Download lra11 CT Brain Without Contrast Clinical History: [Dictated

lra11
CT Brain Without Contrast
Clinical History: [Dictated]
Technique: Standard. No IV contrast.
Comparison: [Dictated; default- None.]
Findings:
There is no evidence of hemorrhage, infarction, mass or hydrocephalus. No acute bony
abnormality.
IMPRESSION: Negative.
==========================================
lra12
CT Brain with Contrast
Clinical History: [Dictated]
Technique: With intravenous contrast. ___ mL Isovue 370.
Comparison: [Dictated; default- None.]
Findings:
There is no evidence of hemorrhage, infarction, mass or hydrocephalus. No acute bony
abnormality. No abnormal enhancement.
IMPRESSION: Negative.
==========================================
lra13
CT Brain with and without Contrast
Clinical History: [Dictated]
Technique: With and without intravenous contrast. ___ mL Isovue 370.
Comparison: [Dictated; default- None.]
Findings:
There is no evidence of hemorrhage, infarction, mass or hydrocephalus. No acute bony
abnormality. No abnormal enhancement.
IMPRESSION: Negative.
================================
lra16
MRI Brain without contrast
Clinical History: [Dictated]
Technique: Routine noncontrast images.
Comparison: [Dictated; default- None.]
Findings: There is no evidence of hemorrhage, infarction, mass or hydrocephalus. Gray-white
matter is within normal limits for the patient's age. Major flow voids are present.
IMPRESSION: Negative.
=================================
lra17
MRI Brain with and without contrast
Clinical History: [Dictated]
Technique: Pre and post intravenous gadolinium enhanced images performed. ___ mL
Multihance.
Comparison: [Dictated; default- None.]
Findings: There is no evidence of hemorrhage, infarction, mass or hydrocephalus. Gray-white
matter is within normal limits for the patient's age. Major flow voids are present. No abnormal
enhancement.
IMPRESSION: Negative.
=====================================
lra18 [Imaging anterior fontanelle and mastoid view]
Neonatal Head Ultrasound
Clinical History: Premature Infant
Comparison: [Dictated; default- None.]
Technique: High resolution imaging through the anterior fontanelle. Imaging of the posterior
fossa also performed.
Findings: There is no hydrocephalus or hemorrhage. There is no mass effect.
IMPRESSION: Negative.
=================================
lra18A [Imaging anterior fontanelle only]
Neonatal Head Ultrasound
Clinical History: Premature Infant
Comparison: [Dictated; default- None.]
Technique: High resolution imaging through the anterior fontanelle.
Findings: There is no hydrocephalus or hemorrhage. There is no mass effect.
IMPRESSION: Negative.
=================================
lra21
Orbit Radiographs for Foreign Body
Clinical History: Possible metal in orbit. Patient for MRI.
Technique: Three views.
Comparison: None.
Findings: No radiopaque foreign body or significant bony abnormality is demonstrated.
IMPRESSION: Negative.
================================
lra22
Sinus Radiographs
Clinical History: [Dictated]
Technique: [Dictated views]
Comparison: None.
Findings: No fracture or bony destructive process. Clear sinuses.
IMPRESSION: Negative.
===================================
lra24 Soft Tissue Neck
Soft Tissue Neck
Clinical History:
Technique: Two views.
Comparison: [Dictated; default- None.]
Findings: No radio-opaque foreign body. Soft tissues unremarkable.
Impression: Negative.
==========================================
lra31 Spine
Spine Radiographs
Clinical History: [Dictated]
Technique: [Dictated]
Comparison: [Dictated; default- None.]
Findings: The vertebral segments are aligned. No fracture or bony destructive process.
IMPRESSION: Negative.
================================
lra 35 Cervical Spine CT
Clinical History:
Technique: Standard noncontrast protocol.
Comparison: [Dictated; default- None.]
Findings: The vertebral segments are aligned. No fracture or bony destructive process.
Impression: Negative.
================================
lra32 Spine Degenerative
Spine Radiographs
Clinical History: [Dictated]
Technique: [Dictated]
Comparison: [Dictated; default- None.]
Findings: The vertebral segments are aligned. No fracture or bony destructive. There are mild
degenerative changes.
IMPRESSION: No acute abnormality. Mild degenerative changes.
================================
lra41 [Generic Bone Radiographs]
Clinical History: [Dictated]
Technique: [Dictated]
Comparison: [Dictated; default- None.]
Findings: No fracture, bony destructive process or acute joint abnormality.
IMPRESSION: Negative.
================================
lra42 [Generic Bone Radiographs- degenerative]
Clinical History: [Dictated]
Technique:[Dictated]
Comparison: [Dictated; default- None.]
Findings: No fracture, bony destructive process or acute joint abnormality. There are mild
degenerative changes.
IMPRESSION: No acute abnormality. Mild degenerative changes.
================================
lra43
Wrist Radiographs
Clinical History: [Dictated]
Technique: [Dictated] Comparison: [Dictated; default- None.]
Findings: No fracture, bony destructive process or acute joint abnormality. If there is suspicion
for occult fracture, particularly of the scaphoid, then further imaging with scintigraphy or MRI
should be considered.
IMPRESSION: Negative.
================================
lra49
Bilateral Hip Ultrasound
Clinical History: [Dictated]
Technique: Gray Scale imaging. Stress maneuvers performed.
Comparison: [Dictated; default- None.]
Findings:
Right Hip: Normal acetabular depth. No dislocation or subluxation at rest. No subluxation or
dislocation with stress.
Left Hip: Normal acetabular depth. No dislocation or subluxation at rest. No subluxation or
dislocation with stress.
IMPRESSION: Negative.
================================
lra61
Two View Chest Radiographs
Clinical History: [Dictated]
Technique: PA and lateral examination.
Comparison: [Dictated; default- None.]
Findings: The lungs are clear. The cardiomediastinal silhouette is not enlarged. No pleural
abnormality..
IMPRESSION: Negative.
================================
lra62
AP Bedside Chest Radiograph
Clinical History: [Dictated]
Technique: AP chest- bedside examination.
Comparison: [Dictated; default- None.]
Findings: The lungs are clear. No pleural abnormality is demonstrated.
The cardiomediastinal silhouette is within normal limits when considering AP technique and
associated radiographic magnification.
IMPRESSION: Negative.
================================
lra63
Rib Radiographs
Clinical History: [Dictated]
Technique: [Dictated]
Comparison: [Dictated; default- None.]
Findings: No displaced rib fracture or bony destructive process. The lungs are clear. The
cardiomediastinal silhouette is not enlarged. No pleural abnormality.
IMPRESSION: Negative.
================================
lra64
AP and lateral Chest Radiography
Clinical History: [Dictated]
Technique: AP and lateral Chest Radiography.
Comparison: [Dictated; default- None.]
Findings: The lungs are clear. No pleural abnormality is demonstrated.
The cardiomediastinal silhouette is within normal limits when considering AP technique and
associated radiographic magnification.
IMPRESSION: Negative.
=========================================================
lra65
Chest CT Scan with Contrast
Clinical History:
Technique: Intravenous contrast administered. ___mL Isovue 370.
Comparison: [Dictated; default- None.]
Findings:
Lungs: No lesion or consolidation.
Mediastinum: No enlarged lymph nodes by CT size criteria.
Chest wall and pleura: No pleural effusion or mass.
Comments: [exclude if none dictated.]
Impression: [Dictated; default- Negative.]
=========================================================
lra65A
Chest CT Scan without Contrast
Clinical History:
Technique: Standard noncontrast protocol.
Comparison: [Dictated; default- None.]
Findings:
Lungs: No lesion or consolidation.
Mediastinum: No enlarged lymph nodes by CT size criteria.
Chest wall and pleura: No pleural effusion or mass.
Comments: [exclude if none dictated.]
Impression: [Dictated; default- Negative.]
=========================================================
lra66
Chest, Abdomen and Pelvis CT Scan with Contrast
Clinical History:
Technique: Intravenous contrast and oral administered. ___mL Isovue 370.
Comparison: [Dictated; default- None.]
Findings:
Lungs: No lesion or consolidation.
Mediastinum: No enlarged lymph nodes by CT size criteria.
Chest wall and pleura: No pleural effusion or mass.
Liver: No lesion.
Spleen: Within normal limits in size.
Pancreas: No lesion.
Adrenals: Within normal limits in size.
Kidneys: No solid lesion or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Pelvis: No mass or free fluid.
Comments: [exclude if none dictated.]
Impression: [Dictated; default- Negative.]
=========================================================
lra66a
Chest, Abdomen and Pelvis CT Scan without Contrast
Clinical History:
Technique: Noncontrast images were performed. The lack of IV contrast limits intrinsic organ
evaluation.
Comparison: [Dictated; default- None.]
Findings:
Lungs: No lesion or consolidation.
Mediastinum: No enlarged lymph nodes by CT size criteria.
Chest wall and pleura: No pleural effusion or mass.
Liver: No gross lesion on noncontrast images.
Spleen: Within normal limits in size.
Pancreas: Within normal limits in size.
Adrenals: Within normal limits in size.
Kidneys: No calculi or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Pelvis: No mass or free fluid.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
======================================================
LRA69 OVER-READ OF TCI CORONARY CTA
The initial acquisition field of view of the coronary CTA was retrospectively reconstructed
through to a 32 cm field of view. This report is a review of the non-cardiac and non-coronary
findings. A separate report for the cardiac and coronary findings will be issued by the TCI
Cardiology group.
======================================================
lra71
Abdomen and Pelvis CT Scan with Contrast
Clinical History:
Technique: Oral and intravenous contrast administered. ___cc Isovue 370 mL.
Comparison: [Dictated; default- None.]
Findings:
Lower Chest: No lesion or consolidation.
Liver: No lesion.
Spleen: Within normal limits in size.
Pancreas: No lesion.
Adrenals: Within normal limits in size.
Kidneys: No solid lesion or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Pelvis: No mass or free fluid.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
========================================================
lra71A
Noncontrast Abdomen and Pelvis CT Scan
Clinical History: [Dictated]
Technique: Noncontrast images were performed from above the diaphragm through the pelvis.
The lack of IV contrast limits intrinsic organ evaluation.
Comparison: [Dictated; default- None.]
Findings:
Lower Chest: No lesion or consolidation.
Liver: No gross lesion on noncontrast images.
Spleen: Within normal limits in size.
Pancreas: Within normal limits in size.
Adrenals: Within normal limits in size.
Kidneys: No calculi or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Pelvis: No mass or free fluid.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
================================
lra71B
Abdomen and Pelvis CT Scan with and without IV Contrast
Clinical History:
Technique: Oral contrast administered. Initially images performed of the abdomen without
intravenous contrast, followed by intravenous contrast enhanced images of the abdomen and
pelvis. ___mL Isovue 370.
Comparison: [Dictated; default- None.]
Findings:
Noncontrast images: No abnormal calcifications.
Lower Chest: No lesion or consolidation is demonstrated.
Liver: No lesion.
Spleen: Within normal limits in size.
Pancreas: No lesion.
Adrenals: Within normal limits in size.
Kidneys: No solid lesion or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Pelvis: No mass or free fluid.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
========================================================
lra71C
Abdomen CT Scan with and without IV Contrast
Clinical History:
Technique: Oral contrast administered. Initially images performed of the abdomen without
intravenous contrast, followed by intravenous contrast enhanced images of the abdomen. ___mL
Isovue 370.
Comparison: [Dictated; default- None.]
Findings:
Noncontrast images: No abnormal calcifications.
Lower Chest: No lesion or consolidation is demonstrated.
Liver: No lesion.
Spleen: Within normal limits in size.
Pancreas: No lesion.
Adrenals: Within normal limits in size.
Kidneys: No solid lesion or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
=======================================================
BW 71e
CT enterography. Abdomen and Pelvis CT Scan with Contrast.
Clinical History:
Technique: Oral contrast [water density] and intravenous contrast administered. ___mL Isovue
370.
Comparison: [Dictated; default- None.]
Findings:
Noncontrast images: No abnormal calcifications.
Lower Chest: No lesion or consolidation is demonstrated.
Liver: No lesion.
Spleen: Within normal limits in size.
Pancreas: No lesion.
Adrenals: Within normal limits in size.
Kidneys: No solid lesion or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Bowel: No bowel wall thickening. No lesion. No abnormal dilation.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
=======================================================
lra71W
Abdomen and Pelvis CT Scan with Contrast
Clinical History:
Technique: Intravenous contrast administered. ___mL Isovue.
Comparison: [Dictated; default- None.]
Findings:
Lower Chest: No lesion or consolidation is demonstrated.
Liver: No lesion.
Spleen: Within normal limits in size.
Pancreas: No lesion.
Adrenals: Within normal limits in size.
Kidneys: No solid lesion or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Pelvis: No mass or free fluid.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
================================
lra72
Air Contrast Esophagram
Clinical History: [Dictated; default- None.]
Technique: Air contrast and single contrast images of the esophagus. Swallowing function
evaluated under fluoroscopy. Barium tablet administered.
Comparison:
Findings: No ulcerations, mass or constrictive lesion is seen involving the esophagus.
Swallowing function is unremarkable. Barium tablet readily passed into the stomach.
Impression: Negative.
=========================================================
lra73 Air Contrast Upper GI Series
Clinical History:
Technique: Standard air contrast examination.
Comparison: [Dictated; default- None.]
Findings: No ulceration, mass or constrictive lesion is seen involving the esophagus, stomach or
duodenum.
Impression: Negative.
=========================================================
lra73A
Upper GI Series [Single Contrast]
Clinical History:
Technique: Standard single contrast images.
Comparison: [Dictated; default- None.]
Findings: No abnormality is seen involving the esophagus, stomach or duodenum. Position of
ligament of Treitz is within normal limits.
Impression: Negative.
=============================================================
lra74
Small Bowel Follow Through
Clinical History: [Dictated; default- None.]
Technique: Standard single contrast images.
Comparison:
Findings: Normal small bowel transit. Normal small bowel caliber. No small bowel lesion.
Impression: Negative.
=========================================================
lra75
Abdominal Ultrasound
Clinical History: [Dictated]
Comparison: [Dictated; default- None.]
Technique: Transabdominal imaging.
Findings:
Liver: No lesion is demonstrated.
Gallbladder and Common Duct: There is no evidence of cholelithiasis, gallbladder wall
thickening or pericholecystic fluid. The common duct is not dilated, measuring ___ mm.
Spleen: Within normal limits in size.
Pancreas: The visualized pancreas is unremarkable.
Right Kidney: [dictate measurements]. There is no evidence of a solid renal mass or
hydronephrosis.
Left Kidney: [dictate measurements]. There is no evidence of a solid renal mass or
hydronephrosis.
Aorta and IVC: The visualized aorta and IVC are unremarkable.
Comments: [exclude if none dictated]
Impression: Negative. [or dictated]
======================================================
lra77
Single View Abdomen Radiograph
Clinical History: [Dictated]
Technique: Supine view of the abdomen.
Comparison: [Dictated; default- None.]
Findings: No dilated loops of bowel are seen to suggest obstruction. There is no gross evidence
of pneumoperitoneum; erect images would optimally evaluate for free air. There are no abnormal
appearing calcifications.
IMPRESSION: Negative.
================================
lra78
Erect and Supine Views of the Abdomen.
Clinical History: [Dictated]
Technique: Erect and supine views of the abdomen.
Comparison: [Dictated; default- None.]
Findings: No dilated loops of bowel are seen to suggest obstruction. There is no
evidence of pneumoperitoneum. There are no abnormal appearing calcifications.
IMPRESSION: Negative.
================================
lra79
Acute Abdomen Series
Clinical History: [Dictated]
Technique: Erect and supine views of the abdomen. Chest radiograph.
Comparison: [Dictated; default- None.]
Findings: The lungs are clear. The heart is not enlarged. No pleural abnormality is demonstrated.
No dilated loops of bowel are seen to suggest obstruction. There is no evidence of
pneumoperitoneum. There are no abnormal appearing calcifications.
IMPRESSION: Negative.
================================
lra80
Noncontrast Abdomen and Pelvis CT.
Clinical History: [Dictated]
Technique: Noncontrast images were performed from above the diaphragm through the pelvis.
The lack of IV contrast limits intrinsic organ evaluation, including evaluation for a renal mass.
Comparison: [Dictated; default- None.]
Findings:
Lower Chest: No lesion or consolidation.
Liver: No gross lesion on noncontrast images.
Spleen: Within normal limits in size.
Pancreas: Within normal limits in size.
Adrenals: Within normal limits in size.
Kidneys: No calculi or hydronephrosis. Negative for ureterolithiasis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Pelvis: No mass or free fluid.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
========================================================
lra82
VCUG
Clinical History:
Technique: Fluoroscopy and images performed while contrast administered retrograde through a
bladder catheter.
Comparison:
Findings: No vesicoureteral reflux is seen. The bladder is unremarkable and smooth in contour.
Impression: Negative
========================================================
lra84
Renal Ultrasound
Clinical History: [Dictated]
Comparison: [Dictated; default- None.]
Technique: Transabdominal imaging.
Findings:
Right Kidney: [dictate measurements]. There is no evidence of a solid renal mass or
hydronephrosis.
Left Kidney: [dictate measurements]. There is no evidence of a solid renal mass or
hydronephrosis.
No abnormality is seen on targeted evaluation of the bladder.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
========================================================
lra85
Pelvic Ultrasound
Clinical History:
Technique: High resolution abdominal and transvaginal ultrasound.
Comparison: [Dictated; default- None.]
Findings:
Uterus: [dictate measurements]. No intrinsic myometrial abnormality noted.
Endometrium: [dictate measurements]. (normal thickness for a premenopausal woman: up to
14mm. Normal thickness for a postmenopausal woman: up to 4-6mm.)
Right Ovary: [dictate measurements]. The ovary is not enlarged. There is no suspicious mass.
Left Ovary: [dictate measurements]. The ovary is not enlarged. There is no suspicious mass.
Cul de sac: No substantive free fluid.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
========================================================
lra87 CT UROGRAPHY
EXAM: CT Urography
CLINICAL HISTORY: [ ]
COMPARISON: [ ]
TECHNIQUE: Multiple transverse CT images were obtained of the abdomen and pelvis both
without and with IV contrast utilizing the CT Urography protocol. Multiplanar reformatted
images and 3D reformatted images were provided utilizing an Independent 3D Workstation.
____ mL of ________was administered by power injector.
Comparison: [Dictated; default- None.]
Findings:
Noncontrast images: No abnormal calcifications.
Lower Chest: No lesion or consolidation is demonstrated.
Liver: No lesion.
Spleen: Within normal limits in size.
Pancreas: No lesion.
Adrenals: Within normal limits in size.
Kidneys: No solid lesion or hydronephrosis.
Para-aortic Region: No enlarged lymph nodes by CT size criteria.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
================================
lra88
Scrotal Ultrasound
Clinical History:
Technique: High resolution scrotal ultrasound with Doppler.
Comparison: [Dictated; default- None.]
Findings:
Right Testicle: [dictated measurement]. No testicular lesion is seen. No epididymal lesion.
Normal Doppler.
Left Testicle: [dictated measurement]. No testicular lesion is seen. No epididymal lesion.
Normal Doppler.
Comments: [exclude if none dictated]
Impression: [Dictated; default- Negative.]
=======================================================
lra89
Prostate Ultrasound
Clinical History:
Technique: High resolution transrectal ultrasound.
Comparison: [Dictated; default- None.]
Findings:
Measurements: ___ mm X ___mm X ___mm. Volume: ___cc
[Normal prostate size is 20 – 30 cc]
Comments: [exclude if none dictated]
Note: The sensitivity and specificity of sonography for prostate carcinoma is limited.
Correlation with PSA and prostate biopsy may be necessary regarding evaluation for prostate
carcinoma.
Impression: [Dictated; default- Negative.]
=======================================================
lra91
Lower Extremity Doppler
Examination: [DICTATE SIDE OR BILATERAL] Lower Extremity Ultrasound with Venous
Duplex Doppler.
Clinical History: [Dictate]
Technique: Color Doppler, spectral Doppler and gray scale evaluation with and without
compression of the lower extremity from groin through the calf was performed. The deep
venous system was imaged as was the greater
saphenous vein.
Comparison: [Dictated; default- None]
Findings:
Gray scale evaluation of the peripheral external iliac, common femoral, femoral and popliteal
veins demonstrates normal venous appearance and compression. Color Doppler images are
unremarkable. Normal venous waveforms, with respiratory variation and augmentation, are seen
with spectral Doppler. The visualized calf veins demonstrate normal compression and
augmentation. The greater saphenous vein compresses.
Impression:
Negative.
=================================
lra91-U
Upper Extremity Doppler
Examination: [DICTATE SIDE OR BILATERAL] Upper Extremity Ultrasound with Venous
Duplex Doppler.
Clinical History: [Dictate]
Technique: Color Doppler, spectral Doppler and gray scale evaluation with and without
compression of the upper extremity from the neck to wrist was performed. The deep venous
system was imaged. The cephalic and basilic veins were also interrogated.
Comparison: [Dictated; default- None]
Findings:
Gray scale evaluation of the internal jugular, subclavian, axillary and brachial veins demonstrates
normal venous appearance and compression where possible. Color Doppler images are
unremarkable. Normal venous waveforms, with respiratory variation and augmentation, are seen
on spectral Doppler. The deep veins of the forearm demonstrate normal compression and
augmentation. The basilic and cephalic veins compress.
Impression:
Negative.
==========================================
lra94
Noninvasive Lower Extremity Arterial Examination
Clinical History: [Dictated]
Comparison: [Dictated; default- None.]
Technique: Continuous wave Doppler. Pressure measurements. Great toe plethysmography.
Findings:
Right Brachial Pressure:____mmHg Left Brachial Pressure:____mmHg
Right Leg:
Posterior Tibial Artery: Pressure- ____mmHg; Waveform- _______
Dorsalis Pedis Artery: Pressure- ____mmHg; Waveform- _______
Great Toe: Pressure- ____mmHg
Ankle-Brachial Index [high brachial pressure/high ankle pressure]: _____
Left Leg:
Posterior Tibial Artery: Pressure- ____mmHg; Waveform- _______
Dorsalis Pedis Artery: Pressure- ____mmHg; Waveform- _______
Great Toe: Pressure- ____mmHg
Ankle-Brachial Index [high brachial pressure/high ankle pressure]: _____
Impression: Negative. [or dictated]
=======================================================
lra94a
Noninvasive Upper Extremity Arterial Examination
Clinical History: [Dictated]
Comparison: [Dictated; default- None.]
Technique: Continuous wave Doppler. Pressure measurements. Great toe
plethysmography.
Findings:
Right Brachial Pressure:____mmHg Left Brachial Pressure:____mmHg
Right Leg:
Low Thigh: Pressure- ____mmHg; Thigh-Brachial Index _____; Waveform_______
High Calf: Pressure- ____mmHg; Calf-Brachial Index _____; Waveform_______
Posterior Tibial Artery: Pressure- ____mmHg; Waveform- _______
Dorsalis Pedis Artery: Pressure- ____mmHg; Waveform- _______
Great Toe: Pressure- ____mmHg
Ankle-Brachial Index [high brachial pressure/high ankle pressure]:
_____
Left Leg:
Low Thigh: Pressure- ____mmHg; Thigh-Brachial Index _____; Waveform_______
High Calf: Pressure- ____mmHg; Calf-Brachial Index _____; Waveform_______
Posterior Tibial Artery: Pressure- ____mmHg; Waveform- _______
Dorsalis Pedis Artery: Pressure- ____mmHg; Waveform- _______
Great Toe: Pressure- ____mmHg
Ankle-Brachial Index [high brachial pressure/high ankle pressure]:
_____
Impression: [Dictated; default- Negative.]
=======================================================
lra95
Carotid Duplex
Examination: Ultrasound Duplex scan of the Extracranial Arteries- Bilateral Carotid
Clinical History: [Dictate]
Comparison: [Dictated; default- None]
Technique: Ultrasound of the bilateral carotid arteries was performed with color Doppler,
spectral Doppler, and gray scale evaluation. The common carotid, internal carotid, external
carotid, and vertebral arteries were evaluated. Carotid stenosis measured using NASCET
guidelines.
Comparison: [dictate]
Findings:
RightPSV Common Carotid (cm/sec):[Dictated]
EDV Common Carotid(cm/sec):[Dictated]
PSV Internal Carotid(cm/sec):[Dictated]
EDV Internal Carotid(cm/sec):[Dictated]
PSV External Carotid (cm/sec):[Dictated]
PSV Internal/Common Carotid Ratio:[Dictated]
Vertebral Flow: Antegrade.
Comments: Gray scale and color Doppler images demonstrate [DICTATE]
LeftPSV Common Carotid (cm/sec):[Dictated]
EDV Common Carotid(cm/sec):[Dictated]
PSV Internal Carotid(cm/sec):[Dictated]
EDV Internal Carotid(cm/sec):[Dictated]
PSV External Carotid (cm/sec):[Dictated]
PSV Internal/Common Carotid Ratio:[Dictated]
Vertebral Flow: Antegrade.
Comments: Gray scale and color Doppler images demonstrate [DICTATE]
IMPRESSION: [Dictated]
=======================================================
lra99 "LRA CTA Template"
EXAM: CTA of XXX
Clinical History: [Dictate]
Comparison: [Dictated; default- None]
TECHNIQUE: CT angiogram imaging of the [XXX see title] was performed. Angiographic
images were obtained utilizing multiple transverse CT images
following the administration of IV contrast. Maximum Intensity Projection [MIP] angiographic
reformatted images were provided in multiple planes. ____ mL of ________was administered.
Findings: [Dictated]
Impression: [Dictated]
==========================================
lra101 Procedure Technique
A timeout was taken. The nature of the procedure, including risks, benefits, potential
complications and alternatives were discussed with the patient. The patient consented to the
procedure. Using sterile technique, and after local anesthesia, the procedure was performed.
==========================================
lra105 Fleishner Criteria
Fleishner Criteria for the Follow-up and Management of Nodules Smaller than 8mm Detected
Incidentally on Nonscreening CT:
Low Risk Patients:
Less that or equal 4 mm
Greater than 4 - 6 mm
Greater than 6 - 8 mm
Greater than 8 mm
No follow-up needed.
Follow-up CT at 12 mos; if no change, no further follow-up
Initial F/u at 3-6 mos; then at 18 to 24 mos
F/u at 3, 6, 12 mos. Consider dynamic CT, PET or biopsy
High Risk Patients:
Less that or equal 4 mm
Greater than 4 - 6 mm
Greater than 6 - 8 mm
Greater than 8 mm
Follow-up CT at 12 mos; if no change, no further follow-up
Initial F/u at 3-6 mos; then at 18 to 24 mos
Initial F/u at 3-6 mos; 9 - 12 mos, then at 24mos
F/u at 3, 6, 12 mos. Consider dynamic CT, PET or biopsy
==========================================
lra110
Whole Body FDG-PET Scan
Clinical History:
Comparison: [Dictated; default- None]
Technique: ____ millicuries F-18 Fluorodeoxyglucose (FDG) were injected
intravenously. _______ minutes after the injection, scans were acquired from the skull base to
the thighs. Computed tomography was used for attenuation correction. Blood glucose was
measured at ____mg/dL. Uptake values described below are SUV max (representing the highest
standard uptake unit in an image pixel in the measured tumor region), unless otherwise indicated.
Findings: [Dictated]
Impression: [Dictated]
==========================================
lra110a
Whole Body and Neck FDG-PET Scan
Clinical History:
Comparison: [Dictated; default- None]
Technique: ____ millicuries F-18 Fluorodeoxyglucose (FDG) were injected
intravenously. _______ minutes after the injection, scans were acquired from the skull base to
the thighs. This was followed by separate focused imaging of the neck from the skull base to the
upper chest. Computed tomography was used for attenuation correction. Blood glucose was
measured at ____mg/dL. Uptake values described below are SUV max (representing the highest
standard uptake unit in an image pixel in the measured tumor region), unless otherwise indicated.
Findings: [Dictated]
Impression: [Dictated]
==========================================
lra110b
Whole Body and Lower Extremity FDG-PET Scan
Clinical History:
Comparison: [Dictated; default- None]
Technique: ____ millicuries F-18 Fluorodeoxyglucose (FDG) were injected
intravenously. _______ minutes after the injection, scans were acquired from the skull base to
the thighs. This was followed by separate imaging of the lower
extremities from hips through the feet. Computed tomography was used for attenuation
correction. Blood glucose was measured at ____mg/dL. Uptake values described below are
SUV max (representing the highest standard uptake unit in an image pixel in the measured tumor
region), unless otherwise indicated.
Findings: [Dictated]
Impression: [Dictated]
==========================================
lra112 LRA thyroid NM scan
Nuclear Medicine Thyroid Uptake and Scan
Clinical History:
Technique: ___mCi of Iodine-123 capsule PO.
Comparison:
Findings:
4 Hour Uptake:
[Normal 4% - 18%]
24 Hour Uptake:
[Normal 9% - 35%]
Comments:
Note: Scintigraphic resolution limits evaluation for small thyroid lesions, particularly those less
than one cm.
Impression: [Dictated]
=======================================================
lra113
Nuclear Medicine Whole Body White Blood Cell Ceretec Scan
Clinical History:
Technique: ___ mCi of Technetium-99m Ceretec intravenously. Whole body images obtained.
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
======================================================
lra113A
Nuclear Medicine Targeted White Blood Cell Ceretc Scan
Clinical History:
Technique: ___ mCi of Technetium-99m Ceretec intravenously. Targeted images of
_________.
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
=======================================================
lra114
Whole Body Bone Scan
Clinical History:
Technique: ___ mCi of Technetium-99m MDP intravenously.
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
=======================================================
lra114A
Nuclear Medicine Targeted Delayed Phase Bone Scan
Clinical History:
Technique: ___ mCi of Technetium-99m MDP intravenously. Targeted images of
_________.
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
=======================================================
lra114B
Nuclear Medicine Three Phase Bone Scan
Clinical History:
Technique: ___ mCi of Technetium-99m MDP intravenously. Blood flow, blood pool and
delayed imaging of the _________.
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
=======================================================
lra115
Nuclear Medicine Stress and Rest Cardiololite Mycoardial Perfusion Examination
Clinical History:
Technique: ____ mCi of Technetium-99m Sestamibi at rest. ____ mCi of Technetium-99m
Sestamibi. Gated images obtained.
Patient stressed by Dr._______
Resting heart rate: ___
Percent of maximum predicted heart rate achieved: ___
Exercise time: ___
Test terminated due to ________
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
=======================================================
lra115A
Nuclear Medicine Stress and Rest Cardiololite Mycoardial Perfusion Examination
Clinical History:
Technique: ____ mCi of Technetium-99m Sestamibi at rest. ____ mCi of Technetium-99m
Sestamibi. Gated images obtained.
Patient stressed by Dr._______
Stressed with: _______
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
=======================================================
lra116
NUCLEAR MEDICINE VENTILATION PERFUSION SCAN
CLINICAL HISTORY:
Technique:
______ mCi of Xenon-133 gas by ventilation.
______ mCi of Technetium-99m-labeled macroaggregated albumin intravenously.
Comparison: [Dictated]
Findings: [Dictated]
Impression: [Dictated]
=======================================================
lra117
Nuclear Medicine Hepatobiliary Scan with Ejection Fraction
Clinical History:
Technique: ____mCi of Technetium-99m Choletec intravenously. ____ micrograms Sincalide
[CCK] intravenously at 60 minutes.
Comparison:
Findings:
Activity seen in the gallbladder at ___
Activity seen in the small bowel at ____
Ejection fraction at 20 minutes after injection of Sincalide calculation:_____
[Normal ejection fraction 35%.]
Comments: Hepatic uptake is within normal limits.
Impression: [Dictated]
=======================================================
lra117A
Nuclear Medicine Hepatobiliary Scan
Clinical History:
Technique: ___mCi of Technetium-99m Choletec intravenously.
Comparison:
Findings:
Activity seen in the Gallbladder at ___ minutes.
Activity seen in the small bowel at ___ minutes.
Comments: Hepatic uptake is within normal limits.
Impression: [Dicated]
==========================================
BW 117G
Nuclear Medicine Solid Gastric Emptying Scan
Clinical History:
Technique: ___ mCi of Technetium-99m Sulphur Colloid PO in one scrambled egg, followed by
water.
Comparison:
Findings: Measured gastric emptying at 90 minutes calculated at ____%
[Normal at 90 minutes is 50%]
Impression:
=======================================================
LRA121 QI macro 1 [AKA No Discrepency]:
A preliminary report was submitted by On-Line Radiology. There is no clinically significant
discrepancy between that preliminary report and this final report.
===============================
LRA 122 QI macro 2 [AKA Discrepency]:
A preliminary report was submitted by On-Line Radiology. There is discrepancy between that
preliminary report and this final report, as follows:
===============================
lra 123 Bone Density
Bone Density Report
Clinical History: {Include indications and risk factors from questionnaire}
AP Spine:
BMD(1):
T Score(2):
Z Score(2):
Classification(3):
[Dictated] g/cm2
[Dictated]
[Dictated]
[Dictated]
Femoral Neck:
BMD(1):
T Score(2):
Z Score(2):
Classification(3):
[Dictated] g/cm2
[Dictated]
[Dictated]
[Dictated]
Total Hip:
BMD(1):
T Score(2):
Z Score(2):
Classification(3):
[Dictated] g/cm2
[Dictated]
[Dictated]
[Dictated]
World Health Organization criteria for BMD interpretation classify patients as Normal (T-score
at
or above -1.0), Osteopenic (T-score between -1.0 and -2.5), or
Osteoporotic (T-score at or below -2.5).
Notes:
1- See attached DXA results summary for each scan acquisition. Total and regional bone
mineral density values, percentiles, images, and graphs are provided.
2- T score is the number of standard deviations the BMD measurement differs from young
normal
values. This is the most important value in measuring
osteoporosis and fracture risk. Treatment is commonly based upon the lower acquired T scores.
Z score is the number of standard deviations the BMD
measurement differs from age matched normal values. This is a less important value, but helps
relate how a patient compares to others their age.
3- Classifications and fracture risk calculations are based upon World Health Organization
(WHO) categories, which specifically address central DXA BMD
measurements for postmenopausal caucasian women. The classification is generalized for other
sites and patient groups for convenience.
Comments: [exclude if none dictated]
================================