s, 38.1 cm; CTDIvol = 5.9 mGy (Body) DLP = 220.1 mGy-cm. Total DLP (Body) = 239 mGy-cm. COMPARISON: CT chest from ___ FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the segmental level without filling defect to indicate a pulmonary embolus. Evaluation of the subsegmental pulmonary arteries is limited due to timing of the contrast bolus. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. There are extensive coronary calcifications, particularly in the left main and left anterior descending coronary arteries. Severe mitral annular calcifications are redemonstrated. The pericardium, is normal limits. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. Redemonstration of a moderate hiatal hernia, with a patulous esophagus. PLEURAL SPACES: No pneumothorax. Trace right pleural effusion is new. Mild biapical pleuroparenchymal scarring. LUNGS/AIRWAYS: The lungs are patent to the subsegmental level. Moderate bronchial wall thickening is overall unchanged to slightly improved. No focal consolidation to suggest pneumonia. Stable 4 mm right upper lobe pulmonary nodule (series 6:46). Mild relaxation atelectasis at the right lung base. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: Diffuse osteopenia is redemonstrated. A stable sclerotic lesion in the lateral aspect of the right seventh rib likely represents a bone island. There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism centrally through the segmental pulmonary arteries. Evaluation of the subsegmental pulmonary arteries is limited due to timing of the contrast bolus. 2. Trace right nonhemorrhagic pleural effusion is new from prior. 3. Stable to slightly improved diffuse bronchial wall thickening. 4. Stable right upper lobe 4 mm pulmonary nodule. 5. Severe coronary artery and mitral annular calcifications. 6. Moderate hiatal hernia and patulous esophagus, which may predispose to aspiration.

19985545-RR-206

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2145-07-18 14:14:00

2145-07-18 14:46:00

EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old man with multiple myeloma // evaluate for DVT - evolving DOE and c/f PE TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: Prior lower limb Doppler study done ___ FINDINGS: There is normal compressibility, color flow, and spectral doppler of the bilateral 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. There is a left-sided popliteal fossa (___) cyst measuring to 3.0 cm (previously 4 cm). IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins. Left-sided ___ cyst measuring 3 cm.

19985545-RR-78

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2138-11-04 19:07:00

2138-11-04 20:30:00

HISTORY: Decreased cognitive abilities. TECHNIQUE: Noncontrast MDCT axial images were acquired through the head. Bone reconstructions and coronal and sagittal reformations were provided for review. COMPARISON: No relevant comparisons available. FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarct. Mildly prominent ventricles and sulci are compatible with global age-related volume loss. Basal cisterns are preserved. There is no shift of normally midline structures. Gray-white matter differentiation is preserved. No osseous abnormality is identified. There is mild mucosal thickening with aerosolized secretions in the right maxillary sinus with scattered opacification of the ethmoid air cells. The mastoid air cells and middle ear cavities are clear. The globes and orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. If clinical concern for stroke or intracranial mass is high, MRI is more sensitive. 2. Aerosolized secretions in the right maxillary sinus.

19985545-RR-97

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2140-10-23 12:23:00

2140-10-23 12:44:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with multiple myeloma presents with general fatigue and cough. Evaluate for pneumonia. TECHNIQUE: Chest PA and lateral COMPARISON: CT of the chest from ___ FINDINGS: The lungs are clear.The cardiac, hilar and mediastinal contours are normal.No pleural abnormality is seen. IMPRESSION: No acute cardiopulmonary process.

19986107-RR-41

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2171-06-23 23:21:00

2171-06-24 01:51:00

EXAMINATION: CTA ABD AND PELVIS INDICATION: History: ___ with abd pain, hemoperitoneum // eval for splenic artery pseudoaneurysm vs aneurysm TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous, and delayed phase images were acquired through the abdomen and pelvis. IV Contrast: 150mL of Omnipaque Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: DLP: 3136 mGy-cm (abdomen and pelvis). COMPARISON: Reference CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: Bibasilar dependent atelectasis is noted in the lung bases. There is no 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, without stones or gallbladder wall thickening. Portal venous system is patent. 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. A 3.0 x 2.9 cm simple cyst arises from the upper pole of the right kidney. No stones. No nephrolithiasis. 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 is not definitely visualized, but there are no secondary signs of acute appendicitis. There is no evidence of mesenteric lymphadenopathy. There is small volume perihepatic hemoperitoneum (4:215), that has not significantly changed compared to the outside CT performed on ___. Hemorrhagic fluid is is also present within the left upper quadrant about the spleen, which is continuous with a more localized but ill-defined collection along the greater curvature of the stomach that measures approximately 4.4 x 3.8 cm; this closely abuts the wall of the stomach with no intervening fat plane, and an underlying lesion cannot be excluded. There is mild surrounding fat stranding (4b:241). There is a long hyperdense curvilinear structure within this collection that most likely represents a vessel rather than active contrast extravasation given background collateralization within the left upper quadrant. Additionally, the size of this perigastric collection has not significantly increased. A small amount of hemorrhagic fluid continues to track inferiorly along the left abdomen. The volume of hemorrhagic fluid within the pelvis is little changed or minimally increased. VESSELS: Abdominal aorta is normal in caliber. Celiac axis, common hepatic artery and its branches are patent. Left gastric artery is patent. Status post splenic artery embolization, with collateralization towards the splenic hilum. Superior mesenteric artery and bilateral single renal arteries are patent. Inferior mesenteric artery is patent. Bilateral iliac branches are unremarkable in appearance. No evidence of aneurysm or pseudoaneurysm. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: Urinary bladder is largely collapsed around a Foley catheter. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Uterus is unremarkable. No adnexal masses are identified. 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 aneurysm, pseudoaneurysm or active extravasation. 2. Small volume hemoperitoneum in the upper abdomen and pelvis, little changed from the outside hospital CT performed several hours earlier. 3. More localized fluid with surrounding stranding along the greater curvature of the stomach, raising the possibility that the source of bleeding is from the gastroepiploic territory. However, an underlying lesion cannot be excluded, and an MRI is recommended for further evaluation when clinically appropriate. RECOMMENDATION(S): MRI Abdomen to exclude underlying lesion along the greater curvature of the stomach. NOTIFICATION: Recommendation for MRI was communicated by Dr. ___ with Dr. ___ on the telephoneon ___ at 9:58 AM, 30 minutes after attending review.

19986107-RR-42

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2171-06-24 14:41:00

2171-06-24 18:44:00

INDICATION: ___ year old woman with multiple hematomas in the abdomen // please assess for extravasation COMPARISON: CTA ___ TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Sedation was provided by administrating divided doses of 50 mcg of fentanyl and 0 mg of midazolam. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site MEDICATIONS: 50 mcg fentanyl. CONTRAST: 137 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 16.0 min, 854 mGy PROCEDURE: 1. Right common femoral artery access. 2. Celiac artery arteriogram. 3. Gastroduodenal artery arteriogram. 4. Gastroepiploic artery arteriogram. 5. Left gastric artery arteriogram. 6. Gel-Foam embolization of the left gastric artery. 7. Superior mesenteric artery arteriogram. PROCEDURE DETAILS: Following the discussion 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. Both groins were sterilely prepped and draped in the typical sterile fashion. Using palpatory and fluoroscopic guidance, the right common femoral artery was punctured using a micropuncture set at the level of the mid-femoral head. An 0.018 wire was passed easily into the vessel lumen. A small skin incision was made over the needle. Then the inner dilator and wire were removed and a ___ wire was advanced under fluoroscopy into the aorta. The micropuncture sheath was exchanged for a 5 ___ sheath which was attached to a continuous heparinized saline side arm flush. A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire was removed and the celiac artery was injected with contrast to confirm position. A celiac arteriogram was performed. The C2 Cobra catheter was advanced over a Glidewire into the gastroduodenal artery. The wire was removed, and the gastroduodenal artery was injected with contrast to confirm position. A gastroduodenal artery arteriogram was performed. A Transcend wire and STC micro catheter were then advanced into the gastroepiploic artery. The wire was removed, and the gastroepiploic artery was injected with contrast to confirm positioning. A gastroepiploic artery arteriogram was performed. The micro catheter and micro wire were then removed. The C2 Cobra catheter was exchanged for a SOS catheter over ___ wire. The SOS catheter was used to select the celiac artery. The Transcend wire and STC micro catheter were then carefully advanced into the left gastric artery. The wire was removed, and the left gastric artery was injected with contrast to confirm positioning. A left gastric artery arteriogram was performed. Gel-Foam embolization of the left gastric artery was then performed. The micro catheter was removed. The SOS catheter was used to select the superior mesenteric artery. The superior mesenteric artery was injected with contrast to confirm position. A superior mesenteric artery arteriogram was performed. The catheter was removed over a wire. The sheath was then removed. Hemostasis was achieved with manual pressure. A sterile dressing was applied. The patient tolerated the procedure and there were no immediate complications. FINDINGS: 1. Celiac artery arteriogram demonstrates no active extravasation. 2. Gastroduodenal artery arteriogram demonstrates no active extravasation. 3. Gastroepiploic artery arteriogram demonstrates no active extravasation. 4. Left gastric artery arteriogram demonstrates no active extravasation. The left gastric artery is abnormal in appearance, with hyperemia. 5. Gel-Foam embolization of the left gastric artery. 6. Superior mesenteric artery arteriogram demonstrates no active extravasation. IMPRESSION: Abnormal appearance of the left gastric artery treated with Gel-Foam embolization. Otherwise, normal arteriograms of the celiac, gastroduodenal artery, gastroepiploic artery, and superior mesenteric artery, without active extravasation.

19986107-RR-43

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2171-06-25 15:54:00

2171-06-25 17:37:00

EXAMINATION: MRI of the Abdomen INDICATION: ___ year old woman with hemoperitoneum // eval for tumor (?gastric per radiology due to hemoperitoneum centered around the greater curvature of stomach) TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 9 mL Gadavist COMPARISON: CTA abdomen pelvis ___, ___, mesenteric angiogram ___. FINDINGS: Lower Thorax: Bibasilar atelectasis is present, right greater than left, with small bilateral pleural effusions. The visualized heart and pericardium are unremarkable. Liver: There is no significant hepatic steatosis. There are no morphologic changes concerning for cirrhosis. There are no focal liver lesions. Biliary: There is no intrahepatic or extrahepatic biliary ductal dilatation. The gallbladder is distended, and a 4 mm polyp is noted. There is no cholelithiasis or sludge. There are no findings concerning for cholecystitis. Pancreas: The pancreas is not well visualized due to artifact from proximal splenic embolization coils. The main pancreatic duct is dilated, with the proximal portion measuring 6 mm (series 7, image 34). The main pancreatic duct and common bile duct terminate fairly abruptly at the ampulla. A focal area of T2 hypointense signal at the ampulla may represent the ampulla itself, but a stone at the ampulla or ampullary stenosis cannot be excluded. Spleen: The spleen is normal in size. There is no evidence of focal splenic lesions. Adrenal Glands: The right adrenal gland is unremarkable. The left adrenal gland is difficult to visualize given adjacent artifact. Kidneys: The kidneys are normal in size without hydronephrosis. Multiple simple cysts are seen in the kidneys. The largest is in the upper pole of the right kidney measuring 3.0 cm. Gastrointestinal Tract: Artifact from proximal splenic artery embolization coils limits assessment of the stomach. Assessment for a gastric tumor cannot be performed on diffusion or pre or postcontrast images. However, the portions of gastric wall better visualized on the out of phase and T2 weighted images appear unremarkable. There is no abnormal T1 hyperintensity to suggest ectopic pancreas. Again seen is a hematoma just outside the gastric body, intimately associated with the gastric wall. This intimate association raises the consideration of a gastric wall or a gastroepiploic vessel abnormality resulting in hematoma. There is a small focus of T1 hyperintensity within the hematoma, suggestive of blood products of a variant age (series 9, image 67). There is no evidence of active extravasation. Lymph Nodes: There is no mesenteric or retroperitoneal lymphadenopathy. Vasculature: The abdominal aorta is normal in caliber. The patient is status post coil embolization of the proximal splenic artery, with resultant artifact. The celiac and SMA are not well assessed due to artifact. Portions of the portal vein are also not well assessed. The hepatic veins and IVC are patent. Osseous and Soft Tissue Structures: Bone marrow signal is normal. IMPRESSION: 1. Limited exam due to the artifact from splenic artery embolization coils. Diffusion, and pre and post contrast sequences cannot be used to assess for tumor given this artifact. However, no obvious signal abnormality or other finding is seen in the gastric wall on other T1 or T2 weighted sequences. 2. Similar appearance of hematoma along the greater curvature of the stomach, intimately associated with the gastric wall, again raising the possibility of a gastroepiploic artery or gastric wall vascular abnormality as the etiology of this finding. 3. Main pancreatic ductal dilation to 6 mm without extrahepatic or intrahepatic biliary dilation. A stone at the ampulla or ampullary stenosis is not excluded. 4. Bibasilar atelectasis, right greater than left. 5. 4 mm gallbladder polyp. No specific follow-up is needed for this finding. RECOMMENDATION(S): ERCP may be considered to further evaluate the pancreatic duct and ampulla if clinically indicated. NOTIFICATION: The change from the initial wet read to the final Impression was discussed by Dr. ___ with Dr. ___ on the telephone on ___ at approximately 11:00 AM.

19986107-RR-44

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2171-06-27 11:35:00

2171-06-27 22:22:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman s/p L gastric artery gelfoam embolization // Please assess for interval change . Review of OMR indicates the the patient has undergone assessment for new onset hemo peritoneum. COMPARISON: Chest x-ray from ___ FINDINGS: There are curvilinear areas of parenchymal opacity in the right mid zone and an additional irregular opacity in the left base posteriorly. These are of indeterminate acuity. There are opacities that are somewhat similar in distribution seen on the ___ chest x-ray, but the distribution is not identical hand both opacities are larger and more pronounced on today's examination. There is mild cardiomegaly and mild prominence of the cardiomediastinal silhouette. Although cardiac silhouette itself is probably not significantly changed, the mediastinal prominence is new and not clearly fully accounted for by technique. Within the limits of plain film radiography, no hilar adenopathy is detected. No CHF, air bronchograms or effusions are identified. Mild elevation of the right hemidiaphragm is more pronounced than in ___. Mild left greater right apical pleural thickening is also more pronounced. Probable embolization material seen projecting over the upper abdomen distal left of midline, similar to ___. IMPRESSION: Opacities at the right base and posterior left lower lobe are new or significantly changed compared with ___. These are of indeterminate acuity and not fully characterized by a chest x-ray. The differential includes infectious, inflammatory and neoplastic processes. Further assessment with chest CT is recommended. Prominence of the mediastinum appears increased compared with ___. Has there been a change in body habitus to account for this? Attention to this area at the time of the chest CT is recommended. Mild cardiomegaly. Mild left-greater-than-right apical pleural thickening, slightly increased compared with ___. Embolization in the upper abdomen, likely in the region of the left gastric artery. The appearance is grossly unchanged compared with ___. RECOMMENDATION(S): Chest CT recommended to further assess opacities in the right middle and left lower lobes, with additional attention to mediastinal prominence. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ ___ on ___ at 22:21 into the Department of Radiology critical communications system for direct communication to the referring provider.

19986107-RR-45

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2171-06-27 14:50:00

2171-06-28 01:32:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman hypotensive with increasing O2 requirement s/p L gastric artery gelfoam embolization // r/u PE COMPARISON: None. FINDINGS: Compared with ___ at 11:39 a.m. and allowing for technical differences, no definite change is identified. Again seen is patchy opacity in the right infrahilar region and at the left base (previous chest x-ray suggested in the left lower lobe). Cardiomediastinal silhouette is unchanged. There is upper zone redistribution, without overt CHF. No new focal opacity is detected. No pneumothorax is identified. Densities in the upper abdomen likely relate to prior embolization. IMPRESSION: Allowing for technical differences, doubt significant interval change compared with earlier the same day. Again noted (but better seen on the most recent prior study), are non-specific patchy opacities in the right middle and left lower lobes. Chest CT is recommended for further assessment of these opacities and for evaluation of the apparent interval increase in the size of the mediastinum compared with ___. RECOMMENDATION(S): Chest CT is recommended for further assessment of these opacities and for evaluation of the apparent interval increase in the size of the mediastinum compared with ___.

19986107-RR-46

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2171-06-28 02:41:00

2171-06-28 05:45:00

INDICATION: ___ year old woman with h/o hemoperitoneum, unknown etiology, now with episodes of hypotension and desats, please eval for hemoperitoneum or interval change. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. IV Contrast: 130 mL Omnipaque. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 888 mGy-cm. COMPARISON: CT abdomen and pelvis ___. FINDINGS: LOWER CHEST: Scattered streaky opacities at the lung bases are compatible with subsegmental atelectasis; otherwise, the partially imaged lung bases are clear. There is no pleural or pericardial effusion. There is no hiatus hernia. CT ABDOMEN: HEPATOBILIARY: The liver enhances homogeneously without evidence of concerning focal lesion. There is no intrahepatic biliary ductal dilation. The portal vein is patent. The gallbladder is unremarkable without evidence of wall thickening or inflammation. PANCREAS: There is diffuse fatty pancreatic atrophy. There is no peripancreatic stranding or ductal dilation. SPLEEN: Apparently new since prior exam is a 1.9 cm irregularly hypoenhancing region of superior splenic parenchyma (series 601b, image 43), possibly an infarct or contusion. The remainder the spleen is unremarkable. There is no perisplenic fluid. ADRENALS: The adrenal glands are normal. URINARY: There is a 2.6 cm simple renal cyst arising from the right upper renal pole. Smaller hypodensities elsewhere in the renal cortices are too small to characterize accurately by CT. Otherwise, the kidneys enhance normally and symmetrically. There is no hydronephrosis. GASTROINTESTINAL: Coils are identified near the region of the left gastric artery from recent coil embolization. Again identified is hyperdense fluid appearing to originate from the anterior aspect of the spleen and tracking along the greater curvature of the stomach, decreased in amount in comparison to prior CT from ___ (for example see series 2 images ___, consistent with a small amount of hemoperitoneum. The stomach and duodenum are otherwise unremarkable. Non-dilated small bowel loops are normal in course and caliber without evidence of wall thickening or obstruction. The colon is unremarkable. The appendix is normal. VASCULAR AND LYMPH NODES: The abdominal aorta is normal in caliber without evidence of aneurysm or dilation. Major proximal tributaries are patent. There is no mesenteric or retroperitoneal lymphadenopathy by CT size criteria. In addition to the right upper quadrant free fluid, trace amount of hemo peritoneum is seen interspersed between small bowel loops in the right lower quadrant (see series 2, image 73), as well as in the pelvis (series 2, image 75). CT PELVIS: A tiny focus of intraluminal bladder air likely relates to recent catheterization. Otherwise, the imaged pelvic organs are unremarkable. A trace amount of free fluid in the pelvis is hyperdense, likely extending from more superior known hemoperitoneum. There is no pelvic sidewall or inguinal lymphadenopathy. Stranding around the right common femoral artery and vein likely relates to recent vascular access. No hematoma. MUSCULOSKELETAL: The thoracolumbar vertebral bodies are normally aligned. No concerning focal lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. New or newly apparent 1.9 cm irregularly hypoenhancing region of superior splenic parenchyma, possibly an infarct or contusion. 2. Mild interval decrease in the amount of small volume hemoperitoneum centered along the greater curvature of the stomach, as well as layering dependently in the right lower quadrant and pelvis. 3. Coils seen in the region of left gastric artery from recent embolization. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ in personon ___ at 5:56 AM, 30 minutes after discovery of the findings.

19986107-RR-47

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2171-06-28 14:30:00

2171-06-29 00:18:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman 24 hours s/p x2 episodes of presyncope w/ desats and hypotension following coughing // Please asses for interval change, ?PNA ?PE COMPARISON: Chest x-ray dated ___ at 14:54 FINDINGS: Inspiratory volumes are slightly low. There is new platelike atelectasis the right lung base. Again seen is patchy opacity in the right cardiophrenic region, similar to the prior study. There is subsegmental atelectasis at the left lung base, similar to the prior study. Slight lateralization of left hemidiaphragm and minimal blunting of the left costophrenic angle is unchanged . No CHF or gross right effusion. Radiographs or limited for assessment of pulmonary embolism, but no pathognomic changes of PE are identified. IMPRESSION: 1. Slightly low inspiratory volumes. 2. Patchy opacity left lower lobe again seen, consistent with left lower lobe collapse and/or consolidation. 3. Minimal patchy opacity in the right cardiophrenic region is unchanged. New platelike atelectasis at the right lung base. 4. No CHF, gross effusion or pneumothorax detected.

19986183-RR-21

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2193-08-11 04:30:00

2193-08-11 06:03:00

EXAMINATION: Chest PA and lateral INDICATION: History: ___ with cough, fever// ? pna TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Lungs are adequately inflated, without focal consolidation. The cardiomediastinal and hilar silhouettes are within normal limits. There is no pulmonary edema. No pleural effusions. No pneumothorax. IMPRESSION: No acute intrathoracic process.

19986230-RR-45

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2188-12-12 11:44:00

2188-12-12 14:03:00

EXAMINATION: CT abdomen/pelvis with contrast. INDICATION: History: ___ with RLQ pain, fever. Evaluation for appendicitis. 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: Acquisition sequence: 1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 21.7 mGy (Body) DLP = 10.8 mGy-cm. 2) Spiral Acquisition 6.0 s, 47.1 cm; CTDIvol = 27.6 mGy (Body) DLP = 1,296.8 mGy-cm. Total DLP (Body) = 1,308 mGy-cm. COMPARISON: Abdominal ultrasound from ___. FINDINGS: LOWER CHEST: Minimal bibasilar atelectasis is noted. Visualized lung fields are otherwise within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There are multiple subcentimeter hyperdensities noted, with the largest measuring 8 x 4 mm in segment IV, compatible with likely simple cysts. 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: There is a hypodensity in the left adrenal gland measuring 1.4 x 1.0 cm (02:28). The right adrenal gland is normal in size and shape. URINARY: There is an obstructive renal stone within the distal right ureter measuring approximately 9 mm x 6 mm x 5 mm (2:70, 601: 53), with upstream mild to moderate dilatation of the ureter, right collecting system, and kidney. The right kidney is moderately enlarged with surrounding perinephric stranding. There is delayed excretion of contrast from the right kidney as compared to the left. In addition, there is very subtle likely slightly delayed perfusion of the right kidney as compared to the left. The left kidney is normal size with normal nephrogram. 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 is unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is not visualized. There is a hypodense mass within the left ovary measuring 1.8 x 1.0 cm (601:42). The right ovary is unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: Moderate multilevel degenerative changes noted throughout the thoracolumbar spine, most notably including posterior osteophytes and mild disc bulge most prominent at L1-L2 and L3-L4, causing mild central canal narrowing. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. 9 mm obstructive renal stone within the distal right ureter resulting in upstream right hydroureteronephrosis. Mild right perinephric stranding. Delayed excretion of contrast from the right kidney. 2. 1.8 x 1.0 cm hypodensity is noted within the left ovary, likely representing a simple cyst. However, a follow-up ultrasound is recommended in 12 months given a lesion of this size in a postmenopausal woman. 3. Mild central spinal canal stenosis at L1-L2 and L3-L4, secondary to posterior osteophytes and mild disc bulge. 4. Hypodense lesion within the left adrenal gland measuring 1.4 x 1.0 cm. If there is no history of malignancy, this is probably benign. Follow up dedicated adrenal CT in 12 months could be considered. If there is a history of malignancy, a dedicated adrenal CT is recommended. RECOMMENDATION(S): Incidentally discovered adrenal lesion without prior studies for comparison measuring 1-2 cm. If there is no history of malignancy, this is probably benign. Follow up dedicated adrenal CT in 12 months could be considered. If there is a history of malignancy, a dedicated adrenal CT is recommended. Recommendations based on ___ ACR guidelines: ___

19986230-RR-46

RR

2188-12-12 16:00:00

2188-12-12 21:05:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with fever, evaluate for pna? COMPARISON: Prior CT of the chest dated ___ as well as a prior chest radiograph dated ___. FINDINGS: PA and lateral views of the chest provided. Right lung is clear. There is subtle opacity in the left lower lobe which is concerning for an early pneumonia. No large effusion or pneumothorax. Cardiomediastinal silhouette is stable. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: Subtle opacity in the left lower lobe concerning for an early pneumonia.

19986230-RR-47

RR

2188-12-12 18:46:00

2188-12-12 22:21:00

INDICATION: Indication not provided. Intra op abdominal radiograph TECHNIQUE: Intra op abdominal radiograph COMPARISON: CT abdomen pelvis ___. FINDINGS: Static images of a retrograde place right ureteral stent with contrast seen filling the right renal pelvis. There appears to be appropriate positioning of the upper ureteral stent. The distal ureteral stent was not imaged. There are no abnormally dilated loops of large or small bowel. Osseous structures are unremarkable. IMPRESSION: Static images of a retrograde place right ureteral stent with contrast seen filling the right renal pelvis. There appears to be appropriate positioning of the upper ureteral stent. The distal ureteral stent was not imaged.

19986230-RR-48

RR

2188-12-13 20:36:00

2188-12-13 21:02:00

INDICATION: ___ year old woman with postop fever// eval for atelectasis TECHNIQUE: Portable chest x-ray COMPARISON: Chest x-ray ___ FINDINGS: There is no consolidation. Minimal atelectasis is seen at the right lung base. There are no large pleural effusions. There are low lung volumes. Cardiomediastinal silhouette is similar to previous. The trachea is midline. IMPRESSION: Low lung volumes. Minimal atelectasis right base.

19986309-RR-5

RR

2117-06-01 09:01:00

2117-06-01 10:48:00

EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ male with history of lung cancer and brain metastasis presenting with new subarachnoid hemorrhage concerning for new metastatic lesion. TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 9 mL of Gadavist intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: ___ head and neck CTA. FINDINGS: There is extensive bilateral background cortical siderosis consistent with prior subarachnoid hemorrhages. There is sulcal FLAIR hyperintensity within the right central sulcus, precentral sulcus, and superior frontal sulcus with corresponding leptomeningeal enhancement. There is a small focus of leptomeningeal enhancement at the posterior left frontal superior gyrus (100:94). There is extensive bilateral confluent periventricular and subcortical white matter FLAIR hyperintensity consistent with sequela of chronic microangiopathy. There is no acute infarct follow mass, or mass effect. There is prominence of the ventricles and cortical sulci consistent with volume loss. The vasculature is patent. The orbits, calvarium, and soft tissues are unremarkable. There is mild mucosal thickening within the frontal and ethmoid sinuses. The mastoid air cells and middle ears are clear. IMPRESSION: 1. Sulcal FLAIR hyperintensity and leptomeningeal enhancement involving the right central, precentral and superior frontal sulci. Additional focus of leptomeningeal enhancement at the left frontal superior gyrus. Findings may represent reactive changes secondary to subarachnoid hemorrhage versus leptomeningeal carcinomatosis, given clinical history of lung cancer. Consider correlation with CSF cytology and/or follow up imaging to characterize the evolution of these findings. 2. Extensive bilateral cortical siderosis consistent with prior subarachnoid hemorrhages. 3. No discrete parenchymal lesion.

19986309-RR-6

RR

2117-06-01 08:29:00

2117-06-01 10:45:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old man with prior SCLC with new SAH // mass? infection TECHNIQUE: PA and lateral chest radiographs. COMPARISON: None available FINDINGS: The lungs are mildly hyperinflated. The cardiomediastinal contour is within normal limits. The heart is not enlarged. There is a slightly prominent epicardial fat pad along the right heart border. No consolidation, pneumothorax or pleural effusion seen. There are moderately severe multilevel degenerative changes in the thoracic spine. IMPRESSION: No acute cardiopulmonary process seen. The lungs appear mildly hyperinflated.

19986341-RR-40

RR

2169-10-13 18:51:00

2169-10-13 20:06:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: History: ___ with new SOB eval PNA/CHF// History: ___ with new SOB eval PNA/CHF TECHNIQUE: Upright AP view of the chest COMPARISON: Chest radiograph ___ FINDINGS: Patient is status post median sternotomy, aortic valve replacement and CABG. Heart size is moderate to severely enlarged, somewhat accentuated due to lower lung volumes. The mediastinal and hilar contours are unchanged. Crowding of bronchovascular structures is present due to low lung volumes with possible mild pulmonary vascular congestion, but no frank pulmonary edema. Minimal blunting of the left costophrenic angle suggests a trace pleural effusion. Retrocardiac atelectasis is noted without focal consolidation. No pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes with mild retrocardiac atelectasis and trace left pleural effusion. Possible mild pulmonary vascular congestion without frank pulmonary edema.