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19990545-RR-25

RR

2139-10-12 12:03:00

2139-10-12 17:18:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with fevers and n/v/abdominal pain // r/o infection r/o infection IMPRESSION: There are no prior chest radiographs available. Study is read in conjunction with images of the lower chest on an abdomen CT ___. The heart is mildly enlarged. Worsened consolidation left lower lobe could be new pneumonia or atelectasis. Previous small pleural effusions are probably still present. Upper lungs are clear.

19990545-RR-26

RR

2139-10-14 13:03:00

2139-10-14 16:32:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with fevers and increased wbc count // r/o pneumonia r/o pneumonia IMPRESSION: Heart size and mediastinum are stable. New right middle lobe opacity mA also potentially represent focus of infection. Left basal consolidation on the other hand has improved. There is minimal amount of left pleural effusion suspected. There is no pneumothorax.

19990545-RR-27

RR

2139-10-15 18:03:00

2139-10-15 21:55:00

EXAMINATION: CT abdomen and pelvis with contrast INDICATION: ___ year old woman with know acute cholecystitis s/p ERCP induced pancreatitis and ? perforation. Now with low grade fevers and rising WBC. Thank you // please evaluate for interval change in know peritonitis, retroperitoneal fluid collection, air and inflammation, ascites. Please evaluate for possible right PNA. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Total DLP (Body) = 808 mGy-cm. COMPARISON: CT abdomen ___. Abdominal ultrasound ___. FINDINGS: LOWER CHEST: Small bilateral pleural effusions, further evaluated on the concurrently performed although separately dictated CT chest. 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 contains gallstones without significant pericholecystic fat stranding or gallbladder wall thickening. 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. GASTROINTESTINAL: The stomach is unremarkable. There is redemonstration of retroperitoneal, extraluminal fluid and air, centered posterior to the second portion the duodenum, and extending inferiorly along the right perirenal space These are again most consistent with perforation of the duodenum, without defect identified. There are multiple, likely communicating organizing fluid collections throughout the abdomen, most pronounced in the right hemi abdomen with new rim enhancement. The largest pocket measures approximately 5.8 x 2.6 cm in the right lower abdomen (2:80). Additionally, there is enhancement of the peritoneum, likely reflecting a degree of peritonitis. Multiple small hyperdensities are identified within the ascending colon, which may reflect intraluminal gallstones, potentially related to gallstone ileus. There is mild gaseous and fluid distention of multiple small bowel loops up to 2.4 cm, with multiple air-fluid levels, further suggestive of ileus. Mildly prominent fluid-filled loops of small bowel may reflect a reactive ileus. Persistent thickening of the partially decompressed ascending and descending colon may reflect inflammatory change. The appendix is not visualized. PELVIS: The urinary bladder and distal ureters are unremarkable. There is moderate free fluid within the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. 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. Unchanged extraluminal retroperitoneal air and fluid posterior to the second portion of the duodenum and extending throughout the right perirenal space, remaining suggestive of duodenum perforation. 2. Moderate free fluid throughout the abdomen pelvis is slightly increased from prior with new rim enhancement suggestive of organizing fluid collections/ early abscess formation. New peritoneal enhancement, particularly in the pelvis, suggestive of peritonitis. 3. Mildly prominent small bowel loops with air-fluid levels are suggestive of reactive ileus. 4. Probable reactive colonic mucosal thickening. 5. No definite CT evidence of acute cholecystitis.

19990545-RR-28

RR

2139-10-15 18:23:00

2139-10-15 21:21:00

EXAMINATION: CT CHEST W/CONTRAST INDICATION: Fevers, evaluation for pneumonia. TECHNIQUE: MD CT axial imaging of the chest following intravenous administration of contrast using split bolus technique a conjunction with a CT of the abdomen and pelvis. Multiplanar reformatted images are provided. DOSE: Total DLP (Body) = 808 mGy-cm. COMPARISON: CT abdomen and pelvis ___. Abdominal ultrasound ___. FINDINGS: FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: Thyroid appears unremarkable. Multiple nonenlarged axillary lymph nodes are seen bilaterally. Punctate macrocalcification within the right breast is noted. UPPER ABDOMEN: Please refer to the report from the concurrent CT scan of the abdomen and pelvis for intra-abdominal findings. MEDIASTINUM: No lymphadenopathy or hemorrhage. HILA: No lymphadenopathy. HEART and PERICARDIUM: Trace pericardial fluid. Heart size is within normal limits. PLEURA: Small bilateral pleural effusions, decreased from prior. LUNG: -PARENCHYMA: Mild right lower lobe enhancing atelectasis may reflect relaxation atelectasis. Superimposed infection is not definitively excluded although is felt to be less likely. -AIRWAYS: The airways are patent to the subsegmental bronchi bilaterally. -VESSELS: Aorta and great vessel origins appear normal. Pulmonary arteries appear unremarkable. CHEST CAGE: Normal. No evidence of osseous abnormality. IMPRESSION: Small bilateral pleural effusions, decreased from prior, with improving mild right lower lobe atelectasis. Superimposed pneumonia is felt to be less likely.

19990545-RR-29

RR

2139-10-16 09:23:00

2139-10-16 20:50:00

EXAMINATION: CT-guided drainage INDICATION: ___ s/p ERCP c/b duodenal perforation n/w RP abscess // RIGHT retroperitoneum COMPARISON: CT from ___ PROCEDURE: CT-guided drainage of a retroperitoneal and pelvic collections. OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees 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 left lateral position on the CT scan table. Limited preprocedure CT scan was performed to localize the retroperitoneal collection. Based on the CT findings an appropriate skin entry site for the drain placement was chosen. The site was marked. Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the retroperitoneal collection below the level of the right kidney. A 0.038 ___ wire was placed through the needle. Attempts were made to manipulate the wire superiorly into the retro duodenum aspect of the collection, which was not successful. The needle was removed in the ___ wire was left in place and secured to the skin with a Tegaderm. Manipulation of the wire will be continued under fluoroscopic guidance. Additionally, the patient was placed supine and under CT fluoroscopic guidance, an 18 gauge ___ needle was inserted into the the pelvic collection from an anterior approach. A ___ wire was placed through the needle and the needle was exchanged for a 6 ___ catheter. 20 cc of dark red/yellow fluid was aspirated and sent for microbiology. The catheter was secured in place with sutures and a stat lock device. DOSE: Acquisition sequence: 1) Spiral Acquisition 14.1 s, 43.0 cm; CTDIvol = 11.8 mGy (Body) DLP = 491.9 mGy-cm. 2) Stationary Acquisition 5.1 s, 1.4 cm; CTDIvol = 52.7 mGy (Body) DLP = 75.9 mGy-cm. 3) Spiral Acquisition 14.1 s, 43.0 cm; CTDIvol = 14.9 mGy (Body) DLP = 622.5 mGy-cm. 4) Stationary Acquisition 3.3 s, 1.4 cm; CTDIvol = 33.9 mGy (Body) DLP = 48.8 mGy-cm. 5) Spiral Acquisition 5.6 s, 17.1 cm; CTDIvol = 18.1 mGy (Body) DLP = 284.6 mGy-cm. Total DLP (Body) = 1,548 mGy-cm. SEDATION: General anesthesia was provided by anesthesiology. FINDINGS: Limited intraoperative fluoroscopic CT demonstrated the ___ wire coiled within the inferior aspect of the right retroperitoneal collection. Additional intra procedural fluoroscopic CT demonstrated the 6 ___ catheter in appropriate position within the pelvis. IMPRESSION: Successful CT-guided placement of a 6 ___ catheter within the pelvic fluid collection. ___ wire was placed within the inferior aspect of the right retroperitoneal fluid collection. The patient will be moved into the angiography suite for further manipulation and placement of a retroduodenal drain.

19990545-RR-31

RR

2139-10-16 12:45:00

2139-10-16 16:41:00

INDICATION: ___ year old woman with wire in place into abscess. request into duodenal perf area. continuation of CT procedure // ___ year old woman with wire in place into abscess. request into duodenal perf area. continuation of CT procedure ; ___ s/p ERCP c/b duodenal perforation n/w RP abscess // ? superinfected pelvic ascites COMPARISON: CT of the abdomen from ___ TECHNIQUE: OPERATORS: Dr. ___, performed the procedure. ANESTHESIA: General MEDICATIONS: None CONTRAST: 10 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 9.5 min, 54 mGy PROCEDURE: 1. Repositioning of wire placed under CT guidance from the retroperitoneal abscess into the retro duodenum region 2. Placement of 8 ___ biliary drain over wire with pigtail formed in the retro duodenum region 3. Upper GI series through NG tube to evaluate for persistent duodenum perforation 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 ___ from the CT scanner and placed left side down on the table. A pre-procedure time-out was performed per ___ protocol. The patient's existing wire which was placed under CT guidance was prepped and draped in the usual sterile fashion. Then a Kumpe the catheter was introduced over the wire. The ___ wire was removed and a Glidewire were utilized to navigate slowly up the abcesses tract into the retro duodenual area. At this point, the copy was placed over the Glidewire the Glidewire removed. A small contrast injection was performed which delineated the abscess tract, but the decision was made to utilize a cone beam CT to assure positioning as this catheter was to be use for surgical guidance. Rotational cone-beam CT was performed to help delineate the anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered images of the abscess anatomy required post-processing on an independent workstation under direct physician ___. These images were used in the interpretation, decision making for intervention and reporting of this procedure. Once confirmed in appropriate position, an Amplatz wire was placed through the Kumpe the catheter. The copy was removed and an 8 ___ biliary catheter was placed. The pigtail was formed and locked. The catheter was secured to the skin with 0 silk sutures and placed to drainage bag. Then, attention was turned to the requested upper GI fluoroscopic examination for leak. Contrast is administered through the existing NG tube, and the patient was turned right-side-down order to assist drainage. Despite this, contrast with only passed to the first portion the duodenum. No contrast was seen passing into the retroperitoneal space nor into the third or fourth portions of the duodenum. The lack of passage of contrast was likely due to edema around the area. No definitive leak was identified. The patient tolerated the procedure well and was returned to the PACU for ongoing care. FINDINGS: 1. The existing CT-guided wire placement in a retroperitoneal abscess collection 2. Successful navigation of the catheter up the retroperitoneal abscess collection into the retroduodenal area 3. Placement of a 8 ___ biliary drain in the retroduodenal area 4. No definitive visualization of a duodenal leak from the upper GI series however limited overall evaluation given that contrast would not passed through the second portion of the duodenum, likely secondary to edema in this area. IMPRESSION: Successful placement of 8 ___ biliary drain into the retro duodenal area for source control as well as for operative guidance as requested by the surgical team

19990545-RR-32

RR

2139-10-16 12:46:00

2139-10-16 16:41:00

INDICATION: ___ year old woman with wire in place into abscess. request into duodenal perf area. continuation of CT procedure // ___ year old woman with wire in place into abscess. request into duodenal perf area. continuation of CT procedure ; ___ s/p ERCP c/b duodenal perforation n/w RP abscess // ? superinfected pelvic ascites COMPARISON: CT of the abdomen from ___ TECHNIQUE: OPERATORS: Dr. ___, performed the procedure. ANESTHESIA: General MEDICATIONS: None CONTRAST: 10 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 9.5 min, 54 mGy PROCEDURE: 1. Repositioning of wire placed under CT guidance from the retroperitoneal abscess into the retro duodenum region 2. Placement of 8 ___ biliary drain over wire with pigtail formed in the retro duodenum region 3. Upper GI series through NG tube to evaluate for persistent duodenum perforation 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 ___ from the CT scanner and placed left side down on the table. A pre-procedure time-out was performed per ___ protocol. The patient's existing wire which was placed under CT guidance was prepped and draped in the usual sterile fashion. Then a Kumpe the catheter was introduced over the wire. The ___ wire was removed and a Glidewire were utilized to navigate slowly up the abcesses tract into the retro duodenual area. At this point, the copy was placed over the Glidewire the Glidewire removed. A small contrast injection was performed which delineated the abscess tract, but the decision was made to utilize a cone beam CT to assure positioning as this catheter was to be use for surgical guidance. Rotational cone-beam CT was performed to help delineate the anatomy. Multiplanar CT images were reconstructed and 3D volume-rendered images of the abscess anatomy required post-processing on an independent workstation under direct physician ___. These images were used in the interpretation, decision making for intervention and reporting of this procedure. Once confirmed in appropriate position, an Amplatz wire was placed through the Kumpe the catheter. The copy was removed and an 8 ___ biliary catheter was placed. The pigtail was formed and locked. The catheter was secured to the skin with 0 silk sutures and placed to drainage bag. Then, attention was turned to the requested upper GI fluoroscopic examination for leak. Contrast is administered through the existing NG tube, and the patient was turned right-side-down order to assist drainage. Despite this, contrast with only passed to the first portion the duodenum. No contrast was seen passing into the retroperitoneal space nor into the third or fourth portions of the duodenum. The lack of passage of contrast was likely due to edema around the area. No definitive leak was identified. The patient tolerated the procedure well and was returned to the PACU for ongoing care. FINDINGS: 1. The existing CT-guided wire placement in a retroperitoneal abscess collection 2. Successful navigation of the catheter up the retroperitoneal abscess collection into the retroduodenal area 3. Placement of a 8 ___ biliary drain in the retroduodenal area 4. No definitive visualization of a duodenal leak from the upper GI series however limited overall evaluation given that contrast would not passed through the second portion of the duodenum, likely secondary to edema in this area. IMPRESSION: Successful placement of 8 ___ biliary drain into the retro duodenal area for source control as well as for operative guidance as requested by the surgical team

19990545-RR-33

RR

2139-10-17 15:38:00

2139-10-17 15:59:00

INDICATION: ___ year old woman with picc // s/p r 40cm ___ ___ Contact name: ___: ___ TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: There has been interval placement of a right PICC line whose tip projects over the right atrium. Retraction by approximately 1.6 cm would place the tip in the region of the cavoatrial junction. Low bilateral lung volumes. Mild left basilar atelectasis, unchanged. No large pleural effusion or pneumothorax is identified. The size of the cardiac silhouette is enlarged but unchanged. A catheter projects over the lower mid abdomen. IMPRESSION: Interval placement of a right PICC line whose tip projects over the right atrium and retraction by approximately 1.6 cm would place the tip in the region of cavoatrial junction. Mild left basilar atelectasis.

19990545-RR-34

RR

2139-10-22 05:51:00

2139-10-22 10:19:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman w/ continued fever episdoes // ? infectious processes, ? PNA ? infectious processes, ? PNA IMPRESSION: In comparison with the study of ___, the patient has taken a better inspiration. The right subclavian PICC line is been pulled back so that the tip is at the midportion of the SVC. No evidence of acute pneumonia or vascular congestion. Of incidental note is a

19990545-RR-35

RR

2139-10-24 11:39:00

2139-10-24 14:39:00

EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ year old woman post ERCP pancreatitis c/b duodo perforation and RP fluid collection pod ___ s/p ___ drain placement // RP fluid collection ?progression TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following administration of 130 cc of Omnipaque with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 1.0 s, 0.5 cm; CTDIvol = 4.8 mGy (Body) DLP = 2.4 mGy-cm. 2) Spiral Acquisition 5.0 s, 54.9 cm; CTDIvol = 12.4 mGy (Body) DLP = 677.9 mGy-cm. Total DLP (Body) = 680 mGy-cm. COMPARISON: CT abdomen and pelvis ___ FINDINGS: LOWER CHEST: There is mild bibasilar dependent atelectasis. No pleural effusions. Mild cardiomegaly. Partially imaged small pericardial effusion appears grossly similar to ___. ABDOMEN: HEPATOBILIARY: The liver is diffusely hypoattenuating relative to the spleen, suggestive of fatty infiltration (2:21). There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. There is cholelithiasis. Air within the gallbladder and CBD are likely a result of recent sphincterotomy. 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. No hydronephrosis. Tiny hypodensity in the interpolar region of the right kidney is too small to characterize, but statistically likely represents a cyst (2:41). No parenchymal lesions are identified on the left. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Apparent wall thickening of the descending and sigmoid colon are likely due to under distention (2:46,77). Colon and rectum are otherwise unremarkable. The appendix is not visualized. Since the prior study performed on ___, there has been interval placement of a pigtail catheter into a retroperitoneal fluid collection. The superior aspect of the fluid collection located adjacent to the pancreatic head/second part of the duodenum has decreased in size from 4.0 x 2.3 cm to 3.4 x 2.1 cm on the current study (2:36). More inferiorly shortly after the catheter enters the peritoneal cavity, the collection has also decreased from 5.8 x 2.6 cm to 4.3 x 1.4 cm (2:54). However, remainder of the multiloculated fluid collections in the right perirenal space are not significantly changed in size. For instance, the fluid measures approximately 6.3 x 1.2 cm TV x AP anterior to the right kidney (2:40), and 3.8 x 1.9 cm posteriorly (2:42), which are similar to prior. Degree of surrounding rim enhancement is unchanged. Free fluid in the abdomen and pelvis that was noted on the prior study has essentially resolved. There is a fluid collection adjacent to the left adnexa that now appears newly organized, measuring 3.7 x 1.9 cm (2:73), may represent walled-off ascites. A crescent-shaped fluid collection abutting the posterior uterine wall is slightly smaller (2:74). PELVIS: The urinary bladder and distal ureters are unremarkable. REPRODUCTIVE ORGANS: Uterus is unremarkable in appearance. Hypodensity in the region of the endometrial canal is nonspecific in a premenopausal woman, and may represent hemorrhagic products. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Subcutaneous soft tissue nodule in the right gluteal region may represent an injection granuloma (2:86). Abdominal and pelvic wall is otherwise within normal limits. IMPRESSION: 1. Interval placement of a pigtail catheter, with resulting decrease in size of the retroperitoneal fluid collection along its course. 2. However, remainder of the small multiloculated perirenal fluid collections on the right are unchanged in size. 3. Within the pelvis, a new 3.7 x 1.9 cm organized collection in the region of the left adnexa could represent walled-off ascites. Fluid collection along the posterior uterine wall has decreased. 4. Fatty infiltration of the liver. 5. Trace pericardial effusion, grossly unchanged.

19990545-RR-36

RR

2139-10-25 15:18:00

2139-10-25 16:53:00

EXAMINATION: CT-guided right perinephric collection drainage/pigtail catheter placement. INDICATION: ___ year old woman with post ERCP pancreatitis c/b RP fluid collection s/p drain placement now with growing and increasingly organized pelvic fluid collection. // Growing and organizing fluid collection in pelvis COMPARISON: CT of the abdomen and pelvis ___ PROCEDURE: CT-guided drainage of right perinephric collection. OPERATORS: Dr. ___ trainee and Dr. ___ radiologist. Dr. ___ supervised the trainee during the key components of the procedure and reviewed and agrees 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 prone position on the CT scan table. Limited preprocedure CT scan was performed to localize the collection. Based on the CT 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 intermittent CT fluoroscopic guidance, an 18-G ___ needle was inserted into the collection. A 1cc sample of fluid was aspirated, confirming needle position within the collection. 0.038 ___ wire was placed through the needle and needle was removed. This was followed by placement of ___ Exodus pigtail catheter into the collection. The plastic stiffener and the wire were removed. The pigtail was deployed. The position of the pigtail was confirmed within the collection via CT fluoroscopy. Approximately 1 cc of purulent fluid was aspirated with a sample sent for microbiology evaluation. AN additional 5cc was aspirated from the collection. The catheter was secured by a StatLock. The catheter was attached to suction bulb. 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 Versed and fentanyl throughout the total intra-service time of 15 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: Preprocedure CT re- demonstrates a perinephric collection. Intra procedure CT demonstrates appropriate positioning of the needle. Postprocedure CT demonstrates appropriate positioning of the pigtail catheter. IMPRESSION: Successful CT-guided placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation.

19990545-RR-41

RR

2140-03-03 12:35:00

2140-03-03 13:58:00

INDICATION: ___ year old woman with hx CBD stones, post-ERCP pancreatitis, duodenal rupture with subsequent RP abscess p/w increased abdominal pain// Eval for evidence perforation (free air) TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: ___ FINDINGS: There is a nonobstructive bowel gas pattern. No large air-fluid levels are seen. There is no evidence of free air. Right upper quadrant surgical clips are from presumed cholecystectomy. The lung bases are grossly clear. IMPRESSION: No bowel obstruction or free air.

19990545-RR-44

RR

2140-03-04 08:16:00

2140-03-04 18:50:00

EXAMINATION: MRCP INDICATION: ___ year old woman s/p ERCP with microperf of duodenum ___ s/p CCY ___ episodic spasms of severe pain// rule out biliary anatomy abnormality TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: 6 mL Gadavist. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: CT abdomen pelvis dated ___. And ___. FINDINGS: Lower Thorax: No pleural effusion or focal consolidation. Liver: The liver is normal in size and signal intensity. There is no enhancing focal liver lesion identified. Biliary: Patient is post prior the ERCP with history of micro perforation of the duodenum. There is no intrahepatic or extrahepatic biliary ductal dilatation. Pneumobilia is noted. Pancreas: Pancreas is normal in bulk and signal intensity. The pancreatic duct is normal in caliber. There is no peripancreatic stranding to suggest acute pancreatitis. No evidence of contrast extravasation to suggest bile leak. Spleen: Spleen is normal in size and signal intensity. Adrenal Glands: These renal glands are normal. Kidneys: The left and right kidneys are normal in size. There is no hydronephrosis or focal enhancing renal lesion identified. Gastrointestinal Tract: Visualized loops of bowel are normal in caliber. There is no evidence of bowel obstruction. Lymph Nodes: No lymphadenopathy Vasculature: Visualized vessels are patent. No abdominal aortic aneurysm. Osseous and Soft Tissue Structures: No suspicious bone lesion is identified. IMPRESSION: 1. Post prior ERCP with history of microperforation of the duodenum. No intrahepatic or extrahepatic biliary ductal dilatation. Pneumobilia is present. 2. No evidence of biliary leak.

19990786-RR-81

RR

2154-11-02 11:40:00

2154-11-02 12:40:00

EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY INDICATION: History: ___ with chest pain, eval for PE // eval for PE or aortic dissection TECHNIQUE: Axial multidetector CT images were obtained through the thorax after the uneventful administration of 100 cc of Omnipaque intravenous contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique maximal intensity projection images were submitted to PACS and reviewed. DOSE: DLP: 495.72 mGy-cm COMPARISON: None available. FINDINGS: The aorta and its major branch vessels are patent, with no evidence of stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present. Note is made of a bovine aortic arch. The pulmonary arteries are well opacified to the subsegmental level, with no evidence of filling defect within the main, right, left, lobar, segmental or subsegmental pulmonary arteries. The main and right pulmonary arteries are normal in caliber, and there is no evidence of right heart strain. There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is no pleural effusion. The heart is not enlarged. Note is made of coronary artery calcifications. Debris is seen within the upper trachea. There is mild dependent atelectasis bilaterally. No pneumothorax or pleural effusion. No concerning pulmonary nodules are identified. There is a small hiatal hernia. Few small gallstones are present. Limited images of the upper abdomen are unremarkable. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Small hiatal hernia. 3. Cholelithiasis.

19991085-RR-17

RR

2125-01-02 09:22:00

2125-01-02 12:53:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new lymphoma diagnosis. // Patient has a pacemaker and will need a spinal MRI. We need to check where there is any other hardward besides the pacemaker in her chest prior to the MRI TECHNIQUE: Portable chest COMPARISON: ___ FINDINGS: Compared to the prior study there is no significant interval change. There is a dual lead pacemaker with the leads projecting over the expected location. No other radiopaque foreign bodies are visualized.The cardiac and mediastinal silhouettes are normal and are unchanged compared to prior.

19991085-RR-18

RR

2125-01-02 16:36:00

2125-01-03 08:37:00

EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with newly diagnosed lymphoma chronic neurological finding suggesting possible brain involvement, and PET finding suggesting cord impingement. // Concern for spread of lymphoma to brain (based on exam findings) and cord and for cord compression (based on exam and PET findings). TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of 10 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: ___ whole-body PET-CT. FINDINGS: There is motion artifact which degrades image quality particularly on the pre and postcontrast axial T1, postcontrast MP rage, and axial T2 sequences. There is diffuse leptomeningeal pachymeningeal nodular enhancing disease consistent with lymphoma, as follows: There is nodular extra-axial enhancing disease at the anterior left frontal operculum (30 01:15), anterior parafalcine left frontal cortex (___), suprasellar cistern, ambient cistern, cerebellopontine angles, fourth ventricle, and posterior cranial fossa base. There is diffuse nodular enhancement coating the posterior fossa structures including the midbrain, pons, medulla, and visualized upper cervical spine. There is enhancing disease involving the expected course of multiple cranial nerve courses, foramen of Luschka and Magendie, however the fine detail is obscured by motion artifact. There is enhancing disease within the right internal auditory canal, indicated leptomeningeal disease. There is mass like enhancing disease within the spinal canal at the C3 level which extends across the near entirety of the spinal canal either infiltrating or compressing the traversing cervical cord and producing spinal cord edema. This measures 1.0 cm x 1.7 by 1.1 cm (101:20). There is no acute hemorrhage, territorial infarct, or shifting of the normally midline structures. The ventricles are unremarkable. The orbits and soft tissues are unremarkable. The paranasal sinuses and mastoid air cells are clear. There is diffuse T1 hypointensity of the calvarial marrow. IMPRESSION: 1. Study is limited by motion artifact, as described, limiting the spatial resolution. 2. Diffuse nodular enhancing disease involving the leptomeningeal and pachymeningeal extra-axial spaces, as described, predominantly within the basal cisterns consistent with intracranial lymphoma. 3. Mass like enhancing disease within the visualized upper cervical canal from C1 through C3 levels, which may be compressing or infiltrating the adjacent cervical cord. 4. Low signal within the cranial marrow which is nonspecific and may be seen with hematopoetic marrow or infiltration. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 9:18 AM, 10 minutes after discovery of the findings.

19991085-RR-19

RR

2125-01-02 16:37:00

2125-01-03 09:18:00

EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE INDICATION: ___ female with newly diagnosed lymphoma experiencing chronic neurological deficits. Prior PET-CT suspicious for cord impingement. TECHNIQUE: Patient with a cardiac device therefore is seen in consultation by electrophysiology cardiology and radiology. Patient was explained the risks and benefits of MR imaging in the setting of a cardiac device and signed informed consent. A limited cardiac device protocol was utilized with low SAR, with sagittal T2, stir, T1, and postcontrast T1 imaging. Axial postcontrast T1 imaging was performed. Postcontrast imaging was obtained following the uneventful intravenous administration of Gadavist, gadolinium base contrast. COMPARISON: ___ whole-body PET-CT. FINDINGS: CERVICAL: There is motion artifact which limits spatial resolution. There is normal cervical alignment. The vertebral body heights and marrow signal are preserved. The intervertebral disc spaces demonstrate normal signal height. There are mild degenerative changes without significant neural foraminal stenosis. There is diffuse thin leptomeningeal postcontrast enhancement consistent with carcinomatosis. There is more nodular enhancing disease as follows: There is a 0.8 AP by 1.1 TV by 1.1 SI cm enhancing mass at the left lateral aspect of the nodule cervical junction at the foramen magnum which mildly deforms the traversing cord. There is a large 2.0 TV by 1.1 AP by 1.1 SI cm enhancing mass centered at the left lateral aspect of the spinal canal at the C3 level which severely narrows the spinal canal compressing and displacing the traversing cord to the right with associated underlying cord T2 signal hyperintensity extending from C1-C2 to the C4 levels (15:19). THORACIC: There is a normal thoracic alignment the vertebral body heights and marrow signal are preserved. The intervertebral disc spaces demonstrate preserved height. There are mild degenerative changes without significant neural foraminal stenosis. There is nodular enhancing intradural extramedullary disease at the right lateral aspect of the thoracic spinal canal centered at the T8 level measuring 1.0 AP by 0.5 T the by 2.1 SI cm which mildly deforms and leftward displaces the traversing cord. There is no definitive intrinsic cord signal T2 hyperintensity on sagittal T2 and STIR sequences. There is diffuse trace leptomeningeal enhancement throughout the remainder of the thoracic spinal canal. LUMBAR: There is normal lumbar alignment. The vertebral body heights are preserved. There is a T1 hypointense, T2 hyperintense, enhancing circumscribed lesion within the anterior aspect of the S2 vertebral body measuring 8 mm (12:13). There is there is low signal within the T12-L1, L4-L5, and L5-S1 intervertebral disc spaces. The conus terminates appropriately at the L1 level. There is diffuse nodular enhancing leptomeningeal disease throughout the visualized conus and cauda equina without definitive cord or nerve root compression. There are mild degenerative changes without significant neural foraminal stenosis. There are prominent bilateral iliac chain lymph nodes measuring up to 7 mm in short axis on the right (17:34) and 9 mm in short axis on the left (17:41). IMPRESSION: 1. Motion artifact which limits space resolution of this study. 2. Diffuse total spine leptomeningeal carcinomatosis consistent with lymphoma. 3. More focal areas of nodular masslike enhancing disease, as described, with large 2 cm lesion at the C3 level severely compressing the traversing cervical cord causing intrinsic cord edema. 4. Enhancing lesion within the S2 vertebral body which may represent metastatic osseous disease. 5. Prominent bilateral iliac chain lymph nodes, as described. NOTIFICATION: Results discussed with Dr. ___ by Dr. ___ at ___ on ___ via telephone 5 minute after discovery.

19991085-RR-22

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2125-01-02 22:55:00

2125-01-02 23:48:00

EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT INDICATION: ___ year old woman with likely new lymphoma diagnosis. She has no tissue diagnosis yet, but she has brain and spinal cord involvement that may require emergent steroid treatment which would obliterate any path diagnosis. Thus, she requires an emergent excisional lymph node biopsy to preserve the chance of accurate diagnosis. Patient needs excisional lymph node biopsy, and surgery is asking that the right lymph node be marked by ultrasound. TECHNIQUE: Grayscale ultrasound images were obtained of the superficial tissues of the right groin. COMPARISON: FDG PET dated ___. FINDINGS: Transverse and sagittal images were obtained of the superficial tissues of the right groin demonstrates multiple normal-appearing lymph nodes, largest measures 0.8 in short axis with a normal central fatty hilum and normal cortex. No enlarged abnormal appearing lymph node identified. IMPRESSION: 1. No abnormal right groin lymph node identified for marking. 2. Few normal-appearing right groin lymph nodes. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 11:46 ___, 5 minutes after discovery of the findings.

19991085-RR-23

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2125-01-03 21:15:00

2125-01-04 08:21:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with lymphadenopathy s/p mediastinoscopy with biopsy // postop; any pneumo? TECHNIQUE: Portable chest ___. FINDINGS: There is subsegmental atelectasis in both lower lungs. There is no pneumothorax. The appearance of the dual lead pacemaker is unchanged. The upper lungs are clear

19991085-RR-24

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2125-01-07 13:01:00

2125-01-11 10:53:00

EXAMINATION: HAND (PA,LAT AND OBLIQUE) BILATERAL INDICATION: ___ year old woman with probable sarcoid vs lymphoma // Eval for cystic changes in the phalynx in a patient with likely Sarcoidosis COMPARISON: None. FINDINGS: Right hand: No definite focal lytic lesion to confirm the presence of sarcoid is identified. Subtle lucencies seen in the proximal phalanges of the middle and ring fingers remain relatively non-specific. Possible minimal narrowing and spurring at the first CMC joint consistent with osteoarthritis. Mild narrowing of multiple IP joints is also likely present. There is normal variant ulnar positive variance and accentuated angulation of the distal radial articular surface in the coronal plane (approximately 26 degrees). Mild degenerative spurring at the articulation of the radial styloid with the distal scaphoid and some bony ridging along the lateral aspect of the distal radius are noted. Left hand: No definite focal lytic lesion to confirm the presence of sarcoid is identified. Subtle lucencies seen in the proximal phalanges of the middle and ring fingers and middle phalanges of the ring and small fingers remain relatively non-specific. There is mild osteoarthritis of the first CMC joint and mild degenerative changes at the radioscaphoid articulation and multiple IP joints. Similar to the contralateral side, there is ulnar positive variance with accentuated angulation of the distal radial articular surface. IMPRESSION: Mild degenerative changes in both hands, worst at the left first CMC joint. No definite focal lytic lesion identified in either hand to confirm the presence of sarcoid. Subtle lucencies seen in the proximal phalanges of the middle and ring fingers in both hands and in the proximal phalanx of the index finger and middle phalanges of the ring and small fingers in the left hand remain relatively non-specific and could lie within the range of normal.

19991085-RR-25

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2125-01-08 09:12:00

2125-01-08 13:03:00

EXAMINATION: PELVIS U.S., TRANSVAGINAL INDICATION: ___ year old woman with diffuse lymphadenopathy seen on PET, CT and MRI of spine concerning for sarcoidosis based on biopsy however with ongoing concern for underlying malignancy, evaluate foci of uptake in the vagina and cervix seen on PET scan concerning for malignant foci. 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: PET CT ___. FINDINGS: The uterus is anteverted and measures 8.4 x 4.1 x 4.2 cm cm. The endometrium is homogenous and measures 3 mm. The ovaries are normal. No cervical abnormality is seen. The vaginal canal is not well evaluated. There is no free fluid. IMPRESSION: No abnormality identified in the cervix. Vaginal canal not well evaluated. RECOMMENDATION(S): Pelvic MRI can be considered to better evaluate the vaginal canal.

19991135-RR-153

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2133-07-04 05:15:00

2133-07-04 06:41:00

EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ with hypoxia, tachycardia, concern for PE// Pulmonary Embolism 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) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP = 7.6 mGy-cm. 2) Spiral Acquisition 4.8 s, 38.1 cm; CTDIvol = 11.7 mGy (Body) DLP = 445.6 mGy-cm. Total DLP (Body) = 453 mGy-cm. COMPARISON: CT chest ___. Chest radiograph ___ FINDINGS: HEART AND VASCULATURE: There are numerous filling defects, some of which are occlusive within the pulmonary vascular tree compatible with pulmonary emboli involving both segmental and subsegmental segments predominantly in the right lower, middle and upper lobes as well as the left lingular and lower lobes. Clot is seen as proximally as the right interlobar pulmonary artery. There is no definite bowing of the interventricular septum. However, the right ventricle does appear somewhat prominent, and clinical correlation is recommended for right heart strain. There is no pericardial effusion. Main pulmonary artery is dilated to 3.7 cm. There is also dilatation of the right and left main pulmonary arteries suggesting pulmonary arterial hypertension. The heart, pericardium and great vessels are otherwise within normal limits. Atrial appendage exclusion device. AXILLA, HILA, AND MEDIASTINUM: There is no axillary lymphadenopathy. There are prominent mediastinal lymph nodes, for example in the distal right paratracheal lymph node station measuring 10 mm (02:43). There is no mediastinal mass. PLEURAL SPACES: Trace left pleural effusion. Right apical pleuroparenchymal thickening/scarring. LUNGS/AIRWAYS: There are severe emphysematous changes, predominantly involving the upper lobes, which appear to have progressed in comparison to ___. Postsurgical changes noted in the right upper lung. There is a wedge-shaped region of heterogeneously enhancing soft tissue through the superior left lower lobe. Differential considerations include infection. Pulmonary infarction or atelectasis related to PEs felt to be less likely as no occlusive thrombi are seen to supply this region. There is diffuse bronchial wall thickening. This is seen on a background of diffuse ground-glass opacification which raises the interstitial pneumonitis. There is diffuse bronchial wall thickening and some mucous plugging. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. Thyroid gland is grossly normal. ABDOMEN: Included portion of the upper abdomen is unremarkable. Gallbladder is somewhat distended without evidence of fat stranding or wall edema. Partially visualized left renal cyst. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. Incidental note is made of a chronic healed rib fracture in the posterior right fifth rib. IMPRESSION: 1. Extensive filling defects in the pulmonary vascular tree compatible with pulmonary emboli. These are seen as proximal as the right intralobar artery. Emboli are seen at both the segmental and subsegmental level involving nearly every lobe, but predominantly in the lower lobes. 2. There is mild prominence of the right ventricle. Clinical correlation for right heart strain is recommended. 3. Dilation of the main pulmonary and right and left pulmonary arteries compatible with pulmonary hypertension. 4. Severe emphysematous changes. Ground-glass opacification is seen bilaterally which suggests interstitial pneumonitis. However, in the superior left upper lobe there is a more consolidative appearance favored to represent infection with atelectasis and infarction also considerations. 5. Trace left pleural effusion.

19991135-RR-154

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2133-07-04 21:21:00

2133-07-04 22:03:00

EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with submassive PE.// evaluate for DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: CTA chest ___ 05:24 FINDINGS: There is normal respiratory variation in the common femoral veins bilaterally. RIGHT LEG: There is normal compressibility, flow and augmentation of the common femoral, femoral and popliteal veins. There is lack of compressibility and flow in the calf veins. The gastrocnemius veins are involved as well. LEFT LEG: There is normal compressibility and flow in the common femoral vein. There is lack of compressibility of the superficial femoral vein. A subtle amount of flow is seen within this vessel. The left popliteal vein demonstrates normal flow and compressibility. There is lack of compressibility and flow in the calf veins. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: Nonocclusive deep venous thrombus in the left superficial femoral vein. In addition, there is lack of compressibility and flow in the bilateral calf veins compatible with occlusive deep venous thrombi. On the right, the gastrocnemius veins are involved as well.

19991135-RR-155

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2133-07-07 00:52:00

2133-07-07 10:36:00

INDICATION: ___ yo F with a sig PMHX of atrial fibrillation (on Coumadin), COPD on O2 (2L at rest, up to ___ with ambulation), frequent falls here w/ shortness of breath, dizziness, found to have submassive PE. Now with escalating O2 requirement.// Evidence of edema, consolidation or other etiology of worsening hypoxia? IMPRESSION: Left atrial appendage metallic clip is again seen. There is coarsening of bronchovascular markings, stable. No definite consolidation is seen. Thoracotomy changes on the upper right is again present. There are no pneumothoraces.

19991135-RR-156

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2133-07-07 08:49:00

2133-07-07 11:24:00

INDICATION: ___ year old woman with PE and worsening hypoxia// Pulm edema, PNA COMPARISON: CT scan from ___ and radiographs from 7 hours earlier. IMPRESSION: Metallic atrial appendage clip is again seen and projects over the left infrahilar region. Heart size is enlarged but stable. There are baseline coarse bronchovascular markings bilaterally related to patient's emphysema and scarring. There are areas of increased density within the left mid and lower lung fields which may represent superimposed pneumonia as suggested on the prior CT scan.

19991135-RR-157

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2133-07-08 08:01:00

2133-07-08 09:14:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with PE and history of emphysema and ?pneumonia with acute dyspnea// acute dyspnea acute dyspnea IMPRESSION: Compared to chest radiographs ___. Moderate pulmonary edema, more pronounced in the left lung, developed between ___ and ___, worsened slightly by at ___, is subsequently stable. Small bilateral pleural effusions have accumulated. No pneumothorax. Heart size normal. Atrial appendage clamp in place. Large lung volumes reflect emphysema. Healed posterior displaced right rib fracture, an incidental finding.

19991135-RR-158

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2133-07-08 09:44:00

2133-07-08 11:39:00

EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old woman with Right PICC// Right PICC 45cm, ___ ___ Contact name: ___: ___ Right PICC 45cm, ___ ___ IMPRESSION: Compared to chest radiographs ___ through ___ at 08:00. Mild pulmonary edema has improved, still more pronounced in the left lung, where there may be new consolidation in the left upper lobe sitting on the major fissure or there may be a small fissural fluid collection. Follow-up advised.. Diaphragmatic pleural surfaces are excluded from 58 of previous small dependent pleural effusions cannot be assessed. There is no pneumothorax. Heart size is normal and unchanged. New right PIC line ends at the origin of the SVC.

19991135-RR-159

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2133-07-11 10:56:00

2133-07-11 13:33:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with hx PEs and COPD here with higher O2 requirement and wheezing.// Look for pneumonia or other acute abnormalities IMPRESSION: In comparison with the study of ___, the area of focal opacification in the mid and lower lung zones on the left has substantially cleared. Cardiomediastinal silhouette and hyperexpansion of the lungs are stable. Some elevation of pulmonary venous pressure is again present, and the rib abnormality on the right is again noted.

19991805-RR-25

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2143-01-26 17:56:00

2143-01-26 23:59:00

EXAMINATION: CHEST RADIOGRAPH INDICATION: Worsening oxygen requirement and hypernatremia. History of dementia and recent pneumonia. TECHNIQUE: Chest, portable AP upright. COMPARISON: ___. FINDINGS: Patient is status post coronary artery bypass graft surgery. The cardiac, mediastinal and hilar contours appear unchanged including moderate cardiomegaly. What is new is bilateral opacification of each lung base, which is especially confluent in the retrocardiac region on the left. Particularly on the right, small coinciding pleural effusion is suspected. Indistinct pulmonary vasculature appears mildly distended suggesting coinciding vascular congestion. IMPRESSION: Substantial opacities at both lung bases, raising concern for pneumonia. Findings also suggest mild coinciding vascular congestion and possibly small pleural effusions.

19991805-RR-26

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2143-01-31 18:33:00

2143-01-31 21:27:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with coronary artery disease s/p CABG and PCI, congestive heart failure, and COPD/asthma who admitted with hypoxia and hypernatremia now with increased work of breathing. Growing MRSA in sputum but clinically without cough or fever to suggest PNA. Also has had diuretics held // evaluate for pulmonary edema or PNA evaluate for pulmonary edema or PNA IMPRESSION: In comparison with the study of ___, there has been increase in the bilateral pulmonary opacifications, consistent with moderate pulmonary edema. In the appropriate clinical setting, superimposed pneumonia cannot be excluded. Basilar opacifications are again consistent with small pleural effusions and atelectatic changes in this patient with stable enlargement of the cardiac silhouette.

19992202-RR-68

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2153-02-26 16:58:00

2153-02-26 19:21:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: Ms. ___ is a ___ w/ hx of CAD, stroke w/ residual cognitive deficits, bipolar disorder w/ psychotic features, HTN, asthma, hypothyroidism, multiple falls and other issues who presents from ___ with altered mental status, fever, leukocytosis, and an unwitnessed fall, with positive UA and GNR bacteremia. // Please assess for pulmonary edema/acute process COMPARISON: ___ IMPRESSION: The patient is substantially rotated. No evidence of larger pleural effusions. No pneumonia, no pulmonary edema. Moderate cardiomegaly.

19992365-RR-42

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2167-10-21 00:03:00

2167-10-21 01:18:00

INDICATION: ___ male with acute onset dyspnea and elevated D-dimer. TECHNIQUE: Axial multidetector CT scan from the upper chest to the diaphragm was performed following the administration of intravenous contrast. Multiplanar reformatted images in coronal and sagittal axis were generated. Oblique maximum intensity projection images were prepared and reviewed. Dose 379 mGy-cm COMPARISON: CT chest dated ___. FINDINGS: CT Thorax: The thyroid gland is within normal limits. The airways are patent to the subsegmental level. There is no mediastinal, hilar, or axillary lymph node enlargement by CT size criteria. The heart, pericardium and great vessels are within normal limits. No esophageal abnormality is identified. There is a small hiatal hernia noted. Moderate amount of coronary artery calcifications are noted in the aortic arch. Lung windows demonstrate centrilobular emphysema with multiple bilateral pulmonary nodules recently described on a dedicated CT dated ___. Ground-glass opacities along bilateral major fissures may reflect aspiration though deep dependent atelectasis is probable more likely. There is no pleural effusion. CTA Thorax: The aorta and main thoracic vessels are well opacified. The aorta demonstrates normal caliber throughout the thorax without evidence of dissection or aneurysmal dilatation. The pulmonary arteries are opacified to the subsegmental level. There is no filling defect to suggest pulmonary embolism. Osseous structures: No suspicious lytic or blastic lesions are identified. Although this study is not designed for assessment of the intra-abdominal visceral, the hepatic dome hypodensities are identified (2:87), stable since prior examination. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Centrilobular emphysema with multiple bilateral pulmonary nodules better described on recent dedicated CT dated ___. Recommend imaging followup in ___ months time. 3. Again identified are hepatic dome hypodensities incompletely characterized on this single phase examination.

19992365-RR-43

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2167-10-21 02:09:00

2167-10-21 02:24:00

EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with AMS, unable to stand. Able to stand previously // ICH, stroke TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: DLP: 1003 mGy-cm CTDI: 55 mGy COMPARISON: None. FINDINGS: In the left cerebellar hemisphere, there is a 2.4 x 2.8 cm intraparenchymal hemorrhage with surrounding edema. Mild mass effect is noted with effacement of the fourth ventricle. Note should be made that patient received intravenous contrast for a CTA chest on the same day approximately 2 hr previously accounting for enhanced vasculature. No additional hemorrhage is identified. There is no shift of normally midline structures. Ventricles and sulci are normal in size and configuration for patient's age. Basal cisterns are patent. Gray-white matter differentiation is preserved. Bilateral mucous retention cysts are noted in the maxillary sinuses. Partial opacification and mucosal thickening within the anterior ethmoidal cells as well as left frontal sinus is additionally seen. Extensive atherosclerotic calcifications are noted in the carotid siphon. Bilateral mastoid air cells and middle ear cavities are clear. No acute fracture is identified. IMPRESSION: 2.4 x 2.8 cm left cerebellar acute intraparenchymal hemorrhage with mild mass effect and effacement of the fourth ventricle. Correlate clinically for etiology and further workup. NOTIFICATION: Findings communicated immediately to the ordering physician ___. ___ by Dr. ___ telephone at 2:21 am on ___.

19992365-RR-44

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2167-10-21 10:13:00

2167-10-21 11:23:00

EXAMINATION: MR HEAD W AND W/O CONTRAST INDICATION: Ataxia of the left arm, gait and intermittent nystagmus on leftward gaze found to have left cerebellar hyperdensity. TECHNIQUE: Multiplanar, multi sequence MR images of the head were acquired on a 1.5 Tesla magnet prior to and after the uneventful intravenous administration of 7 cc Gadovist per routine protocol. COMPARISON: CTA head ___, noncontrast head CT ___. FINDINGS: There is re- demonstration of a 26 x 24 mm acute left cerebellar intraparenchymal hematoma with associated T2 prolongation and signal void on gradient echo. This hemorrhage is unchanged in size compared with earlier same day examination. Trace peripheral enhancement is likely related to the bleed. There is no definite underlying mass. Associated surrounding mass effect appears similar to the prior study with effacement of the fourth ventricle. Overall configuration of the ventricles and sulci is unchanged compared to the prior examination remaining prominent, likely secondary to age related involutional change. There is no hydrocephalus. There is mild surrounding vasogenic edema. Other scattered punctate foci of subcortical and deep white matter and T2 prolongation are nonspecific. There is no abnormal focus of diffusion restriction. T2 "dark through" effect is seen in the region of intraparenchymal hemorrhage on diffusion-weighted images. There is otherwise no definite focus of abnormal post gadolinium enhancement. There is no abnormality of the skull base or calvarium. The orbits, periorbital and paracavernous spaces are unremarkable. The major intracranial vascular flow voids are preserved. Mucosal wall thickening is noted in the bilateral frontal sinuses, bilateral ethmoid air cells, bilateral sphenoid air cells and bilateral maxillary sinuses. IMPRESSION: 1. No significant interval change of a 26 x 24 mm acute left cerebellar intraparenchymal hematoma with associated mass effect and effacement of the fourth ventricle. No definite underlying mass with trace peripheral post gadolinium enhancement likely secondary to bleed.

19992365-RR-46

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2167-10-21 10:03:00

2167-10-21 13:37:00

INDICATION: ___ year old man with cerebellar hemorrhage // eval for progression of bleed TECHNIQUE: CT without IV contrast; CT angiogram of the head with IV contrast COMPARISON: CT head ___ FINDINGS: CT HEAD WITHOUT IV CONTRAST: Stable left cerebellar acute hematoma, 2.8 x 3.3cm, with mild surrounding edema and mass effect on the left side of ___ ventricle, similar to the prior study done 8 hr earlier. Slightly increased density of the transverse sinuses on both sides and the tentorial leaflets similar to the prior study. No filling defect on CTA study to suggest thrombosis No hydrocephalus are low lying cerebellar tonsils. No new hemorrhage. Vascular calcifications the cavernous carotid segments. Small retention cyst/mild mucosal thickening in the anterior aspect of the right maxillary sinus, left side of the frontal and the right side of the sphenoid sinus. Mild to moderate ethmoidal mucosal thickening. The mastoid air cells are clear. No suspicious osseous lesions are noted. Incidental note of long styloid processes, left longer than right extending towards the parapharyngeal space. A few calcifications in the right palatine tonsil, likely from prior inflammation. Mildly prominent tonsils and adenoids. Evaluation of the level of the maxilla and mandible limited due to dental artifacts. CT ANGIOGRAM OF THE HEAD WITH IV CONTRAST The major intracranial arteries of the anterior and the posterior circulation are patent. No focal flow-limiting stenosis or occlusion or aneurysm more than 2 mm noted within the resolution of the study. A few nondilated vascular structures are noted in proximity to the left cerebellar hematoma and mildly displaced; these can relate to venous structures. The right posterior inferior cerebellar artery and left superior cerebellar artery are not well seen-? diminutive. The tip of the basilar artery is slightly tortuous in course as also the P1 segment of the right posterior cerebral artery. The posterior communicating arteries are faintly seen. The anterior communicating artery is not well seen. Vascular calcifications are noted in the distal vertebral arteries right more than left and in the cavernous carotid segments on both sides. IMPRESSION: 1. Stable 2.8x3.3cm left cerebellar acute hematoma, 2.8x3.3cm, with mild surrounding edema and mass effect on the left side of ___ ventricle, similar to the prior study done 8 hr earlier. 2. No obvious aneurysm or AV malformation in the vicinity of the left cerebellar hematoma. Minimally displaced nondilated vascular structures adjacent. Correlate clinically for risk factors. INR/NS consult to decide on further workup/mngt. 3. Atherosclerotic calcifications in the distal vertebral and cavernous carotid segments with contour irregularity on both sides. Patent major intracranial arteries as described above. Right posterior inferior cerebellar and Left superior cerebellar artery not well seen. Other details as above.

19992365-RR-47

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2167-10-22 09:14:00

2167-10-22 17:53:00

EXAMINATION: PORTABLE HEAD CT W/O CONTRAST INDICATION: ___ year old man with cerebellar bleed // eval bleed TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without administration of IV contrast. Reformatted coronal, sagittal and thin-section bone algorithm-reconstructed images were acquired. DOSE: DLP: 1000 mGy-cm CTDI: 70 mGy COMPARISON: CT head ___ FINDINGS: The left cerebellar hematoma measures 2.5 x 2.0 cm (AP x TV), previously 2.4 x 2.8 cm on ___. The surrounding edema and mass effect on the left side of the ___ ventricle and rightward shift are not significantly changed from the prior study. There are no new foci of hemorrhage formation. No evidence of midline shift. The lateral ventricles and sulci are within normal limits. Basal cisterns are patent. Gray-white matter differentiation is preserved. No fracture is identified. The paranasal sinuses, mastoid air cells and middle ear cavities clear. Bilateral orbits are unremarkable. IMPRESSION: Stable left cerebellar hematoma with mass effect on the left side of the ___ ventricle; slightly increased mass effect on ___ ventricle. Limited assessment of position of cerebellar tonsils, due to dental artifacts and lack of sagittal and coronal reformations is performed as a portable study. Consider standard CT head study as needed and feasible.

19992418-RR-5

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2145-01-10 14:05:00

2145-01-10 15:10:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ post-partum 4 days with chest pain and hypertension. Pneumonia? Widened mediastinum? Pulmonary edema? TECHNIQUE: Single AP upright portable view of the chest COMPARISON: None FINDINGS: No focal consolidation is seen. There is no large pleural effusion or pneumothorax. Cardiac silhouette is borderline to mildly enlarged in size given AP technique. There may be mild central pulmonary vascular engorgement. IMPRESSION: Borderline to mildly enlarged cardiac silhouette size. Mild central pulmonary vascular engorgement.

19992418-RR-7

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2145-01-10 13:14:00

2145-01-10 14:38:00

EXAMINATION: BILAT LOWER EXT VEINS INDICATION: ___ year old woman with bilateral lower extremity swelling. DVT? TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the bilateral lower extremity veins. COMPARISON: None. 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. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the right or left lower extremity veins.

19992418-RR-8

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2145-01-10 14:42:00

2145-01-10 15:15:00

EXAMINATION: CTA CHEST WITH CONTRAST INDICATION: ___ recently post-partum with shortness of breath and chest pain. Pulmonary embolism? 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) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP = 6.0 mGy-cm. 2) Spiral Acquisition 2.6 s, 20.6 cm; CTDIvol = 23.6 mGy (Body) DLP = 485.3 mGy-cm. Total DLP (Body) = 491 mGy-cm. COMPARISON: None FINDINGS: 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.. No pericardial effusion is seen. AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES: No pneumothorax is seen. There may be very trace pleural effusions. LUNGS/AIRWAYS: Ground-glass opacities in the dependent areas of the lung may represent fluid overload. The airways are patent to the level of the segmental bronchi bilaterally. ABDOMEN: Included portion of the upper abdomen is unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. IMPRESSION: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Ground-glass opacities in the dependent areas of the lung may represent fluid overload. 3. Possible very trace pleural effusions.

19992418-RR-9

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2145-01-11 18:04:00

2145-01-12 07:49:00

EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD. INDICATION: ___ year old woman with persistent HA, severe pre-eclampsia// PRES. TECHNIQUE: 3D time-of-flight MRA was performed through the brain. Sagittal and axial T1 weighted imaging were performed along with diffusion imaging. Axial imaging was performed with gradient echo, FLAIR, T2, and T1 technique. The T1 weighted images were repeated after the intravenous administration of 9 mL of Gadavist contrast agent. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. 3D maximum intensity projection and segmented images were generated. This report is based on interpretation of all of these images. COMPARISON: None available. FINDINGS: MR BRAIN: There is no evidence of intracranial hemorrhage,edema,masses,mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. No diffusion abnormalities are detected. Both orbits and globes are unremarkable. Paranasal sinuses and mastoid air cells are unremarkable. MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm formation. IMPRESSION: 1. Unremarkable MRI and MRA of the brain. There is no evidence of acute intracranial process or hemorrhage 2. There is no evidence of abnormal enhancement after contrast administration

19992507-RR-158

RR

2175-06-18 09:53:00

2175-06-18 10:09:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with h/o SBO, vomiting, no flatus// assess for SBO COMPARISON: CT of the chest from ___ FINDINGS: PA and lateral views of the chest provided. Port-A-Cath resides over the right chest wall with catheter tip in the mid SVC region. The lungs are clear bilaterally. There is no focal consolidation, large effusion, pneumothorax or signs of edema. Cardiomediastinal silhouette appears stable. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: No acute findings.

19992507-RR-159

RR

2175-06-18 12:24:00

2175-06-18 13:05:00

EXAMINATION: CT of the abdomen and pelvis INDICATION: ___ with h/o SBO, vomiting, no flatus//assess for SBO TECHNIQUE: Multidetector CT through the abdomen pelvis performed following IV contrast administration with multiplanar reformations provided. DOSE Total DLP (Body) = 1,532 mGy-cm. COMPARISON: Prior CT abdomen pelvis dated ___ FINDINGS: LUNG BASES: The tip of the Port-A-Cath is seen within the low SVC. There is slight narrowing of the SVC near the cavoatrial junction. The heart is normal in size though there is mitral annular and aortic valvular calcifications. The imaged lung bases are clear aside from minimal right basal atelectasis. ABDOMEN: The liver parenchyma appears normal and there is no concerning liver lesion. Trace perihepatic ascites is noted. Main portal vein is patent. No biliary ductal dilation. The gallbladder is normal. The spleen is normal in size. Adrenals are normal bilaterally. The pancreas appears slightly atrophic though without signs of inflammation or focal abnormality. The kidneys enhance symmetrically. No hydronephrosis or worrisome renal lesion. The abdominal aorta is mildly calcified and normal in caliber. The stomach and duodenum appear normal. PELVIS: There are dilated, fluid-filled loops of small bowel, measuring up to 4 cm. There is a left paraumbilical hernia containing small bowel loops. A dilated loop enters and exits this hernia sac and can be traced to a second entry point of small-bowel into this hernia sac, seen best on series 2 image 59, likely representing the point of bowel obstruction as there is complete decompression of small bowel distal to this point. Decompressed small bowel exits the hernia on series 2 image 59 through 64, and can be traced directly to the terminal ileum. Appendix is not definitively visualized though there are no secondary signs of appendicitis. The colon is unremarkable containing a mild fecal load. The uterus is grossly unchanged with slight prominence of the endometrium, as stated on prior, measuring up to 2.8 cm, series 2, image 82 which can be further evaluated by a nonemergent pelvic ultrasound. There is a right adnexal cystic lesion measuring 8.0 x 5.4 x 8.8 cm, previously characterized as a hydrosalpinx. No left adnexal abnormality. No pelvic free fluid. The urinary bladder is mostly decompressed. No pelvic sidewall or inguinal adenopathy. Bones: No worrisome lytic or blastic osseous lesion. Soft tissues: In addition to the small bowel containing large left periumbilical hernia, there are multiple defect in the anterior body wall, containing fat, series 2, image 36 series 2, image 45, series 2, image 48, series 2, image 51, and series 2, image 63. IMPRESSION: 1. Small-bowel obstruction due to a left periumbilical small bowel containing hernia. Please correlate for reducibility. No free fluid, free air or bowel wall thickening. 2. Multiple additional fat containing abdominal wall hernias. 3. Right adnexal cystic lesion, previously characterized as hydrosalpinx. 4. Thickened endometrium, measuring up to 2.8 cm, consider nonemergent pelvic ultrasound to further assess. RECOMMENDATION(S): Nonemergent pelvic ultrasound to further assess endometrium.

19992507-RR-160

RR

2175-06-18 16:30:00

2175-06-18 17:03:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ with NG tube placement// Eval for NG tube placement COMPARISON: ___ FINDINGS: AP portable upright view of the chest. Port-A-Cath resides over the right chest wall with catheter tip in the region of the mid SVC. The NG tube terminates in the mid upper abdomen. The imaged portions of the lungs appear clear. Cardiomediastinal silhouette is stable. No free air seen below the right hemidiaphragm. IMPRESSION: NG tube terminates in the mid upper abdomen.

19992507-RR-161

RR

2175-06-21 15:29:00

2175-06-21 16:19:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ y/o F with leukocytosis, hx lymphoma s/p alloSCTx2, pneumonitis// eval for PNA, atelectasis COMPARISON: Chest radiograph ___ FINDINGS: PA and lateral views of the chest provided. The enteric tube projects over the proximal stomach, with the side port projecting in the distal esophagus. A right chest wall Port-A-Cath terminates in the upper SVC. Lung volumes are low. No consolidation. Small right pleural effusion. No pneumothorax. Cardiomediastinal silhouette is normal. IMPRESSION: 1. No pneumonia. Small right pleural effusion. 2. Enteric tube projects over proximal stomach, with the side port projecting in the distal esophagus. Consider advancement for optimal positioning.

19992507-RR-162

RR

2175-06-25 05:18:00

2175-06-25 12:07:00

INDICATION: ___ w hx marginal zone lymphoma s/p alloSCTx2, remote colon ca s/p resection w incisional hernia, p/w recurrent SBO// SBO vs ileus TECHNIQUE: Portable supine abdominal radiograph was obtained. COMPARISON: CT abdomen and pelvis dated ___ FINDINGS: There are multiple air-filled, mildly dilated loops of small and large bowel, compatible with ileus. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: Multiple air-filled, mildly dilated loops of small and large bowel, compatible with ileus.

19992507-RR-165

RR

2175-06-28 13:59:00

2175-06-28 15:56:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ M p/w recurrent SBO now WBC up// r/o aspiration/Pna TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiographs ___ through ___, chest CT ___ FINDINGS: Redemonstration of a dual lumen right sided Port-A-Cath and an enteric tube. No new focal consolidations. Small right pleural effusion. There is been interval improvement in right lower lobe atelectasis. No pneumothorax. Cardiomediastinal silhouette is unchanged. IMPRESSION: No new focal consolidations. Improved right lower lobe atelectasis. Small right pleural effusion.

19992507-RR-166

RR

2175-06-28 13:59:00

2175-06-28 16:45:00

INDICATION: ___ M presenting with recurrent small-bowel obstruction now WBC elevated. Evaluate for obstruction. TECHNIQUE: Supine and upright abdominal radiographs were obtained. COMPARISON: Abdominal radiograph dated ___ FINDINGS: There is interval improvement in the mildly dilated loops of small and large bowel compared to prior study dated ___. There is no for free intraperitoneal air. Osseous structures are unremarkable. Enteric tube is seen with tip region the gastric antrum. IMPRESSION: Interval decrease in mildly dilated loops of small and large bowel, compatible with improving ileus.

19992507-RR-168

RR

2175-06-28 22:31:00

2175-06-28 23:24:00

EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ w hx marginal zone lymphoma s/p alloSCTx2, remote colon ca s/p resection w incisional hernia, p/w recurrent SBO. Please perform with IV and PO contrast. Please give PO contrast via NGT.// Please perform with IV and PO contrast to assess obstruction. Please give PO contrast via NGT. TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 70.2 cm; CTDIvol = 23.0 mGy (Body) DLP = 1,615.3 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP = 16.8 mGy-cm. Total DLP (Body) = 1,634 mGy-cm. COMPARISON: Multiple prior CT abdomen and pelvis examinations most recent dated ___. FINDINGS: LOWER CHEST: Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous low attenuation throughout suggestive of hepatic steatosis.. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: There is a nasogastric tube in place. Again seen is left periumbilical incisional hernia with a 4.2 cm neck (series 2, image 85) containing multiple loops of small bowel with upstream small bowel dilatation measuring up to 3.4 cm slightly improved from prior exam. The oral contrast material has passed through the trapped loops of small-bowel extending to the transverse colon. There is no evidence of strangulation or ischemia. There is no pneumoperitoneum. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The endometrium is thickhead measuring 0.9 cm as noted on pelvic ultrasound dated ___. There is right hydrosalpinx as seen on prior pelvic ultrasound.. 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: There is no evidence of worrisome osseous lesions or acute fracture. Degenerative changes are seen in the spine. SOFT TISSUES: In addition to aforementioned left periumbilical incisional hernia there is a smaller right ventral abdominal wall hernia containing mesenteric fat with aperture measuring 15 mm (series 2, image 73) similar to prior exam. IMPRESSION: 1. Left periumbilical incisional hernia with a 4.2 cm neck containing loops of small bowel with interval slight improvement of upstream small bowel dilatation. The oral contrast material has passed through the trapped loops of small-bowel in the incisional hernia, however, given the continued upstream dilation, there appears to be an element of persisting partial obstruction. 2. Thickened endometrium measures 0.9 cm as noted on pelvic ultrasound dated ___. Please correlate with prior endometrial biopsy. 3. Unchanged right hydrosalpinx. 4. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings.

19992507-RR-169

RR

2175-06-28 22:32:00

2175-06-28 23:20:00

EXAMINATION: CT CHEST W/CONTRAST ___ INDICATION: ___ w hx marginal zone lymphoma s/p alloSCTx2, remote colon ca s/p resection w incisional hernia, p/w recurrent SBO. Please perform with IV and PO contrast. Please give PO contrast via NGT.// Please perform with IV and PO contrast to assess obstruction. Please give PO contrast via NGT. TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with intravenous infusion of nonionic, iodinated contrast agent, following oral administration of contrast agent for selected abdominal studies, and/or followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck will be reported separately. All images of the chest were reviewed. DOSE: Acquisition sequence: 1) Spiral Acquisition 5.3 s, 70.2 cm; CTDIvol = 23.0 mGy (Body) DLP = 1,615.3 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP = 16.8 mGy-cm. Total DLP (Body) = 1,634 mGy-cm. ** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND PELVIS WITH CONTRAST) COMPARISON: Chest CT scans ___ and ___. FINDINGS: CHEST PERIMETER: No thyroid findings need any further imaging. Supraclavicular and axillary lymph nodes are not enlarged. Breast evaluation is reserved exclusively for mammography. No soft tissue abnormalities elsewhere in the chest wall. Findings below the diaphragm will be reported separately. CARDIO-MEDIASTINUM: Drainage tube traverses normal caliber esophagus. Atherosclerotic calcification is not apparent in head and neck vessels or coronary arteries. Moderate calcification of the aortic valve, unchanged since ___ is sufficient to be hemodynamically significant and should be evaluated with echocardiography, if not already performed. Aorta and pulmonary arteries and cardiac chambers are normal size and pericardium is physiologic. THORACIC LYMPH NODES: As follows: Left lower paratracheal mediastinum, 10 mm, previously 8 mm, probably with no clinical significance. No lymph nodes elsewhere in the chest are either pathologically enlarged or growing. LUNGS, AIRWAYS, PLEURAE: Mild bronchial wall thickening and inflammatory micro nodules in the upper lobes chronic, usually seen in cigarette smokers. Segmental atelectasis right lower lobe reflects elevated hemidiaphragm. No bronchial obstruction. Mild peribronchial ground-glass opacification left lower lobe probably due to aspiration. No pneumonia or measurable pulmonary nodules. Tracheobronchial tree is normal to subsegmental levels CHEST CAGE: Although there are no bone lesions in the imaged chest cage suspicious for malignancy or infection, it should be noted that radionuclide bone and FDG PET scanning are more sensitive in detecting early osseous pathology than chest CT scanning. IMPRESSION: No evidence of intrathoracic malignancy or infection. Right lower lobe segmental atelectasis is a reflection of elevated right hemidiaphragm. Mild aspiration changes, left lower lobe. Chronic calcification, aortic valve could be hemodynamically significant, should be evaluated with echocardiography if not already performed.

19992581-RR-6

RR

2197-03-09 13:58:00

2197-03-09 15:25:00

INDICATION: ___ man with right lower quadrant pain, tenderness, guarding. Evaluate for appendicitis. COMPARISON: None. TECHNIQUE: Contiguous axial imaging was obtained from the lung bases to the pubic symphysis following the administration of intravenous contrast material. Coronal and sagittal reformats were completed. FINDINGS: CT ABDOMEN WITH CONTRAST: There is no pericardial effusion. The visualized lung bases are clear. The liver enhances homogenously without any focal lesions. The portal vein is patent. There is no intra- or extra-hepatic biliary ductal dilatation. The gallbladder, pancreas, spleen and adrenal glands are unremarkable. The kidneys enhance and excrete contrast symmetrically without any focal lesions or hydronephrosis. The small intra-abdominal and large bowel are unremarkable. There is no free air or free fluid within the abdomen. CT PELVIS: The appendix is dilated up to 8 mm, hyperenhancing and fluid-filled, consistent with acute appendicitis. There is associated stranding in the right lower quadrant. There is no abscess, drainable fluid collection or extraluminal air. There is a trace amount of free fluid in the pelvis posterior to the bladder. The bladder, prostate, rectum and sigmoid colon are unremarkable. There is no pelvic lymphadenopathy. OSSEOUS STRUCTURES: There are no suspicious lytic or sclerotic lesions. IMPRESSION: 1. Dilated fluid-filled appendix consistent with acute appendicitis. No abscess, drainable fluid collection or extraluminal air. 2. Trace amount of free fluid in the pelvis.

19992875-RR-100

RR

2163-12-23 10:31:00

2163-12-23 11:18:00

EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ with transplant liver, needs us to eval transplant. please ___ TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Abdominal Doppler ultrasound from ___ FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. The common hepatic duct measures 0.8 cm. There is no ascites, right pleural effusion, or sub- or ___ fluid collections/hematomas. The spleen measures 15.6 cm and has normal echotexture. DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 24. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.74, and 0.79, respectively. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. Patent hepatic vasculature with appropriate waveforms. 2. Stable splenomegaly.

19992875-RR-131

RR

2166-04-21 00:20:00

2166-04-21 00:35:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with SOB in setting of immunosuppression// r/o PNA COMPARISON: Multiple chest radiographs dating back to ___ through ___ and CT chest ___. FINDINGS: PA and lateral views of the chest Posterior fusion hardware in the midthoracic spine stable since multiple priors. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. IMPRESSION: No acute intrathoracic process.

19992875-RR-132

RR

2166-04-21 01:33:00

2166-04-21 02:37:00

EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: History: ___ with liver transplant ___ presenting with generalized weakness// assess for portal vein thrombosis TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Transplant Doppler ultrasound ___ FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. CHD: 4 mm There is no ascites, right pleural effusion, or sub- or ___ fluid collections/hematomas. The spleen has normal echotexture. Spleen length: 16.4 cm, previously 15.6 cm. DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 70.7 cm/second, previously 24 cm/second. Appropriate arterial waveforms are seen in the right hepatic artery with resistive indices of 0.49, previously 0.74. The left hepatic artery was not able to be visualized secondary to poor acoustic windows and patient breathing. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. Patent hepatic vasculature with appropriate waveforms. Please note that the left hepatic artery was not able to be visualized secondary to poor acoustic windows and patient breathing. 2. Splenomegaly.

19992875-RR-133

RR

2166-07-15 01:03:00

2166-07-15 01:19:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with liver transplant weakness// Pneumonia TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___ FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is unchanged. Posterior midthoracic spinal fusion hardware is again noted. There is no acute osseous abnormality. IMPRESSION: No acute cardiopulmonary process.

19992875-RR-134

RR

2166-07-15 01:12:00

2166-07-15 02:01:00

EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: ___ with liver transplant with RUQ pain weakness// chole? PVT? pls get doppler thnx TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Ultrasound from ___ FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. CHD: 6 mm There is no ascites, right pleural effusion, or sub- or ___ fluid collections/hematomas. The spleen has normal echotexture. Spleen length: 13.9 cm DOPPLER: The main hepatic artery shows a high resistance pattern, with sharp systolic upstrokes with diminished antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 31.3 cm/s, previously 70.7 cm/s. The right and left hepatic arteries were not visualized. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. High resistance waveform in the main hepatic artery with diminished antegrade diastolic flow as well as interval decrease in peak systolic velocity (31.3 cm/s), represents a change from ultrasound of ___ and is concerning for possible occlusion. Recommend clinical correlation with LFTs and CT angiogram. 2. Patent portal veins. 3. Splenomegaly. RECOMMENDATION(S): Recommend clinical correlation with LFTs and CT angiogram. NOTIFICATION: The recommendations were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 11:56 am.

19992875-RR-135

RR

2166-07-15 01:45:00

2166-07-15 03:03:00

EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: ___ with IBS versus Crohn's with unknown onset abdominal pain and weaknessNO_PO contrast// Colitis abscess? TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 7.4 s, 58.1 cm; CTDIvol = 12.0 mGy (Body) DLP = 695.3 mGy-cm. Total DLP (Body) = 707 mGy-cm. COMPARISON: CT abdomen and pelvis ___ FINDINGS: LOWER CHEST: Bibasilar atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The patient is status post hepatic transplant. The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas is mildly atrophic, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen is enlarged measuring 14 cm and shows 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 right upper pole. A subcentimeter hypodensity arising from the right lower pole is too small to characterize, but is likely simple cyst. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. Submucosal fat is seen in the sigmoid colon, consistent with the patient's diagnosis of Crohn's disease. There is lipomatosis of the ileocecal valve. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly 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. There is suboptimal evaluation of the hepatic arterial vasculature on this non angiogram study. The transplant main hepatic artery appears to arise from the SMA and is patent to level of the hilum. BONES: Bones are osteopenic. There is no evidence of worrisome osseous lesions or acute fracture. Schmorl's nodes are seen along the superior endplates T12 and L1. There is a chronic/healed right L2 transverse process fracture. SOFT TISSUES: An umbilical hernia containing fat is noted. IMPRESSION: 1. No acute intra-abdominal process. 2. Unremarkable appearance of the liver transplant. The transplant main hepatic artery appears patent to level of the liver hilum. Suboptimal evaluation of the hepatic arterial vasculature on this non dedicated study. 3. Splenomegaly.

19992875-RR-136

RR

2166-07-17 19:57:00

2166-07-17 21:13:00

EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ year old man with hx of PBC s/p liver transplant (___), hemorrhagic pericarditis s/p window, CAD c/b MI x 2 (___), IBSvs Crohn's disease, OA, and pancytopenia who presents with generalized weakness; on RUQ U/S found to have ?decreased hepatic artery flow// main hepatic artery with diminished antegrade diastolic flow. Occlusion? Stenosis? TECHNIQUE: Abdomen CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 2.3 s, 35.7 cm; CTDIvol = 3.4 mGy (Body) DLP = 121.3 mGy-cm. 2) Spiral Acquisition 1.5 s, 19.7 cm; CTDIvol = 12.0 mGy (Body) DLP = 234.9 mGy-cm. 3) Spiral Acquisition 2.5 s, 33.7 cm; CTDIvol = 11.4 mGy (Body) DLP = 383.8 mGy-cm. 4) Spiral Acquisition 1.5 s, 19.7 cm; CTDIvol = 11.9 mGy (Body) DLP = 233.1 mGy-cm. 5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3 mGy-cm. 6) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 16.0 mGy (Body) DLP = 8.0 mGy-cm. Total DLP (Body) = 982 mGy-cm. COMPARISON: Comparison to previous CT ___. FINDINGS: VASCULAR: The main hepatic artery arises from the SMA and is widely patent. The left and right hepatic arteries are relatively small caliber but appear similar to prior CTA chest from ___. There is no evidence of focal stenosis. There is stable postsurgical change along the course of the main hepatic artery. Major portal and hepatic veins are patent. The celiac and SMA are widely patent. There is mild atherosclerotic plaque in the visualized abdominal aorta. LOWER CHEST: There is mild scarring at the left lung base. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout and shows normal enhancement on all phases. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is surgically absent. PANCREAS: The pancreas demonstrates normal attenuation throughout. A 13 x 8 mm cystic lesion in the pancreatic head (303:55) is unchanged from MRCP ___ and likely represents a side-branch IPMN. There is no main duct dilation. SPLEEN: This plane is mildly enlarged at 14.8 cm in the sagittal plane. The parenchyma enhances homogeneously. ADRENALS: The bilateral adrenals are unremarkable. URINARY: There is mild cortical scarring in the right kidney. Adjacent punctate calcifications could represent stones or parenchymal calcifications. There are multiple small cortical hypodensities in the right kidney, incompletely characterized but likely cysts. There is no hydronephrosis. GASTROINTESTINAL: Visualized bowel is grossly unremarkable. No ascites in the field of view. LYMPH NODES: A 1 cm upper abdominal node is stable from ___ (303:28). No new enlarged nodes. BONES: There is stable mild anterior wedge compression deformity of T12 and L1. Nonacute right L1-L3 transverse process fractures are again noted. No aggressive bone lesions. SOFT TISSUES: The abdominal wall is within normal limits aside from a tiny fat containing periumbilical hernia. IMPRESSION: 1. Main, left and right hepatic arteries are patent and appear similar to CTA from ___ with no evidence of focal stenosis. 2. Stable pancreatic cystic lesion is likely a side-branch IPMN and can be re-evaluated at next follow-up.

19992875-RR-32

RR

2160-04-13 15:14:00

2160-04-13 16:50:00

TYPE OF EXAMINATION: Chest AP portable single view. INDICATION: ___ male patient status post left anterior thoracotomy with pericardial window and chest tube placement. Postoperative evaluation. FINDINGS: AP single view of the chest has been obtained with patient in semi-upright position. Comparison is made to the next preceding PA and lateral chest examination of ___. The patient has undergone left-sided anterior thoracotomy and pericardial window creation. A transverse running row of cutaneous surgical clips overlying the left upper abdominal quadrant indicating the entrance for the left-sided thoracotomy. One chest tube in this area terminates in the lower left-sided pleural space. The second tube has a course which suggests its placement within the pericardial space. There is no evidence of pneumothorax in the apical area. In the right hemithorax, a diffuse hazy density has developed obliterating the right-sided diaphragmatic contours and reaching along the lateral chest wall. This is compatible with pleural effusion layering in the posterior depending portions of the right-sided pleural space. A circular translucency overlying the right lung base compatible with a loculated air bubble top of the thorax as the patient in steep recumbent, almost supine position. Referring physician, ___. ___, was paged at 4:30 p.m. Situation was discussed with Dr. ___ confirmed that pericardium was evacuated from bloody content and that pleural effusions were present at the time of the operation. Confirmed that the patient was in practically supine position at the time of the radiograph.

19992875-RR-33

RR

2160-04-14 02:32:00

2160-04-14 08:31:00

SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Pericardial window Comparison is made with prior study performed a day earlier. Moderate enlargement of the cardiomediastinal silhouette has minimally improved. There is no evident pneumothorax. Left chest tube and a second tube projecting over the heart are in unchanged position. Enlarged right pleural effusion is grossly unchanged allowing the difference in positioning of the patient associated with adjacent atelectasis. A rounded radiolucency projecting in the right lower hemithorax is again noted, this could be due to air in the pleural space or aerated lung surrounding by atelectasis.

19992875-RR-35

RR

2160-04-15 03:21:00

2160-04-15 05:18:00

INDICATION: Patient with history of pericardial effusion, cardiac tamponade, status post pericardial window. COMPARISON: Multiple chest radiographs dating back to ___. TECHNIQUE: MDCT-acquired contiguous images through the chest were obtained at 5-mm slice thickness. Coronally and sagittally reformatted images are provided. FINDINGS: Heart is mildly enlarged. There is a thickened pericardium and a 2moderately large heterogeneous pericardial effusion, which measures up to 40 Hounsfield units in attenuation, compatible with hemorrhagic effusion. No prior CTs are available for direct comparison. Small locules of gas are seen adjacent to the cardiac silhouette within the pericardium, which likely relate to recent procedure. Post-surgical changes related to left-sided thoracotomy are noted. Multiple surgical staples project over lower left chest. Left-sided chest tube is seen terminating at the left lung base. The pericardial drain has been removed since ___ radiograph. There is a small left-sided pneumothorax. There is a nonhemorrhagic moderately large right pleural effusion and small left pleural effusion. Adjacent areas of consolidations most likely represent atelectasis. Paraseptal emphysema is evident at the lung apices. Small amount of fluid is seen layering along the major fissures bilaterally. No suspicious pulmonary mass or nodule is detected. The pulmonary artery is well opacified without apparent perfusion defects. The intrathoracic aorta is normal in caliber without evidence of dissection. The great vessels are unremarkable. There are scattered mediastinal lymph nodes, which do not meet CT criteria for pathologic enlargement. There is no hilar lymphadenopathy. No pathologically enlarged axillary lymph nodes are seen. This study is not tailored for subdiaphragmatic evaluation. The spleen is enlarged measuring 15 cm. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen. Mild anterior wedge deformity and Schmorl's node involving lower thoracic vertebral bodies are noted. IMPRESSION: 1. Moderately large intermediate density pericardial effusion, which is likely hemorrhagic. Adjacent small locules of gas, likely relate to recent procedure. 2. Small left pneumothorax. Left-sided chest tube is in place terminating at the left lung base. 3. Moderate non-hemorrhagic right and small left pleural effusions. Adjacent areas of consolidations most likely represent atelectasis. 4. Splenomegaly. The findings discussed with Dr. ___ at 4:50 a.m. ___ by phone at the time of the discovery.

19992875-RR-36

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2160-04-15 12:10:00

2160-04-15 13:50:00

PORTABLE CHEST FILM ___ AT 1219 CLINICAL INDICATION: ___ post chest tube removal, question pneumothorax. Comparison to prior study of ___ at 242. A portable upright chest film ___ at 1219 is submitted. IMPRESSION: Stable cardiac enlargement. There is right basilar and lateral pleural thickening with associated patchy basilar airspace disease which could reflect atelectasis. There has been interval removal of the left chest tubes with residual patchy basilar opacity likely representing areas of atelectasis. Possible tiny left apical pneumothorax given the presence of an area of focal lucency at the apex. Follow up imaging is advised. No evidence of pulmonary edema.

19992875-RR-37

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2160-04-16 07:14:00

2160-04-16 11:13:00

PORTABLE AP CHEST FILM ___ AT 722 CLINICAL INDICATION: ___ with loculated pericardial effusion and pleural effusions, status post pericardiocentesis, left thoracotomy and pericardial window, question interval change. Comparison is made to the patient's prior study dated ___ at 1219. AP portable upright chest film ___ at 722 is submitted. IMPRESSION: 1. Stable cardiac enlargement and stable mediastinal contours. There continue to be bilateral pleural effusions with associated patchy and linear opacities at the right base and more focal airspace consolidation at the left base. These findings may represent atelectasis, although superimposed infection cannot be entirely excluded. No evidence of pulmonary edema. Previously seen lucency at the left apex is no longer seen. No pneumothorax is appreciated. There are some bullous cystic changes at both apices consistent with known paraseptal emphysema seen on recent CT study of ___.

19992875-RR-39

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2160-05-20 09:04:00

2160-05-20 09:55:00

HISTORY: ___ male with cirrhosis and acutely worsening liver functions. TECHNIQUE: Transabdominal grayscale and duplex Doppler ultrasound examination of the upper abdomen was performed. COMPARISON: ___ and ___. FINDINGS: The liver demonstrates coarsened nodular echotexture, consistent with cirrhosis. No focal liver lesions are detected. There is no intra or extrahepatic biliary ductal dilation. The gallbladder is collapsed and therefore incompletely evaluated. The spleen is enlarged measuring 19.4 cm. The pancreas is not well seen on this study due to overlying bowel gas. The right kidney measures 11.6 cm. A 1 cm non-obstructing calculus is seen in the right renal upper pole. The left kidney measures 10.1 cm. Neither kidney demonstrates hydronephrosis or large masses. No ascites is detected. The main, right anterior, right posterior, and left portal veins are patent; flattened waveform in the portal vein is consistent with known cirrhosis. The left, middle, and right hepatic veins are patent with normal waveforms. The main, right, and left hepatic arteries are patent with normal waveforms. The inferior vena cava, superior mesenteric vein, and splenic vein demonstrate normal waveforms. A prominent splenic artery appears unchanged compared to chest CT dated ___. IMPRESSION: 1. No sonographic evidence for portal vein thrombosis. 2. Cirrhosis with splenomegaly. No liver lesions or ascites detected. 3. Non-obstructing 1 cm right renal calculus.

19992875-RR-40

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2160-05-21 11:09:00

2160-05-21 12:49:00

ABDOMINAL RADIOGRAPH SERIES, DATED ___ COMPARISON: Scout images of the abdomen from an abdominal CT dated ___. FINDINGS: A large amount of stool is present throughout the colon extending into the rectosigmoid region. Scattered air-fluid levels are also present within non-distended loops of small bowel. There is no evidence of free intraperitoneal air. Prominent soft tissue in left upper quadrant of the abdomen probably relates to known splenic enlargement reported on prior CT scan. Within the imaged portion of the chest, note is made of interstitial opacities in the mid and lower lungs suggestive of interstitial edema, as well as a more focal opacity at the left lung base, which may reflect atelectasis and less likely a focal pneumonia or area of infarction. Small left pleural effusion is also demonstrated.

19992875-RR-41

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2160-06-19 22:32:00

2160-06-20 13:25:00

HISTORY: Evaluation for fecal load and free air in a man with a history of primary biliary cirrhosis and acute abdominal pain. COMPARISON: Abdominal radiograph ___. FINDINGS: Frontal upright and supine radiographs demonstrate a moderate amount of stool throughout the colon extending to the rectosigmoid junction. There are air-filled loops of small bowel that are mildly distended. There is no abnormal air-fluid levels or evidence of free intraperitoneal air. Prominent soft tissues in the left upper quadrant of the abdomen is due to splenic enlargement. There is a small left pleural effusion. IMPRESSION: Moderate fecal load throughout the colon. No free air identified. Small left pleural effusion.

19992875-RR-42

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2160-06-19 22:31:00

2160-06-19 23:24:00

HISTORY: Primary biliary cirrhosis presenting with abdominal pain, assess for a portal vein thrombosis. TECHNIQUE: Grayscale and Doppler examination was performed of the liver. COMPARISON: Abdominal ultrasound of ___. FINDINGS: Again, the liver demonstrates a coarsened and nodular echotexture consistent with cirrhosis. There are no focal liver lesions identified. The spleen remains enlarged, measuring 20.1 cm. There is no ascites. The gallbladder is collapsed. There is no intrahepatic biliary ductal dilation of the common bile duct is not dilated. To the extent visualized, the pancreas is unremarkable. A 0.6 cm nonobstructing stone is incidentally noted in the right kidney. The main, right anterior, right posterior and left portal veins are patent with normal hepatopetal flow. A flattened wave form in the main portal vein is consistent with known cirrhosis. The main, left and right hepatic veins are patent and demonstrate normal respiratory phasicity. The main hepatic artery demonstrates a normal waveform. The inferior vena cava is patent. IMPRESSION: 1. No sonographic evidence for a portal venous thrombosis. Patent portal vein with hepatopetal flow. 2. Cirrhosis with unchanged splenomegaly, no ascites. 3. Incidental, nonobstructing 0.6 cm right renal stone.

19992875-RR-44

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2160-08-29 21:25:00

2160-08-29 22:24:00

ABDOMINAL RADIOGRAPH PERFORMED ON ___ COMPARISON: Prior MRI of the abdomen from ___ and abdominal radiograph from ___. CLINICAL HISTORY: Abdominal pain, assess stool burden. FINDINGS: Supine and upright views of the abdomen and pelvis were provided. There is a large amount of fecal loading within the colon, increased from prior exam. There is no free air below the right hemidiaphragm. No signs of bowel obstruction. Bony structures are intact. IMPRESSION: Large fecal load.No bowel obstruction.

19992875-RR-45

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2160-08-31 09:33:00

2160-08-31 10:00:00

HISTORY: Constipation, to assess for obstruction. FINDINGS: There are mildly dilated loops of both large and small bowel, presenting a nonspecific pattern. General haziness of the abdominal contents with central position of the bowel loops raises the possibility of ascites. There appears to be substantial soft tissues to the left lateral aspect of the mid and upper abdomen, suggesting substantial enlargement of the spleen. If there is serious clinical concern for possible obstruction, CT would be the next imaging procedure.

19992875-RR-46

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2160-08-31 21:58:00

2160-08-31 22:43:00

INDICATION: History of primary biliary cirrhosis with increased bilirubin. COMPARISON: MR abdomen, ___. FINDINGS: The liver is coarse and echogenic, consistent with known cirrhosis. The main portal vein is patent and displays hepatopetal flow. There is no intra- or extra-hepatic biliary ductal dilatation and the common bile duct measures 3 mm. The gallbladder is contracted as seen on prior MR. ___ pancreas is not visualized. The spleen is markedly enlarged, measuring 23.1 cm. There is no ascites. IMPRESSION: 1. Coarsened liver echotexture. No biliary dilatation. 2. Splenomegaly.

19992875-RR-47

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2160-09-02 02:04:00

2160-09-02 09:26:00

HISTORY: Preoperative. FINDINGS: In comparison with study of ___, there is no evidence of acute cardiopulmonary disease. No pneumonia or vascular congestion or pleural effusion. Streaks of opacification at both bases are consistent with atelectatic change.

19992875-RR-48

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2160-09-02 13:06:00

2160-09-02 13:50:00

HISTORY: Swan-Ganz placement. FINDINGS: In comparison with the earlier study of this date, there has been placement of a Swan-Ganz catheter with the tip in the right pulmonary artery. Endotracheal tube tip lies well above the clavicles, approximately 9 cm above the carina. It could be pushed forward several cm to be better seated. There are lower lung volumes, but no evidence of acute pneumonia or vascular congestion. Mild atelectatic changes at the bases.

19992875-RR-49

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2160-09-02 15:08:00

2160-09-02 16:40:00

HISTORY: Tubes advanced, to assess for position. FINDINGS: In comparison with the earlier study of this date, the tip of the endotracheal tube has been advanced to the clavicular level, approximately 4.5 cm above the carina. Nasogastric tube has been advanced so that the side hole lies below the level of the esophagogastric junction. Little change in the appearance of the heart and lungs.

19992875-RR-50

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2160-09-03 08:28:00

2160-09-03 14:09:00

INDICATION: Status post liver transplant. Evaluate flow. COMPARISONS: Liver ultrasound from ___, pretransplant. TECHNIQUE: Gray-scale, Doppler, and spectral ultrasound images were acquired through the right upper quadrant. FINDINGS: The transplanted liver is normal in shape and contour. There is normal echogenicity. No focal hepatic lesions are identified. There is no intra- or extra-hepatic biliary duct dilation. The common bile duct measures 5 mm. The left, middle, and right hepatic veins are patent with normal venous flow. The main, right posterior, right anterior, and left portal veins are patent with normal direction of flow and appropriate velocities. The main hepatic artery is patent with a normal arterial waveform. The resistive index is 0.79. The right hepatic artery is patent with a normal arterial waveform. The resistive index is 0.6. The left hepatic artery is patent with normal arterial waveform. The resistive index is 0.77. There are no fluid collections surrounding the liver. The spleen remains enlarged, measuring 19.4 cm, which is not significantly changed from the prior exam. Limited views of the right kidney are normal. IMPRESSION: 1. Normal appearance of post-transplant liver with normal arterial waveforms in the right, main, and left hepatic arteries, and patent portal and hepatic veins. 2. Unchanged splenomegaly.

19992875-RR-51

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2160-09-03 11:34:00

2160-09-03 15:36:00

HISTORY: Status post line change. ___. FINDINGS: There has been interval replacement of the right IJ Swan-Ganz catheter with a right IJ line. The tip is in the right atrium, just below the cavoatrial junction. The ET tube has been removed. The NG tube tip is in the stomach. 2 right-sided chest tubes are again visualized. Skin staples are again seen. As on the prior study, the colon is slightly prominent measuring up to 5.5 cm. There are bilateral pleural effusions, pulmonary vascular redistribution and alveolar infiltrates compatible with fluid overload. This is worsened compared to the study from the prior day.

19992875-RR-52

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2160-09-11 09:22:00

2160-09-11 10:15:00

HISTORY: ___ male with PSC status post liver transplant postop day 9 with right leg swelling. Evaluate for DVT. COMPARISON: None. FINDINGS: Gray scale and color Doppler ultrasound was performed of the right common femoral, superficial femoral, popliteal, posterior tibial and peroneal veins. There is normal flow, augmentation and compressibility. IMPRESSION: No evidence of DVT in the right lower extremity.

19992875-RR-60

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2160-12-27 02:56:00

2160-12-27 03:33:00

HISTORY: Fever and abdominal pain. TECHNIQUE: CT of the abdomen and pelvis with IV contrast. Coronal and sagittal reformations were reviewed. Oral contrast was administered. COMPARISON: ___ FINDINGS: LOWER CHEST: Scattered bibasilar atelectasis is once again present. . Cardiac apex is unremarkable. ABDOMEN: The transplanted liver enhances homogeneously. There are no focal liver lesions. The main portal vein is patent. Postsurgical changes are around the biliary did jejunal anastomosis are again noted. The gallbladder contains no evidence of stones and there is no pericholecystic fluid or gallbladder wall edema. The pancreas and bilateral adrenal glands are normal. Spleen is enlarged at 18 cm Bilateral kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or suspicious renal masses. A right lower pole hypodensity is too small to accurately characterize, but statistically is most likely a simple renal cyst. The abdominal aorta is normal in course and caliber. Mural thrombus is once again noted just prior to the bifurcation. There is trace abdominal free fluid The stomach, small, and large bowel are normal in caliber. Scattered sigmoid diverticulosis is present without evidence of acute diverticulitis. The cecum is near the inferior tip of the liver. The appendix is normal. PELVIS: The bladder, prostate, and rectum are unremarkable. There is no pelvic free fluid or lymphadenopathy. BONES: There are no suspicious bony lesions. IMPRESSION: No evidence of acute intra-abdominal process.

19992875-RR-62

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2161-05-09 21:32:00

2161-05-09 22:49:00

CHEST RADIOGRAPH PERFORMED ON ___ COMPARISON: Prior chest radiograph from ___. CLINICAL HISTORY: Neutropenia and toxic symptoms, question pneumonia. FINDINGS: PA and lateral views of the chest were provided demonstrating no focal consolidation, effusion or pneumothorax. The cardiomediastinal silhouette appears normal. Subtle opacities projecting over the lower lungs are most compatible with subsegmental atelectasis. No effusion or pneumothorax is seen. Biapical pleural parenchymal scarring is noted. IMPRESSION: No acute osseous abnormality.

19992875-RR-63

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2161-05-09 23:04:00

2161-05-10 00:13:00

INDICATION: Status post liver transplant with fevers and chills. Evaluate for portal vein thrombosis. COMPARISON: Ultrasound ___, CT ___. FINDINGS: The transplated liver is mildly heterogeneous in echotexture. No focal liver lesion is identified. There is no intrahepatic bile duct dilation. The common duct is mildly dilated to 7 mm, which can be seen after cholecystectomy. The pancreas is not seen due to overlying bowel gas. The spleen is enlarged measuring 18.7 cm, previously 21 cm, smaller. There is no ascites. DOPPLER: Color Doppler sonogram with spectral analysis of the hepatic vasculature was performed. The main portal vein is patent with normal hepatopetal flow. The left portal, right anterior and right posterior portal veins are patent with normal forward flow. The left, middle and right hepatic veins are patent with normal waveforms. The main hepatic artery has brisk systolic upstroke and forward flow in diastole with RI 0.82, previously 0.63. The right and left hepatic arteries have brisk systolic upstroke with forward flow in diastole with RIs 0.68 and 0.70, respectively, previously 0.62 and 0.56, respectively. The IVC has normal color flow and normal waveform. IMPRESSION: Normal liver Doppler. No focal liver lesion.

19992875-RR-64

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2161-05-13 16:28:00

2161-05-13 17:34:00

CLINICAL HISTORY: Neutropenic fever, evaluate for pneumonia. CHEST, PA AND LATERAL Heart and mediastinum are normal. No evidence of pneumonia is present. The lung fields are essentially clear.

19992875-RR-77

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2162-09-12 00:15:00

2162-09-12 01:24:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with fatigue elevated LFTs, ___ s/p liver xplant // signs liver rejection, PVT? TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: Liver ultrasound from ___. FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. There is no ascites, right pleural effusion or sub- or ___ fluid collections/hematomas. Evaluation of the pancreas is limited by overlying bowel gas. DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 46.4 cm/sec. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.64, and 0.54, respectively. The main portal vein, right and left portal veins are patent with hepatopetal flow with normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: Patent hepatic vasculature with appropriate waveforms.

19992875-RR-78

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2162-09-12 00:23:00

2162-09-12 06:34:00

EXAMINATION: CHEST RADIOGRAPH INDICATION: History: ___ with fatigue, immunocompromised // PNA? PNA? TECHNIQUE: PA and lateral views of the chest. COMPARISON: Chest CT from ___ and outside chest radiograph from ___. FINDINGS: Aside from mediastinal and extrapleural fat deposition, often seen with chronic steroid use, cardiomediastinal and hilar contours are within normal limits. There is mild atelectasis at the lingula. Lungs are otherwise well expanded and clear. There is no focal consolidation, pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process.

19992875-RR-79

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2162-09-13 16:21:00

2162-09-13 18:00:00

INDICATION: ___ year old man with possible liver transplant failure on high dose aspirin // transjugular liver biopsy COMPARISON: CHEST CT WITHOUT CONTRAST ___ TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr. ___, attending radiologist performed the procedure. Dr. ___ personally supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 35 minutes during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: Fentanyl, midazolam CONTRAST: 20 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 9.1 min, 53 mGy PROCEDURE: 1. Right internal jugular venous access using ultrasound. 2. Right atrial and hepatic venous and balloon-occluded portal pressure measurements. 3. Transjugular hepatic core biopsy with 5 passes. 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. The neck was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent right internal jugular vein was compressible and accessed using a micropuncture needle. Hard copy ultrasound images were obtained before and after intravenous access. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. A small incision was made at the needle entry site. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short ___ wire was advanced distally into the IVC. A 9 ___ sheath was advanced over the wire into the inferior vena cava. Using a Cobra catheter and ___ wire, access was obtained in the right hepatic vein. Appropriate position was confirmed with contrast injection and fluoroscopy. The ___ wire was exchanged for Glide wire and the sheath was advanced into the right hepatic vein. The biopsy needle was advanced through the liver access sheath and 5 x 18 gauge core biopsies were acquired while pointing the biopsy sheath anteriorly. The core biopsies were placed in formalin and labeled for pathology. The wire, catheters and core biopsy needle were then removed, pressure held until hemostasis was achieved and sterile dressings were applied. The patient tolerated the procedure well and there were no immediate post-procedure complications. FINDINGS: 1. Patent right internal jugular vein. 2. Five 18G core biopsies of the liver acquired through transjugular access (because the initial samples were considered less than optimal).. IMPRESSION: Successful transjugular liver biopsy, as above.

19992875-RR-80

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2162-09-16 11:25:00

2162-09-16 18:17:00

EXAMINATION: MRCP INDICATION: ___ year old man with hx PBC s/p liver transplant from ___+ donor (___) c/b CMV viremia and rejection ___ yr ago now on tacro and steroids p/w one week of progressive malaise found to have elevated LFTs concerning for rejection vs infection (hx CMV viremia). // biliary pathology TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were acquired in a 1.5 T magnet. Intravenous contrast: Gadavist 8 cc. Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered for oral contrast. COMPARISON: Abdominal ultrasound from ___, abdominal/pelvic CT from ___, abdominal MRI from ___ and abdominal/pelvic CT from ___. FINDINGS: Lower Thorax: There is persistent increased opacity and increased signal intensity at the left lung base, as seen on prior CT examination from ___. In addition, mild to moderate bibasilar atelectasis is present. Visualized portions of the heart are within normal limits. Liver: Patient is status post orthotopic liver transplant for primary biliary cirrhosis. The transplanted liver is of normal signal intensity. There is no focal hepatic lesion, abscess or biliary collection. Biliary: There is mild intrahepatic biliary ductal dilatation, with a transition point identified between the native and transplant bile ducts. There is a notable transition with a difference in caliber between the native and transplant bile ducts, measuring 10 mm above the transition point and 4 mm below (series 6, image 40). There are no filling defects within the ducts to suggest choledocholithiasis. Pancreas: The pancreas is of normal signal intensity. There are no pancreatic masses or peripancreatic fluid collections. There is focal dilation of the distal pancreatic duct, at the level of the communication with the common bile duct (series 6, image 40). Spleen: The spleen has normal signal intensity and is enlarged, measuring up to 16.4 cm. Adrenal Glands: The adrenal glands are normal. Kidneys: There is cortical scarring in the upper pole of the right kidney. The kidneys otherwise enhance symmetrically with no hydronephrosis or renal masses. Gastrointestinal Tract: The stomach as well as visualized loops of small and large bowel are within normal limits. Lymph Nodes: There are no pathologically enlarged lymph nodes. Vasculature: The portal vein is patent. Visualized portions of the intraabdominal aorta are normal in caliber. The celiac axis, SMA and bilateral renal arteries are patent. Osseous and Soft Tissue Structures: Schmorl's nodes are noted at the superior endplates of the lower thoracic spine, consistent with degenerative changes. IMPRESSION: 1. Status post orthotopic liver transplant with mild intrahepatic biliary ductal dilatation and a transition point identified between the native and transplant bile ducts. It is unclear whether these findings are chronic in nature or could reflect a stricture at the surgical anastomosis. 2. Transplanted liver parenchyma is normal with no focal mass, abscess or biliary collection. 3. Splenomegaly. 4. Persistent increased opacity in the left lower lobe, as seen on CT examination from ___. RECOMMENDATION(S): Consider ERCP for direct assessment of biliary anastomotic caliber if there is clinical suspicion for biliary stricture. NOTIFICATION: Finding #1 was discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 6:15 ___, 15 minutes after discovery of the findings.

19992875-RR-81

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2162-11-12 02:16:00

2162-11-12 06:01:00

INDICATION: History: ___ with cp // eval for cp TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: Normal heart size, mediastinal and hilar contours. No focal consolidation, pleural effusion or pneumothorax. Multiple healed right-sided rib fractures are noted which appear new from ___. IMPRESSION: No acute process. Multiple healing right-sided rib fractures.

19992875-RR-88

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2163-04-01 21:35:00

2163-04-01 22:22:00

EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: History: ___ with PBC s/p liver transplant p/w BRBPR and abdominal pain // graft eval TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the abdomen were obtained. COMPARISON: ___ liver Doppler ultrasound FINDINGS: Liver echotexture is normal. There is no evidence of focal liver lesions or biliary dilatation. There is no ascites, right pleural effusion or sub- or ___ fluid collections/hematomas. The spleen measures 17 cm and has normal echotexture. DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 54 cm/sec. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.64, and 0.58, respectively. The main portal vein, right and left portal veins are patent with hepatopetal flow with normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. Unremarkable liver transplant with patent hepatic vasculature and normal waveforms. 2. Splenomegaly.

19992875-RR-89

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2163-04-02 18:50:00

2163-04-02 19:19:00

EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL) INDICATION: ___ year old man with h/o liver transplant presents with BRBPR and ___ described trouble urinating and suprapubic pain TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and bladder were obtained. COMPARISON: CT A/P dated ___ FINDINGS: The right kidney measures 9.3 cm and contains a simple appearing 1.1 cm lower pole cyst. The left kidney measures 9.7 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is normal in appearance. Postvoid images of the bladder were not obtained secondary to the patient's inability to void. Calculated prostate volume is 22 cc. IMPRESSION: Normal appearance of the bilateral kidneys.

19992875-RR-96

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2163-11-10 14:17:00

2163-11-10 16:23:00

INDICATION: ___ year old man with abdominal pain, diarrhea found to have C. difficile, complaining of increased abdominal pain/bloating. Evaluate for developing ___. TECHNIQUE: 2 portable supine abdominal radiographs were obtained. COMPARISON: ___ CT abdomen and pelvis with contrast FINDINGS: There is gas distending the colon. The colon does not exceed 4.5-5 cm in caliber. There is gas in scattered nondilated small bowel loops. Supine assessment limits detection for free air; there is no gross pneumoperitoneum. A surgical clip is seen in the right upper quadrant. There are degenerative changes in the femoroacetabular joints. There are no unexplained soft tissue calcifications or radiopaque foreign bodies. IMPRESSION: No radiographic evidence of toxic megacolon.

19992875-RR-98

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2163-12-23 09:08:00

2163-12-23 10:07:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ with abd pain, n/v, cp hx of pericarditis // acute process COMPARISON: ___ and CT chest from ___ FINDINGS: PA and lateral views of the chest provided. Faint linear densities in the lower lungs likely reflect platelike atelectasis. The lungs are otherwise clear. There is stable prominence of the mediastinal silhouette, which has been previously assessed by CT chest from ___. The heart size is normal. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: No acute findings.

19992875-RR-99

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2163-12-23 09:20:00

2163-12-23 10:05:00

INDICATION: ___ with c diff COMPARISON: Prior exam dated ___ FINDINGS: Supine and upright views of the abdomen pelvis were provided. Bowel gas pattern is unremarkable without signs of ileus or obstruction. No free air is seen below the right hemidiaphragm. No worrisome calcifications. The imaged osseous structures appear intact. There is a mild dextroscoliosis of the thoracolumbar spine, apex at L1. A clip again noted in the right upper quadrant. IMPRESSION: Unremarkable exam.

19994233-RR-16

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2184-02-10 19:47:00

2184-02-10 21:16:00

INDICATION: Altered mental status. COMPARISONS: None available. TECHNIQUE: MDCT-acquired contiguous images through the head were obtained without intravenous contrast at 5-mm slice thickness. Coronally and sagittally reformatted images are provided. FINDINGS: Evaluation is limited due to suboptimal patient positioning. There is a large intraparenchymal hemorrhage centered in the left frontoparietal region measuring 4.2 x 3.3 cm. Adjacent linear areas of hyperattenuation likely reflect subarachnoid extension of hemorrhage (2:18). There is an adjacent 3-mm left subdural hematoma. There is surrounding vasogenic edema and effacement of overlying sulci. The hemorrhage displays mild mass effect with 3 mm righward shift of normally midline structures. No definite intraventricular hemorrhage is seen. Basal cisterns are not well visualized but appear patent. The sulci and ventricles are prominent, likely age-related involutional changes. Confluent hypodensities are seen in subcortical, deep and periventricular white matter distribution, likely small vessel ischemic disease. No acute fracture is noted. IMPRESSION: Limited evaluation due to patient's positioning. Large intraparenchymal hemorrhage centered in the left frontoparietal region with associated vasogenic edema, and adjacent subarachnoid and subdural hemorrhage. There is mild associated mass effect with 3 mm rightward shift of normally midline structures. ___ consider MRI for further charaterizaion to exclude underlying mass, if clinically indicated.

19994233-RR-17

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2184-02-10 19:56:00

2184-02-10 20:57:00

INDICATION: Altered mental status. COMPARISONS: None available. TECHNIQUE: 2.5-mm axial slices through the cervical spine were obtained without intravenous contrast. Coronally and sagittally reformatted images are provided. FINDINGS: No evidence of acute fracture or malalignment. There is exaggeration of the cervical spine lordosis. Multilevel degenerative disc changes are demonstrated, most pronounced at C4-C5, C5-C6 and C6-C7 with the intervertebral disc space narrowing, subchondral sclerosis and subchondral cyst formations. Disc osteophyte complexes are seen at these corresponding levels which mildly to moderately narrow the thecal sac. Multilevel bilateral neural foraminal narrowing is moderate at these levels as well. Prevertebral soft tissues are unremarkable. The airway is patent. No pneumothorax is seen. Thyroid gland is heterogeneous and enlarged. IMPRESSION: 1. No evidence of acute fracture or malalignment. Multilevel degenerative disc disease. 2. Heterogeneous, enlarged thyroid gland likely reflective of multinodular goiter. Clinical correlation recommended.

19994233-RR-18

RR

2184-02-11 00:29:00

2184-02-11 11:45:00

HISTORY: Breast cancer with large left frontoparietal intraparenchymal hemorrhage, history of atrial fibrillation. Evaluate for amyloid angiopathy or underlying lesion. TECHNIQUE: Multisequence MRI of the brain was obtained before and after the administration of IV gadolinium as per department protocol. COMPARISON: CT of ___. FINDINGS: There is a 5.4 cm AP x 4.9 cm TR left parietal intraparenchymal hematoma causing mass effect upon the adjacent brain parenchyma with associated edema. There are subdural blood products along the left convexity as well as subarachnoid blood products. There is effacement of the occipital horn of the left lateral ventricle. No other areas of acute hemorrhage is noted. There is 3 mm right-sided midline shift. There is mild prominence of the lateral ventricles. There are foci of low signal in the susceptibility sequence along the right frontal lobe and along the left occipital horn, consistent with old hemorrhagic foci. Old blood products along the right occipital sulci is also noted. There is no definite evidence of enhancing mass. Otherwise, there are moderate T2/FLAIR hyperintensities in the subcortical and periventricular white matter which are nonspecific but likely the sequelae of chronic microangiopathy. There is mucosal thickening of the ethmoid air cells. IMPRESSION: Large left parietal intraparenchymal hematoma with subarachnoid and subdural blood products, without evidence of definite underlying mass. At least 2 foci of chronic intraparenchymal hemorrhagic products and old subarachnoid blood products. The presence of these findings suggest amyloid angiopathy, however other etiologies such as hypertensive hemorrhage is also possible. Follow-up after resolution of the blood products is advised to exclude an underlying lesion.

19994233-RR-20

RR

2184-02-11 08:34:00

2184-02-11 11:05:00

HISTORY: Left parietal hemorrhage. TECHNIQUE: Portable frontal chest radiograph, 2 views. COMPARISON: None available. FINDINGS: Heart size is top-normal. The thoracic aorta is mildly tortuous with atherosclerotic mural calcifications. Lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No acute cardiopulmonary process.

19994233-RR-21

RR

2184-02-11 13:07:00

2184-02-11 17:16:00

HISTORY: Hemorrhagic stroke and frontoparietal intraparenchymal hemorrhage. NG tube placed. COMPARISON: ___, 8:35 a.m. TECHNIQUE: Portable frontal chest radiograph. FINDINGS: There has been interval placement of an upper enteric drainage tube which terminates in the mid portion of a non-distended stomach. There is otherwise no short-term interval change from earlier study five hours prior.

19994233-RR-22

RR

2184-02-11 23:47:00

2184-02-12 10:46:00

INDICATION: CHF, admitted with intracranial hemorrhage, now with desaturations and fever. COMPARISON: ___. TECHNIQUE: Portable frontal chest radiograph. FINDINGS: Cardiomediastinal silhouette and hilar contours are stable. Left base atelectasis is noted. The lungs are otherwise clear. There is no pleural effusion or pneumothorax. IMPRESSION: Little change compared to ___ with streaks of atelectasis at the left lung base.

19994233-RR-23

RR

2184-02-12 14:10:00

2184-02-12 16:31:00

HISTORY: ___ with left parenchymal hematoma, as well as subarachnoid and subdural hemorrhage. TECHNIQUE: Contiguous axial MDCT images were obtained through the brain without the administration of IV contrast. COMPARISON: Comparison is made to non-contrast CT of the head from ___ and MR of the head with and without contrast from ___, 14 hours prior. FINDINGS: Allowing for differences in the plane of imaging and inter-modality differences, there is no change in size of previously seen left parietal intraparenchymal hematoma (2a: 20), with surrounding vasogenic edema causing persistent effacement of the posterior horn of the left lateral ventricle. There is unchanged 3 mm rightward shift of normally midline structures. The small adjacent left subdural hematoma again measures 3 mm, unchanged from initial noncontrast CT of the head from ___. There has been interval redistribution of a small amount of subarachnoid hemorrhage, now with intraventricular extension (2a: 15) to the posterior left lateral ventricle. The basal cisterns appear patent. The prominent ventricles and sulci are again noted, consistent with age-related involutional of changes or atrophy. Periventricular white matter hypodensities are again seen, representing the sequelae of chronic small vessel ischemic disease. There is no evidence of obstructive hydrocephalus. No fracture is identified. IMPRESSION: 1. Since the previous MRI from 14 hours prior, there has been no significant change in size of left parietal parenchymal hematoma (allowing for different imaging modalities and planes of scanning). Surrounding vasogenic edema which effaces the occipital horn of the left lateral ventricle is also not signiifcantly changed, with stable 3 mm rightward shift of normally midline structures. 2. Interval redistribution of small amount of subarachnoid hemorrhage, now with intraventricular extension. 3. Stable 3 mm left subdural hematoma. No new focus of hemorrhage is identified.

19994233-RR-24

RR

2184-02-12 14:37:00

2184-02-12 15:08:00

REASON FOR EXAMINATION: Evaluation of the patient with history of heart failure, desaturations and pulmonary edema. Also suspected aspiration. AP radiograph of the chest was compared to ___. Heart size is enlarged. Mediastinum is stable. Left retrocardiac opacity is noted, more pronounced than on the prior study and might reflect interval aspiration. There is no pleural effusion or pneumothorax. The NG tube tip is in the stomach.

19994233-RR-25

RR

2184-02-14 07:52:00

2184-02-14 11:40:00

HISTORY: New NG tube below. COMPARISON: ___. FINDINGS: NG tube tip is in the stomach. The appearance of the lungs is unchanged. IMPRESSION: NG tube in the stomach.

19994379-RR-16

RR

2131-05-05 00:57:00

2131-05-05 04:47:00

EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE INDICATION: ___ with question L1-L2 epidural abscess on outside hospital CT. Evaluate for epidural abscess TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. Axial T2 imaging was performed. Axial GRE images of the cervical spine were performed. After the uneventful administration of 10 mL of Gadavist contrast agent, additional axial and sagittal T1 images were obtained. COMPARISON: ___ MR lumbar spine with without contrast ___ MR thoracic and lumbar spine without contrast FINDINGS: Study is degraded by motion and by lumbar spinal fusion hardware artifact. Within these confines: CERVICAL: There is 2 mm spondylolisthesis of C7 on T1, likely degenerative. Mild loss of cervical vertebral body height without definite associated increased STIR signal are likely degenerative. Low signal intensity within the right lamina of the C3-C6 vertebral bodies on T1 and T2 weighted images likely reflects postoperative change. The visualized portion of the spinal cord is grossly preserved in signal and caliber. There is no definite abnormal enhancement. At C2-3, uncovertebral and facet joint hypertrophy result in mild left neural foraminal narrowing. There is no spinal canal or right neural foraminal narrowing. At C3-4, a disc osteophyte complex, uncovertebral and facet joint hypertrophy result in mild spinal canal narrowing. There is moderate left and severe right neural foraminal narrowing. At C4-5, a disc osteophyte complex, uncovertebral, and facet joint hypertrophy result in mild spinal canal narrowing. There is severe bilateral neural foraminal narrowing. At C5-6, a disc osteophyte complex, uncovertebral, and facet joint hypertrophy result in mild-to-moderate spinal canal narrowing. There is severe bilateral neural foraminal narrowing. At C6-7, a disc osteophyte complex, uncovertebral, and facet joint hypertrophy result in mild spinal canal narrowing. There is severe bilateral neural foraminal narrowing. At C7-T1 a disc osteophyte complex, uncovertebral, and facet joint hypertrophy result in mild spinal canal narrowing. There is mild-to-moderate bilateral neural foraminal narrowing. THORACIC: Vertebral body alignment is preserved. Vertebral body heights are preserved. T8 vertebral body probable hemangioma is noted. The visualized portion of the spinal cord is preserved in signal and caliber. There is no abnormal enhancement. There is mild degenerative disc disease, without moderate or severe spinal canal or neural foraminal narrowing. LUMBAR: There postoperative changes for posterior instrumented fusion with transpedicular screws at the L4-S1 level and anterior fixation screws at right L4 and S1. There is solid osseous fusion of the L2-3, partial osseous fusion of L3-4, L4-5, and L5-S1. Laminectomy changes are detailed below. There is an oblique fracture of the superior endplate of L2 with lateral extension through the lateral margin of the vertebral body. This is likely subacute to chronic, however is a new finding from the ___ MRI. Vertebral body height is otherwise preserved without evidence of an acute fracture. Vertebral body alignment is preserved. The conus medullaris terminates at the L1 level. There is no definite signal abnormality within the conus or cauda equina. There is no abnormal enhancement. At T12-L1 there is no spinal canal or neural foraminal narrowing. At L1-2, there is advanced degenerative endplate change with bone marrow reactive change and associated vacuum disc phenomenon. There is a disc bulge with superimposed central disc extrusion with superior migration, ligamentum flavum thickening, and facet hypertrophy with bilateral synovial cysts that result in severe spinal canal narrowing. There is probable impingement on the traversing bilateral L2 and possibly other nerve roots. There is there is moderate left and severe right neural foraminal narrowing. There is a right facet joint effusion. At L2-3, there is ossification of a residual L2-3 intervertebral disc versus endplate spurs. There are bilateral laminectomy changes with decompression of the spinal canal narrowing. Facet hypertrophy results in severe bilateral neural foraminal narrowing, left worse than right. At L3-4, there is a small disc bulge. There are bilateral laminectomy changes with decompression of the spinal canal. Facet hypertrophy results in moderate bilateral neural foraminal narrowing. At L4-5, facet hypertrophy results in mild bilateral neural foraminal narrowing. There are bilateral laminectomy changes with decompression of the spinal canal. At L5-S1, there are bilateral laminectomy changes with decompression of the spinal canal. Facet hypertrophy results in and moderate left neural foraminal narrowing. OTHER: There is a 5 mm nodule within the left lobe of the thyroid. There is a moderate size loculated right pleural effusion. Signal abnormality within the basilar right lower lobe could reflect atelectasis and/or pneumonia. There is a gastric fundal diverticulum (series 18, image 22). IMPRESSION: 1. Study is degraded by motion and by lumbar spinal fusion hardware artifact. 2. Cervical degenerative disc disease as detailed above, without high-grade spinal canal narrowing or cord signal abnormality. There is severe neural foraminal narrowing at multiple levels. 3. Mild thoracic degenerative disc disease, without high-grade spinal canal or neural foraminal narrowing. 4. Loculated right pleural effusion basilar right lower lobe could reflect atelectasis, however pneumonia cannot be excluded. Chest CT is suggested. 5. Instrumented lumbar fusion at L4-S1, interbody fusion graft at L3-4 with partial osseous fusion, and solid osseous fusion of the L2-3 level as detailed above. 6. L1-2 disc extrusion with superior migration results in severe spinal canal narrowing. There is probable impingement of the traversing L2 and possibly other nerve roots. Allowing for difference technique, finding may be slightly progressed compared to ___ prior exam. 7. Within limits of study, no definite evidence of discitis-osteomyelitis, or epidural abscess. 8. Probable subacute to chronic oblique fracture of the superior endplate of L2 with lateral extension through the lateral vertebral body. 9. Right L1-2 and bilateral L2-3 Severe neural foraminal narrowing.

19994379-RR-17

RR

2131-05-06 11:27:00

2131-05-06 13:11:00

EXAMINATION: Chest radiograph PA and lateral INDICATION: ___ year old man with spinal stenosis, CHF, pleural effusion noted on MRI spine// ?evidence of pleural effusion, volume overload, infection TECHNIQUE: Chest PA and lateral COMPARISON: Compressed includes semi-upright portable chest x-ray done on ___ 14. FINDINGS: Increased opacification of the right hemithorax. There is stable cardiomegaly. Hilar and mediastinal contours are normal. There is a mild to moderate layering right pleural effusion. Otherwise the left lung is clear. There is enlargement of the gastric bubble. There are dilation of colon at the splenic flexure. IMPRESSION: There is a mild to moderate layering right pleural effusion. There is dilation of colon at the splenic fracture.