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10011126-RR-24

RR

2155-11-20 12:10:00

2155-11-20 23:28:00

INDICATION: ___ man with abdominal pain, fever, on chemotherapy. COMPARISON: CT from ___. TECHNIQUE: MDCT-acquired axial images were obtained from the lung bases to the pubic symphysis without intravenous, but with enteric contrast. Coronal and sagittal reformats reviewed. FINDINGS: There are stents or calcifications in the coronary vessels. The lower chest is otherwise unremarkable. ABDOMEN: The liver, gallbladder, spleen, pancreas, and adrenal glands appear normal. The right kidney is without stones, hydronephrosis, or mass. There is a double-J ureteral stent in the left kidney and persistent moderate hydronephrosis when compared to the pre-stent CT. There is increased perinephric stranding about the left kidney. The stomach, small bowel, and large bowel are of normal caliber, without mass or wall thickening. There is diverticulosis without evidence of diverticulitis. There is no ascites, fluid collection, or pneumoperitoneum. The abdominal aorta is of normal caliber. There is no lymphadenopathy. PELVIS: There is a partially evaluated 5.1 x 1.9 cm mass within the bladder, at the location of the left ureteral insertion (2:77). The ureteral stent passes through this and the pigtail catheter is in the neck of the bladder. The prostate contains brachytherapy seeds. There is a minimally enlarged 1.1 cm left pelvic side wall lymph node (2:72). There is a small amount of free fluid in the pelvis. There are a number of prominent presacral lymph nodes as well. There are no destructive osseous lesions concerning for malignancy. IMPRESSION: 1. There is persistent moderate-to-severe left hydronephrosis despite the double-J stent in place. There is increased stranding around the left kidney and infection cannot be fully excluded. 2. Incompletely evaluated bladder mass. 3. The inferior end of the ureteral catheter is placed such that the pigtail is possibly within the neck of the bladder. 4. No other acute infectious or inflammatory process identified.

10011126-RR-25

RR

2156-02-24 04:32:00

2156-02-24 07:35:00

INDICATION: Nausea and vomiting. COMPARISON: ___. FINDINGS: PA and lateral views of the chest. There is no focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal and hilar contours are normal. IMPRESSION: No acute cardiopulmonary process.

10011126-RR-26

RR

2156-02-24 12:59:00

2156-02-24 14:43:00

HISTORY: Prostate cancer, complaining of right upper quadrant pain with positive ___ sign and pulsating epigastric sensation, concerning for AAA. Presents with nausea, vomiting and hypertension. COMPARISON: CT abdomen and pelvis ___. TECHNIQUE: Grayscale and color Doppler ultrasound images of the abdomen were obtained. FINDINGS: There are multiple non-vascularized hypoechoic solid appearing lesions within the liver, the largest in the right lobe measuring 2.0 x 1.5 x 1.9 cm. Another prominent subcapsular lesion in the right lobe measures 1.7 x 1.1 x 2.0 cm. Several other, similar appearing subcentimeter lesions are noted within the left lobe of the liver. A 5-mm simple-appearing cystic lesion is seen within the left lobe of the liver. There is no intra- or extra-hepatic biliary duct dilatation with the common bile duct measuring 3 mm in diameter. The gallbladder is thin-walled and unremarkable without stones. The portal vein is patent with hepatopetal flow. The visualized portion of the pancreas is unremarkable, without ductal dilatation or focal lesion. The pancreatic tail is not well visualized due to overlying bowel gas. The abdominal aorta is normal in caliber without focal aneurysmal segment. The visualized portion of the IVC is unremarkable. The right kidney measures 11.7 cm and the left kidney measures 12.0 cm. The kidneys are unremarkable without hydronephrosis, stone or lesion. The spleen is homogeneous in echotexture, but enlarged measuring 16.9 cm. There is no ascites. IMPRESSION: 1. Multiple scattered isoechoic hepatic lesions, the largest in the right lobe measuring 2.0 cm, suspicious for metastases. Further evaluation with contrast-enhanced MR or multiphasic CTA is recommended. 2. Splenomegaly. 3. Unremarkable gallbladder without stones. 4. No evidence of abdominal aortic aneurysm. Results were discussed over the telephone with Dr. ___ by Dr. ___ at 2:15 p.m. on ___.

10011189-RR-21

RR

2188-02-24 18:01:00

2188-02-24 18:23:00

EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with episode of loss of consciousness, evaluate for pneumonia. TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: None. FINDINGS: Heart size is normal. The mediastinal and hilar contours are unremarkable. The pulmonary vasculature is not engorged. Lungs are clear. No pleural effusion or pneumothorax is present. No acute osseous abnormality is visualized. IMPRESSION: No acute cardiopulmonary abnormality.

10011189-RR-22

RR

2188-02-24 19:22:00

2188-02-24 20:08:00

EXAMINATION: CT HEAD W/O CONTRAST INDICATION: History: ___ with episode of loss of consciousness//?lesion TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain, intermediate and bone windows. Coronal and sagittal reformats were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.4 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no intra-axial or extra-axial hemorrhage, edema, shift of normally midline structures, or evidence of acute major vascular territorial infarction. Ventricles and sulci are normal in overall size and configuration. There is mucosal thickening in the bilateral ethmoid air cells. Remaining paranasal sinuses clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. Visualized orbits are unremarkable. IMPRESSION: No acute intracranial abnormality.

10011189-RR-24

RR

2188-02-26 10:21:00

2188-02-26 14:44:00

EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK INDICATION: ___ year old man with episodes of blurred vision, syncope, tinnitus, and altered consciousness// Evidence of vascular abnormality of the head and neck to explain his recurrent, transient neurologic symptoms. Specific concern would be basilar stenosis. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque350 intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.3 mGy-cm. 2) Spiral Acquisition 4.8 s, 38.1 cm; CTDIvol = 11.4 mGy (Body) DLP = 432.4 mGy-cm. 3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 17.8 mGy (Body) DLP = 8.9 mGy-cm. Total DLP (Body) = 441 mGy-cm. Total DLP (Head) = 747 mGy-cm. COMPARISON: Prior CT brain done ___. FINDINGS: The study is degraded by motion artifact. CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Small lucent calvarial lesions in the convexity are nonspecific, however concerning for marrow infiltration versus the diploic venous lakes (images 29, 30, series 2). CTA HEAD: Anterior projecting wide neck aneurysm arising from the distal bifurcating aspect of the right M1 MCA segment measuring 5 mm (AP) by 4 mm (TV) by 3 mm (cc). The aneurysm has a slightly lobulated/irregular appearance. No evidence of contrast extravasation in this area. No surrounding edema. The rest of the vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: The carotid arteries and their major branches appear normal with no evidence of stenosis or occlusion. There is no evidence of significant internal carotid stenosis by NASCET criteria. There is poor opacification of the left vertebral artery at its origin, this most likely represents moderate to severe stenosis, but vessel tortuosity could also result in artifact. The rest of the vertebral arteries are patent with no significant stenosis. The vertebral arteries appear codominant. No evidence of basilar stenosis. OTHER: The visualized portion of the lungs are clear. Subcentimeter nonsuspicious thyroid nodules. Lobular structure just posterior to the suprasternal notch which seems to connect to the left brachiocephalic vein measuring 24 x 18 mm and 50 ___ (series 3, image 52). The adjacent left brachiocephalic vein also measures the vicinity of 50 ___ units. No other enlarged lymph nodes. Correlation with neck ultrasound advised. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Right MCA aneurysm measuring 5 x 4 x 3 mm. The aneurysm has a slightly lobulated/irregular appearance. 2. No significant ICA stenosis by NASCET criteria. 3. There is poor opacification of the left vertebral artery at its origin, which most likely represents moderate to severe stenosis, but its tortuous course could also result in artifact. The rest of the arteries patent without significant stenosis. 4. Lobular structure just posterior to the suprasternal notch which seems to connect to the left brachiocephalic vein which most likely represents an anomalous venous structure. A soft tissue lesion/cystic remnant should be excluded. Correlation with neck ultrasound is advised. 5. Small possible lytic calvarial lesions are nonspecific, probably consistent with diploic venous lakes, however myeloproliferative bone marrow infiltration cannot be completely rule out. RECOMMENDATION(S): 1. Lobular structure just posterior to the suprasternal notch which seems to connect to the left brachiocephalic vein which most likely represents an anomalous venous structure, correlation with neck ultrasound advised. 2. Small rounded lucent lesions in the calvarial convexity are nonspecific, probably representing diploic venous lakes, however bone marrow infiltration cannot be completely excluded, if clinically warranted, correlation with bone scan is advised. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:45 pm, 10 minutes after discovery of the findings.

10011427-RR-37

RR

2136-03-20 21:34:00

2136-03-20 21:50:00

EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with tunnelled cath removed accidnetally // tip catheter placement? TECHNIQUE: Chest: Frontal and Lateral COMPARISON: Earlier today, ___ at outside institution, at 12:36 FINDINGS: No central venous catheter is seen on the current study.No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No central venous catheter seen on the current chest radiograph.

10011427-RR-38

RR

2136-03-21 00:19:00

2136-03-21 01:23:00

EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with free air in belly. Need to eval pelvis. NO_PO contrast // perf? per ACS request. 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) Spiral Acquisition 4.1 s, 53.7 cm; CTDIvol = 9.6 mGy (Body) DLP = 517.5 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.1 mGy (Body) DLP = 1.5 mGy-cm. 3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 30.5 mGy (Body) DLP = 15.3 mGy-cm. Total DLP (Body) = 534 mGy-cm. COMPARISON: Outside hospital CT abdomen pelvis dated ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: See soft tissue section for pneumoperitoneum. HEPATOBILIARY: The liver demonstrate cirrhotic morphology. Scattered subcentimeter hypoattenuating lesions in the right lobe are too small to characterize. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder contains gallstones without wall thickening or surrounding inflammation. There is small amount of ascites. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen measures 14.6 cm on AP dimension. No focal splenic lesion. 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 in either kidney. Scattered renal cysts are noted measuring up to 5.8 cm on the left lower renal pole. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. There is no bowel obstruction. There is thickening of the cecum and proximal ascending colon consistent with portal colopathy. No pneumatosis. The appendix is not visualized but no secondary signs of appendicitis in the right lower quadrant. PELVIS: The urinary bladder and distal ureters are unremarkable. There is small amount of pelvic ascites. REPRODUCTIVE ORGANS: The uterus is unremarkable. No adnexal mass. 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. The portal venous system is patent without portal venous gas. The celiac artery, SMA, and ___ are patent. There is paraesophageal varices and splenorenal shunts. There is recanalized umbilical vein. BONES: There is no evidence of worrisome osseous lesions or acute fracture. Degenerative changes of the lumbar spine are moderate. There are severe degenerative changes of the left hip. SOFT TISSUES: There is pneumoperitoneum in the anterior abdomen anterior to the bowel loops, improved compared to CT from a hours prior. The air appears to communicate with an umbilical defect. There is diffuse anasarca. IMPRESSION: 1. Cirrhotic liver with findings portal hypertension including splenomegaly, portal venous collaterals, small volume ascites, and portal colopathy. No focal hepatic lesion. 2. Improved pneumoperitoneum in the anterior abdominal cavity compared to a hours prior. The air appears to communicates with an umbilical defect. No portal venous gas or pneumatosis to suggest bowel ischemia. In the setting of recent paracentesis and lack of convincing evidence of bowel ischemia, the pneumoperitoneum could be secondary to the paracentesis and less likely from bowel perforation. Alternatively, the pneumoperitoneum could be secondary to communication with the umbilical defect. 3. No additional acute process within the abdomen or pelvis. NOTIFICATION: The findings were discussed with ___, m.D. by ___, M.D. on the telephone on ___ at 1:22 am, 2 minutes after discovery of the findings.

10011427-RR-39

RR

2136-03-21 09:33:00

2136-03-21 10:49:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with alcoholic cirrhosis and ESRD on HD ___ with acute AMS. // bleeding TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 747.5 mGy-cm. 2) Sequenced Acquisition 1.0 s, 4.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 186.9 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: Prior head CT dated ___. FINDINGS: There is no evidence of fracture, infarction,hemorrhage,edema, or mass. However, given recent contrast administration, the sensitivity for subtle areas of hemorrhage is decreased. The ventricles and sulci are normal in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are normal. There is asymmetric hyperenhancement of the left parotid gland compared to the right side. IMPRESSION: No evidence of hemorrhage, however given the recent contrast administration, the sensitivity for subtle areas of hemorrhage is decreased on this study. Asymmetric hyperenhancement of the left parotid gland is nonspecific but could reflect inflammatory change. This can be correlated with symptoms.

10011427-RR-41

RR

2136-03-21 13:39:00

2136-03-21 14:50:00

EXAMINATION: CHEST PORT. LINE PLACEMENT INDICATION: ___ year old woman with dialysis line // confirm placement of dialysis line Contact name: ___: ___ TECHNIQUE: Chest AP COMPARISON: ___ IMPRESSION: The NG tube projects below the left hemidiaphragm and the tip projects over the stomach. Right-sided central line projects to the right atrium. There is bibasilar atelectasis. No effusions. No pneumothorax. Cardiomediastinal silhouette stable

10011427-RR-42

RR

2136-03-22 07:31:00

2136-03-22 12:15:00

EXAMINATION: CHEST (PORTABLE AP) ___ INDICATION: 68 with cirrhosis and declining clinical status // 68 with cirrhosis and declining clinical status 68 with cirrhosis and declining clinical status IMPRESSION: Compared to chest radiographs ___ through ___. Lungs are low in volume but clear. Previous vascular congestion has resolved. Heart size normal. No pleural abnormality. Nasogastric drainage tube passes into the stomach and out of view. Dual channel right jugular line ends in the upper right atrium, unchanged.

10011427-RR-44

RR

2136-04-04 17:06:00

2136-04-05 15:06:00

INDICATION: ___ year old woman with VRE bacteremia, needs line holiday // remove temp HD line COMPARISON: Tunneled dialysis catheter placement ___ TECHNIQUE: OPERATORS: Dr. ___ radiology resident) and Dr. ___ Dr. ___ performed the procedure. The attending(s) personally supervised the trainee during any key components of the procedure where applicable and reviewed and agrees with the findings as reported below. ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site. MEDICATIONS: None PROCEDURE: 1. Right internal jugular temporary hemodialysis line removal. PROCEDURE DETAILS: At the bedside, the right neck line site was cleaned and draped in standard sterile fashion. The catheter was removed with gentle traction while manual pressure was held at the venotomy site. Hemostasis was achieved after 5 min of manual pressure. A clean sterile dressing was applied. The patient tolerated the procedure well. There were no immediate postprocedural complications. FINDINGS: Expected appearance after line removal. IMPRESSION: Successful removal of a right temporary hemodialysis line.

10011427-RR-45

RR

2136-04-06 10:08:00

2136-04-06 12:42:00

INDICATION: ___ year old woman with etoh cirrhosis HRS on line holiday for vre bacteremia, needs ___ dialysis on ___, can she get line on ___ AM, thank you // can she get tunneled line in am of ___ for pm dialysis on ___, thanks COMPARISON: Tunneled dialysis line placement ___ TECHNIQUE: OPERATORS: Dr. ___ radiology resident) and Dr. ___ performed the procedure. The attending, Dr. ___ was present and supervising throughout the procedure. Dr. ___ radiologist, personally supervised the trainee during the key components of the procedure and reviewed and agreed with the trainee's findings. ANESTHESIA: Moderate sedation was provided by administrating divided doses of 25mcg of fentanyl throughout the total intra-service time of 15 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 CONTRAST: None FLUOROSCOPY TIME AND DOSE: 2:01 min, 7.7 mGy PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the patient. The patient was then brought to the angiography suite and placed supine on the exam table. A pre-procedure time-out was performed per ___ protocol. The left upper chest was prepped and draped in the usual sterile fashion. Under continuous ultrasound guidance, the patent left internal jugular vein was compressible and accessed using a micropuncture needle. Permanent ultrasound images were obtained before and after intravenous access, which confirmed vein patency. Subsequently a Nitinol wire was passed into the right atrium using fluoroscopic guidance. The needle was exchanged for a micropuncture sheath. The Nitinol wire was removed and a short Amplatz wire was advanced to make appropriate measurements for catheter length. The wire was then passed distally into the IVC. Next, attention was turned towards creation of a tunnel over the upper anterior chest wall. After instilling superficial and deeper local anesthesia using lidocaine mixed with epinephrine, a small skin incision was made at the tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The catheter was tunneled from the entry site towards the venotomy site from where it was brought out using a tunneling device. The venotomy tract was dilated using the introducer of the peel-away sheath supplied. Following this, the peel-away sheath was placed over the ___ wire through which the catheter was threaded into the right side of the heart with the tip in the right atrium. The sheath was then peeled away. The catheter was sutured in place with 0 silk sutures. Steri-strips were also used to close the venotomy incision site. Final spot fluoroscopic image demonstrating good alignment of the catheter and no kinking. The tip is in the right atrium. The catheter was flushed and both lumens were capped. Sterile dressings were applied. The patient tolerated the procedure well. FINDINGS: Patent left internal jugular vein. Final fluoroscopic image showing catheter with tip terminating in the right atrium. IMPRESSION: Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use.

10011466-RR-21

RR

2191-08-30 00:02:00

2191-08-30 01:44:00

HISTORY: Right lower quadrant pain for 2 days, concerning for appendicitis. TECHNIQUE: MDCT imaging of the abdomen and pelvis with intravenous contrast was performed. Multiplanar reformats were prepared and reviewed. COMPARISON: None. FINDINGS: ABDOMEN: The visualized lung bases are clear. The liver is homogeneous in texture with no focal lesions. There is no biliary ductal dilatation. The gallbladder is normal. The spleen, pancreas, and adrenal glands are normal. The kidneys are unremarkable. The stomach, duodenum, and intra-abdominal loops of bowel are normal in caliber and unremarkable. The appendix is clearly visualized and demonstrates focal dilation of the midportion to 8 mm but tapers distally. There is no adjacent fat stranding around the appendix but air is not seen distal to the focal dilation. Acute appendicitis is improbable with these findings. There is no retroperitoneal or mesenteric lymphadenopathy. The intra-abdominal aorta is normal in appearance. PELVIS: The sigmoid colon and rectum are normal in appearance. The distal ureters and bladder are normal. The prostate is unremarkable. There is no pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for infection or malignancy is seen. IMPRESSION: Appendix demonstrates dilation of the midportion to 8 mm with tapering distally. No adjacent fat stranding, but air is not seen distal to the focal dilation. Acute appendicitis is improbable with these findings.

10011668-RR-132

RR

2141-04-14 16:32:00

2141-04-14 17:08:00

EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with chest pain // PNA TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Patient is status post median sternotomy. The inferior most sternotomy wire is again seen to be fractured. Lung volumes are relatively low. There is moderate pulmonary vascular congestion/edema. More confluent focal opacity at the right lung base may be due to volume overload, but pulmonary nodule or consolidation is not excluded. Recommend repeat after diuresis. No large pleural effusion or pneumothorax is seen. Cardiac silhouette is enlarged. IMPRESSION: Moderate pulmonary vascular congestion/edema. More focal nodular opacity at the right lung base could be due to volume overload, but pulmonary nodule or consolidation is not excluded. Recommend repeat chest radiographs after diuresis. Cardiomegaly. No large pleural effusion.

10011938-RR-41

RR

2132-01-21 16:50:00

2132-01-21 17:52:00

EXAMINATION: TIB/FIB (AP AND LAT) LEFT INDICATION: ___ year old woman with epilepsy with recent leg fracture. now with heel ulcer// fractures? TECHNIQUE: Frontal and lateral view radiographs of the left tibia and fibula. COMPARISON: None. IMPRESSION: Diffuse osteopenia is noted. There is a healing subacute spiral fracture through the distal tibial metadiaphysis, which demonstrates fibroosseous bridging and callus formation. There is a healed fracture through the distal fibular diaphysis. Multiple well corticated ossific densities inferior to the medial malleolus most likely represent sequela from remote trauma. There are mild degenerative changes of the medial patellofemoral compartment and tibiotalar joint.

10011938-RR-42

RR

2132-01-21 16:51:00

2132-01-21 17:39:00

EXAMINATION: FOOT AP,LAT AND OBL LEFT PORT INDICATION: ___ year old woman with epilepsy with recent leg fracture. now with heel ulcer// heel ulcer, OM? TECHNIQUE: AP, lateral and oblique view radiographs of the left foot. COMPARISON: None. FINDINGS: Diffuse osteopenia is noted. No acute fracture or dislocation is seen. There are sclerotic changes along the second, third and fourth metatarsal necks, which most likely represent subacute/chronic fractures. Mild degenerative changes are seen in the hindfoot and midfoot. There is a small plantar calcaneal spur. There is a small skin defect along the posterior aspect of the calcaneus. There is no adjacent cortical erosion, focal osteopenia or periosteal reaction. IMPRESSION: 1. Small skin defect along the posterior aspect of the calcaneus. No radiographic evidence of osteomyelitis. If there is high clinical concern for osteomyelitis, further evaluation may be performed with MRI with contrast or nuclear medicine bone scan. 2. Sclerotic changes along the second, third and fourth metatarsal necks, which most likely represent subacute/chronic fractures. 3. Please see separate report from concurrently performed radiographs of the left tibia and fibula for additional findings.

10012206-RR-13

RR

2127-07-04 11:50:00

2127-07-04 15:22:00

EXAMINATION: DUPLEX DOPP ABD/PEL INDICATION: Concern for SMV thrombus due to pancreatic pseudocyst compression TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: CT abdomen and pelvis ___, performed at an outside facility. FINDINGS: Liver: The hepatic parenchyma is diffusely echogenic. A hypoechoic region near the gallbladder measures 4.2 x 2.8 x 3.3 cm, likely reflecting focal fatty sparing. No focal liver lesions are identified. There is no ascites. Bile ducts: There is no intrahepatic biliary ductal dilation. CHD: 6 mm Gallbladder: There is cholelithiasis without evidence of cholecystitis. Pancreas: The pancreas is obscured by overlying bowel gas. Spleen: The spleen demonstrates normal echotexture. Heterogeneous collections adjacent to the spleen appears as on the prior CT. Spleen length: 12.6 cm Kidneys: No stones, masses, or hydronephrosis are identified in either kidney. Right kidney: 13.6 cm Left kidney: 13.0 cm Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 31 cm/sec. Right and left portal veins are patent, with antegrade flow. Right, middle and left hepatic veins are patent, with appropriate waveforms. Limited evaluation of the splenic vein and superior mesenteric vein due to overlying bowel gas. The visualized splenic vein and superior mesenteric vein are patent, with antegrade flow. IMPRESSION: 1. Patent hepatic vasculature. 2. Limited evaluation of the splenic vein and superior mesenteric vein. The visualized portions of the splenic and superior mesenteric veins appear patent. 3. Diffusely echogenic liver suggestive of a degenerative cyst or intrinsic liver disease. 4. Heterogeneous collections adjacent to the spleen as on the prior CT, likely sequela of known pancreatitis. 5. Cholelithiasis, without evidence of acute cholecystitis.

10012206-RR-16

RR

2127-07-06 20:51:00

2127-07-06 22:02:00

EXAMINATION: CTA ABD AND PELVIS INDICATION: ___ year old man with possible SMV thrombus// please perform a CTV looking for SMV thrombus TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. MIP reconstructions were performed on independent workstation and reviewed on PACS. DOSE: Acquisition sequence: 1) Spiral Acquisition 3.6 s, 57.7 cm; CTDIvol = 4.0 mGy (Body) DLP = 228.7 mGy-cm. 2) Spiral Acquisition 4.4 s, 57.7 cm; CTDIvol = 14.5 mGy (Body) DLP = 834.5 mGy-cm. Total DLP (Body) = 1,063 mGy-cm. COMPARISON: CT abdomen and pelvis from ___ FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. Focal chronic dissection in the abdominal aortic aorta just inferior to the ___ is noted (series 301, image 93). No aneurysmal dilatation. The common hepatic artery is replaced and originates from the SMA. The main portal vein, portal splenic confluence and proximal SMV are patent. There is nonocclusive thrombus in the splenic vein (series 301, image 60 and series 601, image 62). A second order jejunal branch is highly narrowed however remains patent (series 301, image 91). LOWER CHEST: Bilateral lower lobe atelectasis are noted specially on the left. ABDOMEN: HEPATOBILIARY: The liver is not cirrhotic. In segment IVB, there is a 3 cm hypodense area (series 301, image 57). On the prior exam, this region appears slightly hyperdense which could thus represent a focal area of fat sparing. The gallbladder is within normal limits, without stones or gallbladder wall thickening. PANCREAS: Multiple peripancreatic collections are again noted. This collection are overall unchanged in size as described below on series 301: 1. Collection at the tail of pancreas measuring 5.5 x 3.6 x 6.3 cm (image 64). 2. Perisplenic collection measuring 2.5 x 2 x 3 cm (image 71). 3. Lesser sac collection measuring 2.7 x 3.5 by 2.3 cm (image 51). 4. Collection at the head of the pancreas measuring 3.7 x 2.6 x 3.9 cm (image 92). 5. Multiloculated collection extending inferiorly from the head of the pancreas to the right lower quadrant measures approximately 13 x 3 x 2.6 cm (images 116 and 128). 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. A punctate calcification in the medial limb of the right adrenal gland may represent sequela from prior hemorrhage or inflammation. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of stones, focal renal lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness and enhancement throughout. Colon and rectum are within normal limits. A jejunal tube is noted in the left lower quadrant. Multiple subcentimeter mesenteric reactive lymph node are noted. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: Small fat containing right inguinal hernia. There is a neural stimulator in the subcutaneous tissue at the level of L1. IMPRESSION: 1. Multiple peripancreatic collections are unchanged from recent prior. 2. Nonocclusive thrombus in the splenic vein. A second order jejunal branch of the SMV is narrowed however remains patent.

10012206-RR-17

RR

2127-07-08 17:38:00

2127-07-08 18:24:00

INDICATION: ___ year old man with NJT. Having nausea with tube flushes, want to confirm location// confirm NJ placement TECHNIQUE: Portable supine abdominal radiograph. COMPARISON: CT abdomen and pelvis ___. IMPRESSION: There is a nasojejunal tube which terminates in the expected region of the proximal jejunum in the left hemiabdomen. There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. A spinal cord stimulator device projects over the right side of the abdomen. No acute osseous abnormalities are identified.

10012206-RR-18

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2127-07-09 18:01:00

2127-07-09 20:39:00

INDICATION: ___ year old man with pancreatitis and cholelithiasis with intaabdominal fluid collections around pancreas. Planning for cholecystectomy at some point// Would like evaluation for drainage of peripancreatic fluid collections noted on CT abdomen. Concerned for peripancreatic necrosis COMPARISON: Prior CT abdomen done ___ PROCEDURE: CT-guided right paracolic gutter and left peripancreatic collection aspiration OPERATORS: Dr. ___, radiology 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 left lateral decubitus position on the CT scan table. Limited preprocedure CTscan of the intended aspiration area was performed. Based on the CT findings an appropriate position for the aspiration was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the right paracolic collection. 3 cc of milky fluid was aspirated. Subsequently the patient was placed in a right lateral decubitus position on the CT scan table. Limited preprocedure CTscan of the intended aspiration area was performed. Based on the CT findings an appropriate position for the aspiration was chosen. The site was marked. The site was prepped and draped in the usual sterile fashion. 1% lidocaine were administered to the subcutaneous and deep tissues for local anesthetic effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the peripancreatic collection. 5 cc of straw-colored, blood tinged fluid was aspirated. Postprocedural images through the upper abdomen demonstrate no immediate complications. The procedure was tolerated well and there were no immediate post-procedural complications. DOSE: Acquisition sequence: 1) Spiral Acquisition 4.7 s, 14.4 cm; CTDIvol = 10.3 mGy (Body) DLP = 134.9 mGy-cm. 2) Stationary Acquisition 7.6 s, 1.4 cm; CTDIvol = 79.0 mGy (Body) DLP = 113.8 mGy-cm. 3) Spiral Acquisition 7.7 s, 23.5 cm; CTDIvol = 9.6 mGy (Body) DLP = 213.0 mGy-cm. 4) Stationary Acquisition 32.5 s, 1.4 cm; CTDIvol = 338.7 mGy (Body) DLP = 487.7 mGy-cm. 5) Spiral Acquisition 4.5 s, 13.7 cm; CTDIvol = 10.4 mGy (Body) DLP = 129.5 mGy-cm. Total DLP (Body) = 1,098 mGy-cm. SEDATION: Moderate sedation was provided by administering divided doses of 3 mg Versed and 200 mcg fentanyl throughout the total intra-service time of 51 minutes during which patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. FINDINGS: 1. Sample 1: 3 cc of milky fluid was aspirated from the right paracolic gutter collection. 2. Sample 2: 5 cc of straw-colored, blood tinged fluid was aspirated from the peripancreatic collection. IMPRESSION: Technically successful CT-guided aspiration of the collections as described above.

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2179-10-20 17:44:00

2179-10-20 17:57:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: History: ___ with dizziness// eval PNA TECHNIQUE: Chest PA and lateral COMPARISON: None. FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality.

10012688-RR-21

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2179-10-20 18:41:00

2179-10-20 19:54:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: History: ___ with dizziness, presyncope// eval bleed TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. Coronal and sagittal reformations as well as bone algorithm reconstructions were provided and reviewed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm. COMPARISON: None. FINDINGS: There is no evidence of acute large territorial infarction,hemorrhage,edema,or mass effect. The ventricles and sulci are normal in size and configuration. There is no evidence of fracture. Minimal mucosal thickening is seen within the right sphenoid sinus posteriorly. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: No acute intracranial abnormality.

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2179-10-21 20:43:00

2179-10-21 22:56:00

EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD INDICATION: ___ year old woman with persistent dizziness and gait unsteadiness. Exam notable for L nasolabial fold flattening, truncal ataxia. Eval for infarct.// eval for posterior circulation infarct TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CT head ___ FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. Normal flow voids are demonstrated bilaterally. IMPRESSION: 1. Normal brain MRI.

10012853-RR-12

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2176-06-06 14:39:00

2176-06-06 15:04:00

EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with dizziness, weakness // r/o acute process TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: The lungs are hyperinflated, with flattening of the diaphragms.Bibasilar atelectasis is seen without focal consolidation. There is mild pulmonary vascular congestion. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are grossly stable IMPRESSION: Hyperinflated lungs. Mild pulmonary vascular congestion. No focal consolidation.

10013015-RR-10

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2121-07-28 18:20:00

2121-07-28 18:42:00

EXAMINATION: RENAL U.S. INDICATION: ___ year old woman with ___ on CKD. Non gap Acidosis// Eval for obstruction TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were obtained. COMPARISON: None. FINDINGS: There is a small right pleural effusion. There is no hydronephrosis, stones, or masses bilaterally. There is an 8 mm simple cyst in the right interpolar kidney. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney: 8.4 cm Left kidney: 9.8 cm The bladder is moderately well distended and normal in appearance. IMPRESSION: 1. Atrophic kidneys bilaterally. No hydronephrosis. 2. Small right pleural effusion.

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2121-07-29 15:06:00

2121-07-29 16:19:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ w/ Afib on Coumadin, chronic kidney disease, COPD, severe pulmonary hypertension, O2 dependent, here for 3rd degree heart block, with new bacteremia GPCs in clusters// ?pneumonia, consolidation ?pneumonia, consolidation IMPRESSION: Heart size is top-normal. Mediastinum is stable. Right basal opacities are minimal and unchanged, unlikely to represent infectious process but attention on the subsequent radiographs is recommended to this area. No pleural effusion or pneumothorax is seen

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2121-08-08 20:00:00

2121-08-08 21:00:00

EXAMINATION: CT CHEST W/O CONTRAST INDICATION: Ms. ___ is an ___ female with history of A. fib on Coumadin, chronic kidney disease, COPD on 2L O2, severe pulmonary hypertension who is presenting as a transfer from ___ for bradycardia likely due to metabolic disturbances in the setting ___ from right sided heart failure/HFpEF. RHC showing normal PCWP and severe pulm HTN of unclear etiology.// Please eval lung parenchyma for potential etiology of pulm HTN TECHNIQUE: CT of the chest was performed without IV contrast. DOSE: Acquisition sequence: 1) Spiral Acquisition 9.0 s, 34.7 cm; CTDIvol = 10.0 mGy (Body) DLP = 336.9 mGy-cm. Total DLP (Body) = 349 mGy-cm. COMPARISON: No prior chest CT for direct comparison. Correlation with chest radiographs dated ___ and ___. FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid gland is unremarkable. There is no axillary lymphadenopathy. The chest wall is unremarkable. Left breast shows some skin thickening and increased attenuation of fat probably due to edema. This may be due to fluid shifts, noting bilateral ill-defined subcutaneous fluid that is probably due to fluid overload, along each flank, but left greater than right. It is possible that the asymmetry in the breasts may be positional. UPPER ABDOMEN: There is a small hiatal hernia. There is cholelithiasis without evidence of acute cholecystitis. MEDIASTINUM: There is no mediastinal lymphadenopathy. The upper esophagus is thin walled but ectatic and air-filled. HILA: There is no hilar lymphadenopathy. HEART and PERICARDIUM: The heart is normal in overall size, without pericardial effusion, although left-sided chambers are smaller than right, which is not normal. Coronary artery calcifications are present. PLEURA: There is a small right and trace left pleural effusion. LUNG: 1. PARENCHYMA: There is moderate upper lobe predominant centrilobular emphysema. No focal consolidation is identified. There are a few scattered pulmonary nodules, the largest measuring 4 mm in the right upper lobe (5:81). 2. AIRWAYS: The airways are clear to the subsegmental level. 3. VESSELS: The main pulmonary artery measures up to 2.7 cm (5:123). Central pulmonary arteries are not particularly enlarged. The thoracic aorta is normal in course and caliber, with moderate atherosclerotic calcifications. CHEST CAGE: There are old healed fractures of the left seventh and eighth ribs. Degenerative changes are seen throughout the spine. IMPRESSION: 1. No evidence of interstitial lung disease. 2. Moderate upper lobe predominant centrilobular emphysema. 3. Small bilateral pleural effusions with minor associated atelectasis. '' 4. Coronary calcification. 5. Cholelithiasis without evidence of acute cholecystitis. 6. Few small lung nodules measuring up to at most 4 mm. These are very likely benign, but noting emphysema may be appropriate to consider follow-up chest CT for surveillance in ___ year. RECOMMENDATION(S): Follow-up chest CT is recommended for surveillance of very small, probably benign, lung nodules in ___ year.3.

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2121-08-09 12:26:00

2121-08-09 13:16:00

EXAMINATION: DUPLEX DOP ABD/PEL LIMITED INDICATION: requesting RUQUS with Doppler to evaluate for portopulmonary HTN TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen was performed. COMPARISON: None available FINDINGS: Liver: The hepatic parenchyma is within normal limits. No focal liver lesions are identified. There is no ascites. There is a small right pleural effusion. Bile ducts: There is no intrahepatic biliary ductal dilation. CHD: 5 mm Gallbladder: There is cholelithiasis without evidence of cholecystitis. Pancreas: The imaged portion of the pancreas appears within normal limits, with portions of the pancreatic tail obscured by overlying bowel gas. Doppler evaluation: The main portal vein is patent, with flow in the appropriate direction. Main portal vein velocity is 25.2 cm/sec. Right and left portal veins are patent, with antegrade flow. The main hepatic artery is patent. There is loss of diastolic flow in the main hepatic artery. This is likely secondary to congestive heart failure. Right, middle and left hepatic veins are patent, with appropriate waveforms. IMPRESSION: 1. Patent hepatic vasculature. No evidence for portal vein thrombosis 2. Loss of diastolic flow in the main hepatic artery is likely secondary to hepatic congestion. 3. Cholelithiasis without cholecystitis. 4. Small right pleural effusion.

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2121-08-10 10:31:00

2121-08-10 14:38:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with new P-HTN, undergoing workup for possible causes.// Prior to V/Q scan Prior to V/Q scan COMPARISON: Chest x-ray ___ FINDINGS: The heart is mildly enlarged. Costophrenic angles are sharp. There is mild interstitial pulmonary edema. Right infrahilar and basilar opacity which could represent pneumonia. IMPRESSION: Mild cardiomegaly with mild interstitial pulmonary edema. Right infrahilar and basilar opacity which could represent pneumonia.

10013310-RR-12

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2153-06-10 10:52:00

2153-06-10 11:08:00

EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK INDICATION: History: ___ with stroke s/p tpa// ?thrombus TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP = 2,513.8 mGy-cm. 3) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 76.2 mGy (Head) DLP = 38.1 mGy-cm. 4) Spiral Acquisition 4.7 s, 36.9 cm; CTDIvol = 31.8 mGy (Head) DLP = 1,175.4 mGy-cm. Total DLP (Head) = 4,630 mGy-cm. COMPARISON: None. FINDINGS: CT HEAD WITHOUT CONTRAST: There is gyral swelling and sulci effacement in the left middle cerebral artery territory. There is a subtle hypodensity within the left MCA territory. There is a 1.1 cm hypodensity in the right frontal lobe white matter which likely represents chronic infarction. There is no evidence of hemorrhage or mass. The ventricles and sulci are prominent suggestive of involutional changes. Incidental note is made of cavum septum pellucidum. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits show bilateral lens replacement. CT PERFUSION: Large area of mismatch in the left MCA territory suggestive of infarct. Mismatch volume 48 mL and mismatch ratio of 2. CTA HEAD: There is complete occlusion of the left MCA at the M2 bifurcation. There is decreased density of vessels in the left MCA territory. The remaining vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis, occlusion, or aneurysm formation. The dural venous sinuses are patent. CTA NECK: There is calcification of the V4 segment of the right vertebral artery causing mild stenosis. There mild narrowing of the right internal carotid artery at its origin with no stenosis by NASCET criteria. The area of hypodensity and diameter change in the proximal left vertebral artery is likely due to artifact. There is no evidence of left internal carotid stenosis by NASCET criteria. There is a small outpouching within the neck at the left ICA origin that may represent an ulcer. There are dense calcifications of bilateral cavernous and supraclinoid internal carotid arteries causing mild stenosis. OTHER: The visualized portion of the lungs show dependent atelectasis of the left lobe of the lung. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Evidence of early left MCA infarct with gyral swelling and sulci effacement. 2. Complete occlusion of the left MCA at the M2 bifurcation. 3. Atherosclerotic plaque at the internal carotid artery origins bilaterally with no evidence of stenosis by NASCET criteria. 4. Possible ulcer of the proximal left internal carotid artery. 5. Mild atherosclerotic narrowing of bilateral cavernous and supraclinoid internal carotid arteries and the right V4.

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2153-06-10 14:30:00

2153-06-10 17:05:00

EXAMINATION: Portable AP chest INDICATION: ___ with CVA// r/o PNA TECHNIQUE: Semi-upright portable AP chest COMPARISON: None. FINDINGS: Lungs are well aerated. Heart size and lung markings are accentuated by AP technique. Within this limitation, there is mild cardiomegaly. Mild pulmonary vascular congestion and interstitial edema. No large pleural effusions. No pneumothorax. IMPRESSION: Mild cardiomegaly with mild pulmonary edema.

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2153-06-10 11:11:00

2153-06-11 07:44:00

EXAMINATION: Left internal carotid artery angiogram. Mechanical thrombecomy, left middle cerebral artery. Right common femoral artery INDICATION: ___ year old woman with L MCA syndrome, s/p TPA with nihss 26lkw ___// intervention candidate TECHNIQUE: anesthesia: Conscious sedation with local analgesia provided by anesthesia team, please see separate sheets for medications and dosing. Patient was brought into the angio suite, ID was confirmed via wrist band.The patient was placed supine on fluoroscopy table and bilateral groins were prepped and draped in the usual sterile manner. Time-out procedure was performed per institutional guidelines. The location of the right mid femoral head was located using anatomic and radiographic landmarks. 10 +10 cc of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was used to gain access to the right femoral artery, serial dilation was undertaken until a long 8 ___ groin sheath connected to a continuous heparinized saline flush could be inserted. ___ catheter was connected to the power injector and also to a continuous heparinized saline flush. This was advanced over the 0.038 glidewire brought up the aorta used to select the left internal carotid artery under roadmap guidance. AP and lateral views of the anterior cerebral circulation were obtained . Under direct road map guidance, the diagnostic catheter was removed utilizing an exchange wire and 6 ___ cook shuttle was advanced until it was parked in a satisfactory position the internal carotid artery. New AP and lateral road maps were obtained, ___ ___ intermediate catheter was advanced over synchro 2 wire and Trevo ProVue microcatheter. Synchro 2 wire in the microcatheter were advanced slowly and carefully until positioned beyond the clot in superior division of the MCA, then the ___ ___ was advanced slowly and carefully until proximal M1, synchro wire was removed and a micro injection was done to verify position then 4MM X 30 mm stent was deployed, and the ___ was connected to suction. Few min later, the stent, the microcatheter and the ___ plus were withdrawn as a single unit into the Cook shuttle, then it was removed under direct and constant manual suction. New AP and lateral angio run were obtained from the Cook shuttle which showed worsening of the occlusion to involve the whole MCA (the inferior division was patent at the beginning of the case) Due to that we decided to attempt another pass utilizing the same technique the same instruments which was successful to restore the superior division MCA territory. Third pass was attempted with focus on revascularizing the inferior division, utilizing the same technique and the same instruments. Which was successful. After 3 passes a de magnified angio runs were obtained and showed distal emboli in an M3 and M4 branches of the superior division of the MCA and an embolus in the callosal marginal branch of the ACA. We planned for a fourth attempt to the further re-vascularize the superior division, upon exploration of that branch it was deemed too risky to deploy the stent so this attempt was aborted. Final AP and lateral views of the left anterior circulation were obtained after. The catheter was then pulled back in the aorta fully removed from the body. A common femoral arteriogram was performed prior to use of a closure device, subsequently 8 Angio-Seal was put in. At the conclusion of the procedure, there is no evidence of thromboembolic complication and the patient started to move the affected side on the angio table. Devices inventory: .038" 150cm Angled Glidewire 035 x 150cm ___ Wire ___ x 25cm Terumo Sheath Set ___ ___ 2 Cath. 100cm ___ Micropuncture Set 038 Angled Glidewire Exchange Synchro2 Standard 14 200cm Wire ___ .071 95cm Benchmark Delivery Catheter ___ ___ 0.070 x 125cm Guiding Catheter Trevo Retriever 4 x 30 ___ ___ 3mm x 23mm Mindframe Capture Revascularization Device ___ ???? ___ Angio Seal Evolution Closure Device ___ COMPARISON: None FINDINGS: Left internal carotid artery: Distal left ICA, proximal and distal ACA branches are well-visualized. Pre thrombectomy: No opacifications of the superior division of the MCA. Post thrombectomy: Successful recannulization of the MCA territory compatible with TICI score 2b with distal emboli in an M3 and M4 branches of the superior division of the MCA and an embolus in the callosal marginal branch of the ACA. Otherwise, vessel caliber smooth and tapering. Normal arterial, capillary, and venous phase . No vascular abnormalities identified . Right common femoral artery: Well-visualized with a good caliber size for closure device. I, Abdulrahman ___, participated in the procedure. I, ___, was present for the entirety of the procedure and supervised all critical steps. I, ___, have reviewed the report and agree with the fellow's findings. IMPRESSION: Successful recannulization of the left MCA territory compatible with TICI score 2b after 3 passes. RECOMMENDATION(S): Stroke management as per usual protocol.

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2153-06-10 13:40:00

2153-06-10 15:02:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with ___ F tx from ___ with L MCA infarct. LKW 0829 am ___. TPA 10:05 am ___. taken emergently for thrombectomy distal M1 clot at 11:00 am.// stat NCHCT s/p cerebral angio with apnea and pupil asymmetry, right sided pleagia TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.2 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: CTA head ___. FINDINGS: There is an acute left MCA infarct with sulci effacement and gyral swelling. Diffuse uniform left hemispheric hyperdensity is likely due to contrast enhancement, however superimposed petechial hemorrhage cannot be excluded. There is a small focus of air seen in the subarachnoid space on image 26 of series 2. There is no evidence of new infarction,or mass. Again seen is a hypodensity within the right frontal lobe which appears stable compared to prior study. There is prominence of the ventricles and sulci suggestive of involutional changes. The basal cisterns are patent. Incidental note is made of cavum septum pellucidum. Contrast is seen within the vessels of the circle of ___. There is no evidence of fracture. There is mild mucosal thickening of the ethmoid air cells. The visualized portion of the remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. There is an acute left MCA infarct. 2. Diffuse uniform left hemispheric hyperdensity, most likely due to contrast enhancement, however superimposed petechial hemorrhage cannot be excluded. 3. If the distinction between the cortical hemorrhage and enhancement is significant, this may be pursued with a follow-up head CT or with an MR examination.

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2153-06-11 10:10:00

2153-06-11 11:29:00

EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD INDICATION: ___ year old woman with left MCA syndrome// extent of infarct TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was performed with gradient echo, FLAIR, diffusion, and T2 technique were then obtained. COMPARISON CTA and CT head ___. FINDINGS: There is acute infarction involving predominantly the cortex, involving left frontal, temporal, and parietal lobes, the insula and sub insula, and the left putamen and caudate resulting in an ASPECTS of 1. Left internal capsule is probably not involved. There is involvement of the left occipital lobe. There is blooming gyriform signal on GRE within the inferior parietal lobe, lateral occipital lobe, and posterior temporal lobe suggestive of cortical microhemorrhage. There is no parenchymal hematoma. There is a positive susceptibility vessel sign in the left M3 branch of the MCA, suggestive for intravascular thrombus. There is evidence of local mass effect on the left lateral ventricle. No midline shift. There is evidence of a chronic infarction within the right frontal lobe corona radiata.. There is no evidence of masses, or midline shift. There is generalized brain parenchymal atrophy. No hydrocephalus. IMPRESSION: 1. Acute infarction involving the left MCA territory, ASPECTS of 1. There is involvement of the left occipital lobe. Evidence of cortical microhemorrhage on gradient images only within the parietal, occipital, and temporal lobe. No evidence of parenchymal hematoma 2. Chronic small right frontal lobe infarct. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 11 30 pm, 15 minutes after discovery of the findings.

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2153-06-11 15:23:00

2153-06-11 15:50:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with ___ F tx from ___ hospital with L MCA infarct. LKW 0829 am ___. TPA 10:05 am ___. taken emergently for thrombectomy M1/M2 clot TICI 2b at 11:00 am.// portable to assess placement of NGT portable to assess placement of NGT IMPRESSION: Comparison to ___. The course of the feeding tube is unremarkable, the tip is not included on the image. Low lung volumes. Moderate cardiomegaly with moderate pulmonary edema. No larger pleural effusions. Bilateral subtle areas of atelectasis but no evidence of pneumonia. No pneumothorax.

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2153-06-12 09:19:00

2153-06-12 12:41:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with L MCA infarct, h/o CHF// r/o pulm edema, r/o asp pna TECHNIQUE: Single frontal view of the chest COMPARISON: None. FINDINGS: Enteric tube terminates in the stomach. Severely enlarged cardiac contours is similar to prior. No pneumothorax. No pleural effusions. There is mild bilateral pulmonary edema. IMPRESSION: Mild bilateral pulmonary edema, similar to prior. Severe cardiomegaly unchanged.

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2153-06-13 02:19:00

2153-06-13 11:13:00

EXAMINATION: Chest radiograph INDICATION: ___ year old woman with L MCA// edema TECHNIQUE: Chest AP COMPARISON: Chest radiograph of ___ FINDINGS: An enteric tube terminates underneath the left hemidiaphragm outside of the field of view. There remains mild bilateral pulmonary edema. An asymmetric opacity in the right lower lobe is new from prior, concerning for aspiration. New retrocardiac opacity is most likely atelectasis. Severe cardiomegaly is unchanged. No pleural effusion or pneumothorax. IMPRESSION: -Developing asymmetric opacity in the right lower lobe is suspicious for aspiration or pneumonia. - New left lower lobe atelectasis. -Mild pulmonary edema is otherwise unchanged. -Stable severe cardiomegaly.

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2153-06-14 10:00:00

2153-06-14 12:09:00

EXAMINATION: CHEST (PA AND LAT) INDICATION: ___ year old woman with large stroke// concern for infiltrate versus aspiration versus volume status concern for infiltrate versus aspiration versus volume status IMPRESSION: ___. Left lower lobe atelectasis has improved substantially. Small bilateral pleural effusions are smaller. Moderate to severe cardiomegaly and pulmonary vascular engorgement have both improved. No pulmonary edema. No pneumothorax. Nasogastric drainage tube passes into the stomach and out of view. Compared to chest radiographs

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2153-06-15 19:03:00

2153-06-15 19:56:00

EXAMINATION: Chest radiograph INDICATION: ___ year old woman with CVA// dobhoff placement TECHNIQUE: 3 portable frontal views of the chest. COMPARISON: ___. IMPRESSION: Compared to the examination from 1 day prior, the existing upper enteric tube has been removed and a Dobhoff tube has been placed with the final image demonstrating the tip within the mid gastric body, satisfactory. No other significant interval changes seen. Cardiomegaly is unchanged. The mediastinal silhouette is unchanged. No new dense consolidation is seen. There is probable persistent mild basilar atelectasis.

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2153-06-18 12:53:00

2153-06-18 16:14:00

EXAMINATION: Video fluoroscopy INDICATION: ___ year old woman with new stroke// swallowing abilities TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 02:09 min. COMPARISON: None. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration or penetration. IMPRESSION: No gross aspiration or penetration. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations.

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2153-06-21 00:47:00

2153-06-21 03:45:00

EXAMINATION: CT HEAD W/O CONTRAST INDICATION: ___ year old woman with large left MCA territory stroke s/p TPA and thrombectomy now minimally responsive.// Evaluate for intracranial hemorrhage. TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained without intravenous contrast. Coronal and sagittal reformations and bone algorithms reconstructions were also performed. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.6 cm; CTDIvol = 48.6 mGy (Head) DLP = 903.1 mGy-cm. Total DLP (Head) = 903 mGy-cm. COMPARISON: MRI brain from ___. CT head from ___. FINDINGS: Left MCA infarct redemonstrated with expected evolution, with increased cortical hypodensity of the left frontal, parietal and temporal lobes. In addition, there is subtle gyriform cortical hyperdensity, predominantly involving the frontal, temporal and parietal operculum, likely representing mineralization/cortical laminar necrosis. Subtle hyperdensity of the left putamen and anterior insula is minimally more conspicuous compared to prior examination of ___, compatible with petechial hemorrhage. Otherwise, no evidence of new hemorrhagic conversion. No evidence of new acute large territory infarct. Chronic right frontal lobe infarct again noted. No definite new infarct. Cavum septum ventricles and sulci are unchanged in size and configuration. No acute fracture. The paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. Left MCA infarct redemonstrated with expected evolution. No evidence of new hemorrhagic conversion. 2. Additional findings described above.

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2153-06-21 17:57:00

2153-06-21 18:30:00

INDICATION: ___ year old woman with LMCA stroke, may be aspirating, febrile// PNA/aspiration TECHNIQUE: AP and lateral chest radiographs COMPARISON: ___ FINDINGS: The tip of the Dobhoff projects beyond the field of view of this radiograph on the AP view but likely within the stomach on the lateral view. The size of the cardiac silhouette is enlarged but unchanged. Ill-defined opacities at the left lung base have increased and may reflect atelectasis or aspiration/pneumonia. There is no pleural effusion or pneumothorax. IMPRESSION: Increased left basilar opacities may reflect atelectasis or aspiration/pneumonia.

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2153-06-23 09:29:00

2153-06-23 11:43:00

INDICATION: ___ yoF w/ CVA and s/p STEMI and NSTEMI with stents now on tube feeds with low grade fever. eval for pna// ___ yoF w/ CVA and s/p STEMI and NSTEMI with stents now on tube feeds with low grade fever. eval for pna TECHNIQUE: AP portable chest radiograph COMPARISON: ___ FINDINGS: The size of the cardiac silhouette is enlarged but unchanged. Retrocardiac opacities may reflect atelectasis or pneumonia given the provided clinical history. There is no pleural effusion or pneumothorax identified. IMPRESSION: Retrocardiac opacities may reflect atelectasis and/or pneumonia given the provided clinical history.

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2153-06-23 13:39:00

2153-06-23 14:31:00

EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: ___ yoF w/ CVA and s/p STEMI and NSTEMI with stents now on tube feeds with low grade fever.// ___ yoF w/ CVA and s/p STEMI and NSTEMI with stents now on tube feeds with low grade fever. Eval for any locus of infection TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 2 mm. GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. PANCREAS: The head and body of the pancreas are within normal limits. The tail of the pancreas is not visualized due to the presence of gas. SPLEEN: Normal echogenicity, measuring 9 cm. KIDNEYS: The right kidney measures 12.2 cm. There is no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Unremarkable abdominal ultrasound.

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2153-06-23 17:27:00

2153-06-23 21:42:00

INDICATION: ___ year old woman with new Dobhoff placement// Assess Dobhoff placement TECHNIQUE: AP portable chest radiograph COMPARISON: ___ from earlier in the day FINDINGS: There has been interval placement of a Dobhoff which projects over the stomach. The size of the cardiac silhouette is enlarged but unchanged. Retrocardiac opacities likely reflect atelectasis. There is increased pulmonary vascular congestion as demonstrated by indistinctness of the pulmonary vascular chair. A left pleural effusion is suspected. No pneumothorax. IMPRESSION: The Dobhoff projects over the stomach. Increased pulmonary vascular congestion. Retrocardiac opacities persist may reflect atelectasis or pneumonia.

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2153-06-25 11:38:00

2153-06-25 12:23:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old woman with known aspiration and fevers c/f PNA, also dobhoff placement// dobhoff placement and PNA dobhoff placement and PNA IMPRESSION: Compared to chest radiographs since ___ most recently ___. Moderate cardiomegaly is chronic. Large heart obscures the left lower lobe where there is at least some atelectasis. Lateral view would be helpful to decide if there is pneumonia, and to assess pleural effusions probably small to moderate on both sides. No pulmonary edema. Pulmonary vasculature mildly engorged.

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2153-06-28 15:39:00

2153-06-28 20:45:00

EXAMINATION: Chest radiograph INDICATION: ___ year old woman with dysphagia requiring Dobhoff. DOBHOFF PLACEMENT TECHNIQUE: Frontal x-ray COMPARISON: Prior radiographs, recently ___ FINDINGS: In the first x-ray the dobhoff tube terminates in lower ___ of the esophagus, in the following x-ray terminates in the stomach. No lung consolidations. No evidence of pulmonary congestion or pleural effusions. Moderate cardiomegaly is chronic, left lower lobe minimal atelectasis unchanged. IMPRESSION: Dobhoff tube terminates in the stomach in good position

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2153-06-29 15:49:00

2153-06-29 18:33:00

EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS INDICATION: ___ year old woman with new dobhoff, two step// new dobhoff TECHNIQUE: Chest single view COMPARISON: ___ 16:18 FINDINGS: Feeding tube tip in proximal to mid stomach. Cardiac enlargement, similar. Stable pulmonary vascularity. Improved basilar opacities probable trace pleural effusions. No pneumothorax. IMPRESSION: Enteric tube tip below diaphragm.

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2153-07-01 14:11:00

2153-07-01 15:13:00

EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS INDICATION: ___ year old woman with stroke, dobhoff re-placement after self removal// DOBHOFF placement IMPRESSION: In comparison with study of ___, the opaque portion of the Dobhoff tube again straddles the esophagogastric junction, it could be pushed forward 5-8 cm for more optimal positioning. Otherwise, little change.

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2153-07-04 13:33:00

2153-07-04 15:48:00

EXAMINATION: UNILAT LOWER EXT VEINS INDICATION: ___ year old woman with LLE pain and swelling// c/f DVT TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins.

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2153-07-05 11:33:00

2153-07-05 14:53:00

EXAMINATION: Portable chest radiograph INDICATION: ___ year old woman with tachypnea// pulmonary edema vs new PNA in this pt with recurrent aspiration TECHNIQUE: Portable AP chest COMPARISON: Chest radiograph ___ FINDINGS: Lung volumes are low. There is increased opacification of the right lung base which is likely secondary to atelectasis. There is bibasilar atelectasis, left worse than right, and likely small bilateral pleural effusions. There is minimal pulmonary vascular congestion. The cardiomediastinal silhouette is mildly enlarged and stable. Dobhoff feeding tube projects over the stomach. IMPRESSION: Increased opacity at the right lung base which could be secondary to atelectasis, however a superimposed infectious process/aspiration cannot be excluded. Small bilateral pleural effusions and minimal pulmonary vascular congestion. Stable left basilar atelectasis.

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2153-07-05 13:41:00

2153-07-05 14:20:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old woman with known LMCA stroke this admission, now with breathing pattern with apnea, change in mental status// Evaluate for any new ischemic process, hemorrhage, evolution of known LMCA stroke TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP = 934.3 mGy-cm. Total DLP (Head) = 934 mGy-cm. COMPARISON: MRI brain ___. Head CT ___. FINDINGS: There is large left MCA late subacute, early chronic infarct, which has evolved since priors, with interval volume loss. There are areas of linear increased attenuation within the cortex of the infarcted territory, more prominent since prior, and in the area of inferior left sub insula, which is likely combination of cortical mineralization and/or microhemorrhage, there are areas of microhemorrhage on MRI ___. There is no gyral expansion or edema. There is no hematoma. No definite infarct extension compared to prior. Small chronic infarct right frontal lobe extending into corona radiata, as on prior. There is no evidence of acute infarction,edema,or mass. There is generalized brain parenchymal atrophy, with interval volume loss in the left hemisphere. No hydrocephalus. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. Nasal tube in place. IMPRESSION: Stable distribution of infarcts, with large left MCA late subacute to chronic infarct, with areas of predominant cortical mineralization, with possible smaller components of cortical microhemorrhage, and interval volume loss. There is no gyral expansion or edema. There is no parenchymal hematoma

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2153-07-11 10:52:00

2153-07-11 14:31:00

EXAMINATION: Full AP radiographs. INDICATION: ___ year old woman with CHF, tachypnea// Eval volume status, pulmonary edema TECHNIQUE: AP chest x-ray COMPARISON: Prior chest radiograph dated ___. FINDINGS: A Dobhoff feeding tube is seen terminating within the body of the stomach. A small right pleural effusion with overlying atelectasis has worsened since prior imaging. The small left pleural effusion is unchanged. Interval worsening of pulmonary vascular congestion. Cardiomediastinal silhouette is stable. IMPRESSION: Worsening of pulmonary vascular congestion and small right-sided pleural effusion.

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2153-07-15 16:20:00

2153-07-15 21:53:00

INDICATION: ___ year old woman with MCA stroke, NSTEMI, recurrent aspiration neurological deficits// PEG placement for nutrition. COMPARISON: None. TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___ radiologist performed the procedure. Dr. ___ ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. ANESTHESIA: General anesthesia was administered by the anesthesiology department. Please refer to anesthesiology notes for details. MEDICATIONS: 1 mg of intravenous glucagon. CONTRAST: 15 ml of Optiray contrast. FLUOROSCOPY TIME AND DOSE: 2.9 min, 7 mGy PROCEDURE: 1. Placement of a ___ gastrostomy tube placement. PROCEDURE DETAILS: Following the discussion of the risks, benefits and alternatives to the procedure, written informed consent was obtained from the health care proxy. 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 tube site was prepped and draped in the usual sterile fashion. A scout image of the abdomen was obtained. The stomach was insufflated through the indwelling nasogastric tube. Using a marker, the skin was marked using palpation to feel the costal margins and the liver edge was marked using ultrasound. Permanent ultrasound images were stored. Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed in a triangular position elevating the stomach to the anterior abdominal wall. Intra-gastric position was confirmed with aspiration of air and injection of contrast. A small skin incision was made and a 19 gauge needle was introduced under fluoroscopic guidance and position confirmed using an injection of dilute contrast. An Amplatz wire was introduced into the stomach. After tract dilation using a 12 ___ dilator, a ___ gastrostomy catheter was advanced over the wire into position. The catheter was secured by forming the retaining loop in the stomach after confirming the position of the catheter with a contrast injection. The catheter was then flushed, capped and secured to the skin with a Flexi trak anchoring device and an 0-silk suture. Sterile dressings were applied. The patient tolerated the procedure well and there were no immediate complications. FINDINGS: 1. Successful placement of a ___ gastrostomy tube. IMPRESSION: Successful placement of a ___ gastrostomy tube. The catheter should not be used for 24 hours. RECOMMENDATION(S): 1. Recommend connecting the gastrostomy tube overnight to low wall suction to monitor for bleeding. 2. The new G-tube should not be used for 24 hours. 3. Do not remove the T fastener buttons. They will fall off on their own in a few weeks time. Case and recommendations discussed with Dr. ___ by telephone at ___ on ___.

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2153-07-16 13:33:00

2153-07-16 18:53:00

EXAMINATION: Oropharyngeal video swallow. INDICATION: ___ year old woman with L MCA stroke, recurrent aspiration// swallow eval TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. DOSE: Fluoro time: 04:26 min. COMPARISON: Video swallow from ___. FINDINGS: There was intermittent penetration with nectar thick liquids and consistent with thin liquids due to delayed closure of the laryngeal vestibule. There was consistent deep laryngeal penetration before and during the swallow due to swallow initiation delay and delayed laryngeal vestibular closure. No aspiration was noted. There was retention of contrast material in limited views of the lower esophagus. Esophageal dysmotility cannot be excluded and upper GI series is recommended for further evaluation. IMPRESSION: Intermittent laryngeal penetration with nectar thick liquids and consistent laryngeal penetration with thin liquids. Oral transit and swallow initiation delay. Retention of contrast material noted in limited views of the lower esophagus. Please refer to the speech and swallow division note in OMR for full details, assessment, and recommendations. RECOMMENDATION(S): Upper GI series for further evaluation of esophageal dysmotility.

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2158-12-30 19:50:00

2158-12-30 20:20:00

HISTORY: Likely infected diabetic foot ulcer along the plantar and lateral aspect. TECHNIQUE: 3 views of the right foot. COMPARISON: None. FINDINGS: The patient is status post amputation of the ___ digit at the level of the base of the ___ metatarsal. Soft tissue loss is seen along the plantar and lateral aspect of the foot at the level of the midshaft of the metatarsals, without evidence of adjacent cortical destruction to suggest osteomyelitis. Healed fracture deformities of the ___ through ___ metatarsal shafts are noted with callus formation. The proximal phalanx of the ___ digit appears to have been resected, with a small ossific density noted distal to the ___ metatarsao, possibly heterotopic ossification. Diffuse degenerative changes are seen in the IP joints with osteophyte formation and joint space narrowing. Degenerative spurring is also seen within the mid foot as well as in the tibiotalar joint with subchondral sclerosis, joint space narrowing, and osteophyte formation. No subcutaneous gas or radiopaque foreign bodies are demonstrated. IMPRESSION: Soft tissue ulcer along the plantar and lateral aspect of the foot at the level of the midshaft of the metatarsals. No subcutaneous gas or definite radiographic evidence for osteomyelitis. Please note that MRI or bone scan is a more sensitive exam for the detection of osteomyelitis.

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2158-12-31 11:19:00

2158-12-31 11:50:00

CHEST RADIOGRAPH INDICATION: Diabetes, chronic heart failure, cough. COMPARISON: No comparison available at the time of dictation. FINDINGS: Low lung volumes, no pleural effusions. No parenchymal abnormality, in particular no evidence of pneumonia. Borderline size of the cardiac silhouette without pulmonary edema. No hilar or mediastinal abnormalities.

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2158-12-31 14:32:00

2158-12-31 15:38:00

CHEST RADIOGRAPH INDICATION: PICC line placement. COMPARISON: ___, 11:21 a.m. FINDINGS: As compared to the previous examination, the patient has received a left-sided PICC line. The course of the line is unremarkable, the tip of the line projects over the mid SVC. There is no evidence of complications, notably no pneumothorax. Otherwise, unchanged radiograph.

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2161-05-12 09:38:00

2161-05-12 12:20:00

EXAMINATION: CT LOWER EXT W/C RIGHT INDICATION: ___ year old man with RLE stump abscess // extension of RLE abscess in BKA stump pending irrigation and debridement TECHNIQUE: MDCT axial images through the right mid and distal femur and proximal tibia and fibula were obtained following the administration of intravenous contrast. COMPARISON: None. FINDINGS: The patient is status post below-the-knee amputation. There is thickened periosteal reaction about the distal tibia and fibula. No aggressive appearing periosteal reaction or definite erosion. A linear lucency in the posterior cortex of the proximal tibia (701b:40-42) may reflect a vascular channel. There is cortical thickening about the anterior medial proximal femur which is only partially visualized but seen on the scout radiographs (2:1). Osteopenia is seen about the tibial femoral joints. There is a diffuse muscle atrophy particularly within the posterior and deep posterior compartments of the left calf. There is a small amount of fluid and skin thickening at the stump. No definite abscess is appreciated. IMPRESSION: 1. Thick periosteal reaction about the distal tibia and fibula amputation site. No cortical erosion or aggressive appearing periosteal reaction. If there is concern for osteomyelitis, MRI can be performed. 2. Soft tissue edema and fluid. About the amputation site without absent soft tissue abscess. 3. Area of cortical thickening in the proximal femur incompletely evaluated could reflect prior subperiosteal hematoma or chronic traction changes however dedicated femur radiographs are recommended.

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2167-11-10 18:52:00

2167-11-10 20:33:00

EXAM: Chest, single AP upright portable view. CLINICAL INFORMATION: Dyspnea on exertion, history of CHF. ___. FINDINGS: Single AP upright portable view of the chest was obtained. There has been interval placement of a left-sided pacer device with a lead seen extending to the expected location of the right ventricle and the coronary sinus. There may also be a lead extending to the right ventricle, although this is not well seen on the current study. Right lower hemithorax opacity is seen which may be due to underlying subpulmonic effusion with overlying atelectasis, although underlying consolidation is not excluded. Findings may also be due to elevation of the right hemidiaphragm. If patient able, suggest dedicated PA and lateral views for better evaluation. There is prominence and indistinctness of the hila. The cardiac silhouette remains enlarged. Patient is status post median sternotomy. IMPRESSION: Enlarged cardiac silhouette and engorged pulmonary hila with pulmonary vascular congestion may be due to CHF. Right lower hemithorax opacity could be due to pleural effusions with overlying atelectasis and/or consolidation, elevation of the right hemidiaphragm. If patient able, dedicated PA and lateral views would be helpful for further evaluation.

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2167-11-19 02:55:00

2167-11-19 03:31:00

INDICATION: Dyspnea, shortness of breath. Evaluate for signs of volume overload. COMPARISON: Multiple priors from ___ to ___. FINDINGS: Portable AP chest radiograph demonstrates a large right-sided pleural effusion with associated basilar atelectasis. Concurrent consolidation cannot be excluded. There is otherwise little change from ___. Left pectoral pacemaker leads are in stable position. There is no pneumothorax. There is no pulmonary edema. Evaluation of the heart size is limited due to low lung volumes and AP projection. IMPRESSION: Enlarging right pleural effusion without pulmonary edema. Recommend obtaining PA and lateral chest radiograph.

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2167-11-19 20:51:00

2167-11-20 09:31:00

REASON FOR EXAMINATION: Evaluation of the patient with right-sided pleural effusion. AP radiograph of the chest was compared to ___ obtained at 03:01 a.m. Since the prior study, there is no change in large right pleural effusion and associated atelectasis. Heart size and mediastinum are unchanged including cardiomegaly. Biventricular pacer is redemonstrated. No pneumothorax.

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2167-11-20 05:48:00

2167-11-20 08:47:00

REASON FOR EXAMINATION: Evaluation of the patient with congestive heart failure exacerbation. Portable AP radiograph of the chest was reviewed in comparison to ___. Heart size and mediastinum are within normal limits. Bibasal opacities are noted, right more than left, unchanged since the prior study. Pacemaker leads are in unchanged position. Overall the only difference is increased engorgement of the hilar vessels that might be consistent with worsening of congestive heart failure.

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2167-11-20 18:12:00

2167-11-21 09:11:00

AP CHEST, 6:32 P.M. ___. HISTORY: ___ woman after right thoracentesis. IMPRESSION: AP chest compared to 5:52 a.m. Right pleural effusion, minimal if any. No pneumothorax. Substantial right basal atelectasis persists, moderate cardiomegaly and pulmonary vascular engorgement unchanged. Transvenous right atrial and left ventricular pacer and right ventricular pacer defibrillator leads unchanged in respective positions.

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2167-11-22 16:17:00

2167-11-22 18:59:00

CHEST ON ___ HISTORY: Status post renal transplant, status post thoracentesis with fever. REFERENCE EXAM: ___. Compared to the prior study, there is no significant interval change.

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2167-11-25 14:42:00

2167-11-25 15:59:00

HISTORY: ___ year old woman with h/o renal transplant in ___, now with acute renal failure and UTI. Please eval for obstruction or abscess in transplanted kidney. COMPARISON: Multiple priors, most recently ___ TECHNIQUE: Gray scale and Doppler ultrasound images of the renal transplant were obtained. FINDINGS: The transplant kidney is seen in the right lower quadrant. The renal morphology is normal. The cortical thickness and echogenicity appear normal. The renal sinus fat appears normal. There is no hydronephrosis. There is no perinephric fluid collection. The resistive index of the intrarenal arteries is elevated. They cannot be accurately assessed due to venous flow artifact on the doppler tracing. There is a persistent sharp systolic upstroke within the intrarenal arteries however there is substantially diminished to no diastolic flow. The peak systolic velocity of the main renal artery is also elevated at 150 cm/sec, which is new. The vascularity is symmetric throughout the transplant. The renal vein is patent and shows normal waveforms. IMPRESSION: Again the RIs are elevated compared to the previous examination with diminshed diastolic flow. As well, there is increased peak systolic velocity within the main renal artery. There is no evidence of abscess, pyelonephritis or hydronephrosis.

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2167-11-26 21:03:00

2167-11-27 12:28:00

CHEST RADIOGRAPH INDICATION: Pulmonary artery catheter, evaluation for pneumothorax. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the patient has received a Swan-Ganz catheter via a right internal jugular vein access. The course of the catheter is unremarkable. The tip, however, should be pulled back by approximately 4-5 cm, as it is located to much distally in the right pulmonary artery. No evidence of complications, notably no pneumothorax. Unchanged moderate cardiomegaly with moderate pulmonary edema, now potentially complicated by a small right pleural effusion.

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2167-11-27 02:38:00

2167-11-27 09:27:00

CHEST RADIOGRAPH INDICATION: Acute heart failure, evaluation for Swan-Ganz catheter placement. COMPARISON: ___. FINDINGS: As compared to the previous radiograph, the Swan-Ganz catheter, introduced over the right internal jugular vein, is unchanged in position. The tip is located too much distally and should be pulled back by approximately 4 cm. The course of the catheter is unremarkable. Unchanged appearance of the heart and the lung parenchyma, without substantial interval changes. No pneumothorax.

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2167-11-27 07:56:00

2167-11-27 10:11:00

REASON FOR EXAMINATION: Evaluation of the patient with pulmonary arterial line pulled back. Current chest radiograph is compared to ___ obtained 02:57 a.m. and demonstrates that the tip of the right pulmonary artery catheter is currently in the right main pulmonary artery. The rest of the findings are unchanged including the pulmonary edema, bilateral pleural effusions, and pneumothorax.

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2167-11-28 07:42:00

2167-11-28 09:24:00

SINGLE FRONTAL VIEW OF THE CHEST. REASON FOR EXAM: Patient with CHF, pulmonary hypertension. Comparison is made with prior study, ___. Severe cardiomegaly cannot be evaluated. Pacemaker leads are in standard position. Swan-Ganz catheter tip is in the right main pulmonary artery. Mild-to-moderate pulmonary edema and small-to-moderate right pleural effusion are stable. There is no pneumothorax. Sternal wires are aligned.

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2167-11-27 09:41:00

2167-11-27 11:55:00

INDICATION: ___ female with abdominal distention and acute on chronic renal failure. Evaluate for evidence of ascites. COMPARISON: Renal ultrasound on ___. TECHNIQUE: Grayscale images of all four quadrants of the abdomen were obtained. FINDINGS: No fluid was identified in any quadrant of the abdomen. IMPRESSION: No ascites.

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2167-11-29 08:02:00

2167-11-29 09:52:00

REASON FOR EXAMINATION: Evaluation of the patient with multiple medical problems, possible right lower lobe pneumonia and worsening shortness of breath and hypervolemia. Portable AP radiograph of the chest was compared to ___ and demonstrates slight interval progression of pulmonary edema, currently moderate to severe with the rest of the findings being unchanged.

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2167-11-30 11:29:00

2167-11-30 14:20:00

HISTORY: Change in renal function. COMPARISON: ___. FINDINGS: The study was performed portably. The transplant kidney is seen in the right lower quadrant measuring 13.0 cm, normal in size and echogenicity without hydronephrosis, stone, or mass identified. Tiny right perinephric fluid is new from ___. Doppler assessment with spectral analysis of the renal arteries was performed. The resistive indices of the intrarenal arteries are again elevated. Accurate measurement in the upper pole is difficult due to venous flow artifact on the Doppler tracing. RI's in the mid and lower poles are 1.0 and 0.96, unchanged. There is sharp systolic upstroke in the intrarenal arteries without diastolic flow. The peak systolic velocity in the main renal artery is elevated to 158 cm/s, previously 150 cm/s, unchanged. The main renal vein is patent with a normal waveform. The bladder is decompressed. IMPRESSION: 1. Elevated intrarenal artery resistive indices, unchanged from ___, with diminished or no diastolic flow. Increased peak systolic velocity in the main renal artery, also unchanged. 2. Tiny right perinephric fluid is new from ___.

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2167-12-04 07:27:00

2167-12-04 09:11:00

CHEST RADIOGRAPH INDICATION: Chronic heart failure, pulmonary hypertension, questionable pleural effusion. COMPARISON: ___. FINDINGS: As compared to previous radiograph, the right pleural effusion has decreased in extent and is now minimal. On the left, the blunting of the costophrenic sinus is unchanged. In the interval, the Swan-Ganz catheter has been removed and the patient has received a new PICC line. The tip of the line is difficult to visualize because of overlay with the pacemaker wires. However, it appears to project over the upper aspects of the right atrium and could be pulled back by 2 to 3 cm. Unchanged position of the left pectoral pacemaker, unchanged course of the pacemaker wires.

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2167-12-03 15:54:00

2167-12-03 18:28:00

PICC LINE EXCHANGE/REPOSITIONING INDICATION: Malposition of indwelling PICC line. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Dr. ___ performed the procedure. TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was advanced through the indwelling right arm PICC line, and subsequently into the SVC under fluoroscopic guidance. The old PICC line was then removed and a peel-away sheath was then placed over the guidewire. A new double-lumen PICC line measuring 47 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a new double-lumen PICC line. Final internal length is 47 cm, with the tip positioned in the distal SVC. The line is ready to use.

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2167-12-04 08:23:00

2167-12-04 09:09:00

HISTORY: ___ year old woman with recent cardiogenic shock REASON FOR THIS EXAMINATION: DVT? COMPARISON: None available FINDINGS: Patient is status post bilateral below knee amputations. Normal Doppler waveform with normal respiratory phasicity and normal compressibility of the bilateral common femoral vein, and proximal greater saphenous vein, proximal deep femoral vein, proximal, mid, and distal portions of the femoral vein, and popliteal veins. No evidence of bilateral lower extremity deep venous thrombosis. The arteries were extremely difficult to visualize, of uncertain clinical significance. IMPRESSION: No evidence of bilateral lower extremity DVT.

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2167-12-11 07:07:00

2167-12-11 10:15:00

SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: CHF, EF 25%, possibly right lower lobe pneumonia. Comparison is made with prior study ___. Severe cardiomegaly is stable. Transvenous pacemaker leads are in the standard position. Swan-Ganz catheter tip is located in the right interlobar artery should be withdrawn approximately 4 cm to a more standard position. Sternal wires are aligned. Mild pulmonary edema has markedly improved. Faint opacity in the right lower lobe is a combination of small effusion and adjacent atelectasis. Dr. ___ was paged regarding these findings at 9:45 a.m. on ___.

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2167-12-12 07:28:00

2167-12-12 10:42:00

SINGLE FRONTAL VIEW OF THE CHEST REASON FOR EXAM: Acute on chronic CHF. Comparison is made with prior study ___. Severe cardiomegaly is stable. Transvenous pacer leads are in standard position. Swan-Ganz catheter remains in the distal right pulmonary artery and should be withdrawn approximately 4 cm for a more standard position. Cardiomediastinal contours are unchanged. Right lower lobe opacities are combination of increasing atelectasis and small-to-moderate effusion. Mild-to-moderate pulmonary edema is unchanged.

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2167-12-13 07:51:00

2167-12-13 12:25:00

PORTABLE CHEST FROM ___ AT 8:22 CLINICAL INDICATION: ___ year old with CHF, assess for interval change. ___ at 8:53. A portable upright chest film ___ at 8:22 is submitted. IMPRESSION: 1. A left-sided pacemaker remains in place. A right subclavian PICC line is unchanged. The right internal jugular Swan-Ganz catheter continues to be in the right pulmonary artery with the tip somewhat distal and a pullback of 3-4 cm has been previously conveyed to the house staff on ___ by Dr. ___ ___, but the position remains unchanged. The heart remains stably enlarged. There has been some interval improvement in but there is persistent mild pulmonary edema. No pneumothorax is seen. No focal airspace consolidation is seen to suggest pneumonia. There is likely a layering right effusion with patchy streaky right basilar opacities likely reflectiing compressive atelectasis.

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2172-08-17 04:08:00

2172-08-17 05:48:00

EXAMINATION: CT ABD AND PELVIS WITH CONTRAST INDICATION: NO_PO contrast; History: ___ with abdominal pain, with history of CHF, AFib on anticoagulation, previous SBO, presents with abdominal pain and diarrhea. Evaluate for signs of small bowel obstruction. 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) Spiral Acquisition 3.4 s, 45.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 417.2 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7 mGy-cm. 3) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.0 mGy (Body) DLP = 20.0 mGy-cm. Total DLP (Body) = 439 mGy-cm. COMPARISON: CT from ___. FINDINGS: LOWER CHEST: Visualized lung fields are within normal limits. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is 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: Mild cortical thinning bilaterally. Small cortical hypodensities bilaterally are too small to characterize. Otherwise, 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 small hiatal hernia. The stomach distended with air and fluid. The duodenum and proximal jejunum are normal in caliber. There is circumferential wall thickening involving a segment of jejunum in the left upper quadrant (series 601, image 39). There are several loops of mildly dilated small bowel with suspected transition points in the left mid abdomen and pelvis (series 2, image 32/58). These loops are distal to the segment of jejunal thickening. There is fecalization in the terminal ileum but the distal bowel is otherwise normal in caliber. There is no pneumoperitoneum, or organized fluid collection. PELVIS: The urinary bladder and distal ureters are unremarkable. There is trace free fluid in 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. Mild atherosclerotic disease is noted. BONES: Multilevel degenerative changes of the lumbar spine with a similar appearance of the compression deformity involving the L2 vertebral body. There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: 1. Low-grade small-bowel obstruction with at least 2 probable transition points associated short segments of circumferential wall thickening. 2. No pneumoperitoneum or fluid collections.

10013643-RR-118

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2200-11-08 00:15:00

2200-11-08 01:18:00

EXAMINATION: CTU (ABD/PEL) W/ANDW/O CONTRAST INDICATION: ___ with hx of acalculous cholecystitis with R flank pain and abdominal tenderness // eval for R kidney stone, eval for diverticulitis, signs of cholecystitis. TECHNIQUE: MDCT images were obtained from the lung bases to the pubic symphysis without and after the administration of intravenous contrast. Axial images were interpreted in conjunction with coronal and sagittal reformats. DLP: 1757 mGy-cm COMPARISON: Comparison is made to abdominal and pelvic CT from ___ and ___. FINDINGS: There are small bilateral pleural effusions, left greater than right, mildly increased from ___.. There is a small pericardial effusion, also seen previously, minimally increased. ABDOMEN: The liver enhances homogeneously and is without focal lesions. There is no intra or extrahepatic biliary ductal dilation. The gallbladder is mildly distended, overall similar in size to ___ and smaller than on ___. There is no surrounding fat stranding or pericholecystic fluid. The spleen and adrenal glands are unremarkable. There is fatty atrophy of the pancreatic tail. The remainder of the pancreas is unremarkable. The kidneys enhance and excrete contrast symmetrically. There is no evidence of hydronephrosis. The ureters are normal caliber along their course to the bladder. A subcentimeter hypodensity within the upper pole of the left kidney is too small to characterize, but unchanged from ___. There is no evidence of renal or ureteral calculi. The esophagus is normal without a hiatal hernia. The small bowel is normal in caliber without focal wall thickening. There is diverticulosis of the sigmoid colon without evidence of diverticulitis. The cecum is mildly dilated and stool-filled. The appendix is not definitely visualized but a candidate for a normal-appearing appendix is seen within the lower mid abdomen (4a: 52). The abdominal aorta is heavily calcified without evidence of aneurysm. The major branches off of the abdominal aorta are patent. There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria. PELVIS: The bladder is well distended and normal in appearance. Bilateral ureteral jets are seen. There is no pelvic side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic fluid is identified. OSSEOUS STRUCTURES: Severe multilevel, multifactorial degenerative changes are seen throughout the visualized thoracolumbar spine. No focal lytic or sclerotic lesion concerning for malignancy. IMPRESSION: 1. No evidence of renal, ureteral, or bladder calculi. 2. No evidence of acute cholecystitis. 3. Small bilateral pleural effusions left greater than right and small pericardial effusion, overall mildly increased from ___.

10013724-RR-4

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2180-07-11 08:37:00

2180-07-11 11:47:00

EXAMINATION: UNILAT LOWER EXT VEINS INDICATION: ___ year old man with advanced colon CA -> bowel obstruction s/p remote varicose vein surgery with ? L leg increased in size compared to right. // Please evaluate for DVT. TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed on the left lower extremity veins. COMPARISON: None. FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial and peroneal veins. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins.

10013724-RR-5

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2180-07-11 11:03:00

2180-07-11 14:24:00

EXAMINATION: CT CHEST W/CONTRAST INDICATION: ___ year old man with rectal cancer, tobacco use and bowel obstruction with cough. // Please evaluate etiology of cough and perform staging. TECHNIQUE: Multidetector helical scanning of the chest was coordinated with intravenous infusion of nonionic iodinated contrast agent reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images DOSE: DLP: 272 mGy cm COMPARISON: CT abdomen and pelvis ___ FINDINGS: CT CHEST WITH IV CONTRAST: There is no supraclavicular, axillary, mediastinal or hilar lymphadenopathy. Esophagus is unremarkable. Heart size is normal without pericardial effusion. The thoracic aorta and proximal great vessels are normal in caliber with mild scattered atherosclerosis. The main pulmonary artery is normal in caliber. There is moderate atherosclerosis of the coronary arteries most notably the left main and LAD. The tracheobronchial tree is patent to the subsegmental level. Evaluation of the lung parenchyma is limited by respiratory motion. There is mild-to-moderate bronchial wall thickening with retained secretions. Multiple centrilobular nodules in the left upper lobe may be smoking related. Atelectasis in the right middle lobe, right lower lobe, lingula and left lower lobe is mild to moderate. There appears to be a background of mild centrilobular emphysema. OSSEOUS STRUCTURES: There is no concerning bony lesion. UPPER ABDOMEN: 8 mm right adrenal nodule also seen on yesterday's CT of the abdomen pelvis is re- demonstrated. There is a 3.3 x 2.8 cm portacaval lymph node (5:288). Partially included loops of large bowel remain significantly dilated similar to yesterday. There is a small hiatal hernia. IMPRESSION: CT CHEST: 1. No evidence of intrathoracic metastatic disease. 2. Bronchial wall thickening, retained secretions, and centrilobular nodules may reflect respiratory bronchiolitis, a smoking related condition. 3. There is a background of mild emphysema and moderate atelectasis. UPPER ABDOMEN: 1. 3.3 x 2.8 cm portacaval lymph node could reflect metastatic disease. 2. 8 mm right adrenal nodule. Please refer to folowup recommendations per CT of the abdomen and pelvis dated ___.

10013866-RR-6

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2127-04-30 08:42:00

2127-04-30 09:45:00

INDICATION: Preoperative film for repair of tibio-fibular fracture. COMPARISON: None available. TECHNIQUE: Frontal AP and lateral chest radiograph. FINDINGS: The lungs are well expanded and clear. Cardiomediastinal and hilar contours are unremarkable. There is no pleural effusion or pneumothorax. A tortuous aorta is incidentally noted. IMPRESSION: Unremarkable chest radiographic examination.

10013866-RR-7

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2127-04-30 14:18:00

2127-05-02 10:27:00

HISTORY: Left tibial fracture ORIF. FINDINGS: ___ spot fluoroscopic images of the left tibia were submitted for archival in order to document lateral fixation plate and screw placement across a comminuted distal tibial fracture. For further details, please refer to the operative note. Total operative fluoroscopic time was 141.2 seconds.

10014354-RR-10

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2146-10-10 14:30:00

2146-10-10 14:53:00

EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA RIGHT INDICATION: ___ year old man with Rt shoulder pain, Left leg weakness // shoulder trauma? shoulder trauma? IMPRESSION: No comparison. The soft tissues are unremarkable. No pathologic calcifications. The humeral head is in normal position. Mild narrowing of the humero glenoidal joint space. Mild subcortical sclerosis, suggesting mild degenerative degenerative disease. No evidence of fracture or dislocation.

10014354-RR-12

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2147-06-04 00:11:00

2147-06-04 02:16:00

EXAMINATION: Chest radiograph INDICATION: History: ___ with chest pain // ? cardiopulm pathology TECHNIQUE: Chest PA and lateral COMPARISON: Chest radiograph from ___ FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax. The heart is again top-normal in size. A left pectoral pacemaker is seen with transvenous leads in the right atrium and right ventricle. IMPRESSION: No acute cardiopulmonary process.

10014354-RR-19

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2147-11-14 19:09:00

2147-11-14 19:29:00

EXAMINATION: Chest: Frontal and lateral views INDICATION: History: ___ with sob, hx testicular ca on chemotx// please eval for acute abnormalities, fluid overload, infectious process TECHNIQUE: Chest: Frontal and Lateral COMPARISON: ___ FINDINGS: Dual lead left-sided pacemaker is stable in position. A right-sided Port-A-Cath is seen, distal tip of the catheter not well seen due to overlapping pacer leads, but likely courses at least into the distal SVC. There are low lung volumes, which accentuate the bronchovascular markings. Given this, there is slight prominence of the hila, stable compared to prior. No focal consolidation is seen. Pulmonary nodules reported on chest CT from ___ better appreciated on CT, a more sensitive study. There is no pleural effusion or pneumothorax. No pulmonary edema is seen. Cardiac and mediastinal silhouettes are stable. IMPRESSION: No acute cardiopulmonary process.

10014354-RR-59

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2150-02-04 14:56:00

2150-02-04 15:31:00

EXAMINATION: CTA HEAD WITH PERFUSION PQ148 CT HEAD INDICATION: Suspected stroke with acute neurological deficit, dizziness and visual changes. History of CLL, testicular cancer, diabetes and multiple other cardiovascular risk factors. Please exclude intracranial hemorrhage, signs of early ischemic stroke, large vessel occlusion, or other vascular abnormality. TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP = 903.1 mGy-cm. 2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP = 2,513.8 mGy-cm. 3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP = 32.7 mGy-cm. 4) Spiral Acquisition 5.3 s, 41.9 cm; CTDIvol = 32.0 mGy (Head) DLP = 1,338.7 mGy-cm. Total DLP (Head) = 4,788 mGy-cm. COMPARISON: Head and cervical spine CT dated ___. CTA head and neck dated ___. FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or acute major vascular territorial infarction. Approximately 1 cm well-defined hypodensity in the right basal ganglia, which has become better defined compared to more remote exams from ___, likely represents a chronic lacunar infarct. Periventricular and subcortical white matter hypodensities are nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. The ventricles are normal in size for age. There is prominence of the sulci compatible with mild parenchymal involutional changes, predominantly parietal and at the frontal vertex. Trace mucosal thickening and a small mucous retention cyst within the left posterior ethmoid sinus. Other paranasal sinuses appear clear. Mastoid air cells are well aerated. Status post lens replacement on the right. CTA NECK: There is mild calcified plaque formation at the great vessel origins without flow-limiting stenosis. There is trace calcified plaque at the left, carotid bifurcation. There is mild mixed calcified and noncalcified plaque at the right, carotid bifurcation. No evidence of carotid stenosis by NASCET criteria. Mild calcified plaque at the origin of the dominant right vertebral without flow-limiting stenosis. Mild calcified plaque is noted within the right V4 segment without flow-limiting stenosis. Non dominant cervical left vertebral artery is patent without evidence for significant stenosis. Trace atherosclerotic calcifications involving the left V4 segment without flow-limiting stenosis. CTA HEAD: There are moderate calcifications involving the bilateral cavernous and supraclinoid portions of the internal carotid arteries, as well as the petrous portion of the left internal carotid artery, without flow-limiting stenosis. No evidence for flow-limiting stenosis elsewhere in the intracranial circulation. Fetal origin of the left PCA is noted. No evidence for an aneurysm. The dural venous sinuses are patent. CT PERFUSION: CBF <30%: 0 mL T-max > 6 seconds : 6 mL Mismatch volume: 6 mL Mismatch ratio: Infinite The 6 ml area of T-max > 6 seconds and mismatch project over the left periatrial white matter and left lateral ventricle, possibly an artifact. If clinically indicated, MRI would be more sensitive for the detection of acute infarct. OTHER: Respiratory motion artifact limits evaluation of the included upper lungs. Subcentimeter calcified granuloma is again seen at the left lung apex. The visualized portions of the thoracic esophagus appears patulous, filled with hyperdense fluid material. The thyroid is unremarkable. There is no lymphadenopathy by CT size criteria. Ossification of the posterior longitudinal ligament in the upper cervical spine narrows the spinal canal, as seen on the prior cervical spine CT from ___. IMPRESSION: 1. Head CT: No evidence for acute intracranial hemorrhage or acute major vascular territorial infarction. 2. CT perfusion: 6 ml area of T-max > 6 seconds and mismatch project over the left periatrial white matter and left lateral ventricle, possibly an artifact. If clinically indicated, MRI would be more sensitive for the detection of acute infarct. 3. CTA: No carotid stenosis by NASCET criteria. Atherosclerosis of intracranial carotid and intracranial vertebral arteries without flow-limiting stenosis. 4. Ossification of the posterior longitudinal ligament in the upper cervical spine narrows the spinal canal, as seen on the prior cervical spine CT from ___.

10014354-RR-61

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2150-02-07 18:03:00

2150-02-08 09:00:00

EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD INDICATION: ___ year old man with ***pacemaker***, high risk CLL on venetoclax, insulin-dependent type 2 diabetes, history of left sided cerebrovascular accident, depression withpsychotic features, reported history of conversion disorder,hypothyroidism, hypertension, who is being admitted withleft-sided weakness and diminished sensation in the setting of hypoglycemia and 3 days of vertigo. CT head negative, CTA head and neck with no thrombus on admission. Neuro consulted.// ? stroke/hemorrhage/acute process given persistence of neurological symptoms TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After administration of intravenous contrast, axial imaging was performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was performed and re-formatted in axial and coronal orientations. COMPARISON: CTA head and neck dated ___. FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. There is mild prominence of the ventricles and sulci suggestive involutional changes. There is no abnormal enhancement after contrast administration. There is mild mucosal thickening of the anterior ethmoid air cells. The mastoid air cells and middle ear cavities are clear. The orbits are unremarkable with the exception of changes from right lens surgery. IMPRESSION: No evidence of infarction, hemorrhage, mass, or edema.

10014354-RR-62

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2150-04-10 00:07:00

2150-04-10 01:01:00

EXAMINATION: CTA ABD AND PELVIS INDICATION: History: ___ with abdominal pain// Ischemia? Chondritis? appy? TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast images were acquired through the abdomen and pelvis. Oral contrast was not administered. DOSE: Acquisition sequence: 1) Spiral Acquisition 7.1 s, 56.1 cm; CTDIvol = 7.9 mGy (Body) DLP = 444.6 mGy-cm. 2) Spiral Acquisition 7.2 s, 56.3 cm; CTDIvol = 27.8 mGy (Body) DLP = 1,566.0 mGy-cm. Total DLP (Body) = 2,011 mGy-cm. COMPARISON: CT abdomen pelvis ___ FINDINGS: VASCULAR: There is no abdominal aortic aneurysm. There is moderate calcium burden in the abdominal aorta and great abdominal arteries. Pacer leads are partially visualized. LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no pleural or pericardial effusion. ABDOMEN: The lateral right abdomen pelvis are incompletely visualized due to patient body habitus and artifact. HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesions. There is no evidence of intrahepatic biliary dilation. The common bile duct is within expected post cholecystectomy limits. The gallbladder is is resected. PANCREAS: The pancreas is atrophic, 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 stones, solid renal lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or ureters. There is no perinephric abnormality. GASTROINTESTINAL: Status post gastric bypass. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: Prostate is enlarged. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Grade 1 retrolisthesis of L5 on S1 is stable. IMPRESSION: No acute intra-abdominal process. Specifically, no evidence of mesenteric ischemia. The appendix is not visualized, however, there are no secondary signs to suggest appendicitis.

10014354-RR-7

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2146-10-08 22:09:00

2146-10-08 22:52:00

EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK INDICATION: History: ___ with LLE weakness ___ tpa crt 1.2 // clot? crt 1.2 TECHNIQUE: Contiguous MDCT axial images were obtained through the brain without contrast material. Subsequently, helically acquired rapid axial imaging was performed from the aortic arch through the brain during the infusion of 70 mL of Omnipaque intravenous contrast material. Three-dimensional angiographic volume rendered, curved reformatted and segmented images were generated on a dedicated workstation. This report is based on interpretation of all of these images. DOSE: Acquisition sequence: 1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP = 1,009.3 mGy-cm. 2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP = 24.5 mGy-cm. 3) Spiral Acquisition 5.7 s, 44.5 cm; CTDIvol = 32.1 mGy (Head) DLP = 1,431.3 mGy-cm. Total DLP (Head) = 2,465 mGy-cm. COMPARISON: CT head ___ FINDINGS: CT HEAD WITHOUT CONTRAST: There is no evidence of no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The patient is status post right cataract surgery. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches are patent without stenosis, occlusion or aneurysm formation. There are of atherosclerotic calcifications of the bilateral cavernous and supra clinoid and left petrous internal carotid arteries. There is fetal origin of the left posterior cerebral artery. The dural venous sinuses are patent. CTA NECK: There is a normal 3 vessel branching pattern of the aortic arch. The origins of the great vessels are patent. Minimal atherosclerotic calcifications involve the aortic arch. The bilateral common and external carotid arteries are patent. Minimal calcified and noncalcified plaque is noted at the bilateral carotid bifurcations with no evidence of internal carotid artery stenosis by NASCET criteria. Both vertebral arteries, including their origins, are patent. The right vertebral artery is dominant. OTHER: There are 2 calcified granulomas in the left upper lobe. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. Ossifications of the posterior longitudinal ligament at C2-C3 and C3-C4 cause at least moderate spinal canal stenosis. IMPRESSION: 1. Patent circle of ___. 2. Patent vasculature in the neck with no evidence of internal carotid artery stenosis by NASCET criteria. 3. No acute intracranial abnormality. 4. At least moderate spinal canal stenosis at C2-C3 and C3-C4 secondary to ossifications of the posterior longitudinal ligaments.

10014354-RR-8

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2146-10-09 04:29:00

2146-10-09 10:48:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man with stroke // eval for pna eval for pna IMPRESSION: There no prior chest radiographs available for review. Study is read in conjunction with most recent chest CT ___. Heart is top-normal size. Transvenous right atrial right ventricular pacer leads are continuous from the left pectoral generator. The ventricular lead is sharply bent and its integrity should be documented. Lungs are clear. There is no pulmonary edema or pleural effusion. RECOMMENDATION(S): Assess the integrity of the angulated right ventricular pacer lead.

10014354-RR-9

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2146-10-09 15:12:00

2146-10-09 16:31:00

EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD INDICATION: ___ year old male with stroke, status post tPA. Evaluate for acute intracranial hemorrhage. TECHNIQUE: Contiguous axial images of the brain were obtained without contrast. DOSE: Acquisition sequence: 1) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.4 mGy (Head) DLP = 848.0 mGy-cm. Total DLP (Head) = 848 mGy-cm. COMPARISON: ___ head and neck CTA. FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Atherosclerotic vascular calcifications are noted of bilateral vertebral and cavernous portions of internal carotid arteries. There is no evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. 2. No acute hemorrhage. 3. Please note MRI of the brain is more sensitive for the detection of acute infarct.

10014378-RR-27

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2181-07-21 12:03:00

2181-07-21 12:49:00

EXAMINATION: CHEST (AP AND LAT) INDICATION: History: ___ with cough*** WARNING *** Multiple patients with same last name!// PNA? TECHNIQUE: Upright AP and lateral views of the chest COMPARISON: Chest radiograph ___ and CT chest ___ FINDINGS: Heart size is top-normal. The mediastinal and hilar contours are unremarkable apart from minimal tortuosity of the thoracic aorta and mild atherosclerotic calcifications at the aortic knob. The pulmonary vasculature is normal. Lung volumes are low, but the lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: Low lung volumes. No acute cardiopulmonary abnormality.

10014449-RR-16

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2174-05-28 03:30:00

2174-05-28 04:51:00

INDICATION: Swelling and pain in the right hand with PIC line in place from today. Evaluate for DVT. COMPARISON: None. TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation of the right upper extremity veins. FINDINGS: The left subclavian vein cannot be visualized for comparison. There is normal flow and respiratory variation in the right subclavian vein. The right internal jugular and axillary veins are patent and compressible with transducer pressure. The right brachial and basilic veins are patent and compressible with transducer pressure and show normal color flow. There is a partially occlusive non-compressible thrombus in the cephalic vein which also contains an echogenic focus consistent with a PICC or venous catheter, or the cast of a PICC in thrombus that has been removed (resident caring for patient states PICC has been removed and replaced with peripheral IV). Thrombus does not extend to the axillary veins. IMPRESSION: Non-occlusive thrombus in the right cephalic vein. Clot does not extend to the axillary vein.

10014610-RR-100

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2174-05-26 22:32:00

2174-05-26 23:16:00

INDICATION: ___ year old man with leukocytosis, r/o PNA // evidence of PNA TECHNIQUE: Chest PA and lateral COMPARISON: ___ FINDINGS: No focal consolidation, pleural effusion or pneumothorax. The size of the cardiac silhouette is within normal limits. Unchanged tortuosity of the thoracic aorta. Status post prior median sternotomy. IMPRESSION: No radiographic evidence of acute cardiopulmonary disease.

10014610-RR-102

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2174-05-28 16:16:00

2174-05-29 12:17:00

EXAMINATION: INJ/ASP MAJOR JT W/FLUORO INDICATION: ___ year old man with complex cardiac history, bilateral TKA, enterococci bacteremia ?septic R knee. // ?septic arthritis of R knee TECHNIQUE: The risks, benefits and alternatives were explained to the patient and written informed consent was obtained. A pre-procedure timeout confirmed three patient identifiers. Under fluoroscopic guidance, an appropriate spot was marked. The area was prepared and draped in standard sterile fashion. 4 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent fluoroscopic guidance, a 20-gauge spinal needle was advanced into the right knee pseudocapsule. There is no spontaneous aspiration of fluid. Appropriate position was confirmed by the injection of a small amount of water-soluble contrast. Following this approximately 1 cc of pink tinged clear fluid was reaspirated. The needle was removed, hemostasis achieved, and a sterile bandage applied. The patient tolerated the procedure well and left the department in stable condition. There were no immediate complications. COMPARISON: Right knee radiographs ___. FINDINGS: Fluoroscopic images demonstrated right total knee arthroplasty with adjacent heterotopic ossification. IMPRESSION: 1. Findings - right total knee arthroplasty with adjacent heterotopic ossification. 2. Procedure - successful reaspiration of right knee pseudocapsule yielding 1 cc of pink tinged clear fluid which was sent for Gram stain/culture. NOTIFICATION: The procedure was supervised by Dr. ___, the attending radiologist, who was present for the critical portions of the procedure.

10014610-RR-104

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2174-05-31 00:02:00

2174-05-31 08:41:00

EXAMINATION: CHEST (PORTABLE AP) INDICATION: ___ year old man s/p R TKA explant/abx spacer for PJI // ETT/OG placement ETT/OG placement IMPRESSION: ET tube tip is 4 cm above the carinal. NG tube tip is most likely in the stomach. Heart size and mediastinum are stable. Lungs are overall clear. There is no pleural effusion. There is no pneumothorax.