Radiology Notes

My notes during radiology residency, fellowship, and beyond…

Archive for the ‘sample dictation’ Category

L Spine MRI Dictation

leave a comment »

Indication: [x].

Technique: An MRI of the lumbar spine was performed utilizing the following sequences: [x]

Comparison: [x]

Findings: Normal lumbar lordosis is preserved. Lumbar vertebral heights and alignment are maintained. No expansile or destructive osseous lesion is seen. No focal disk herniation, spinal canal or neural foramina stenosis is identified. The conus and cauda equina appear normal; the conus terminates at the [x] level. No epidural mass or collection is seen.

Impression: Normal lumbar spine MRI.

Written by lmwong

April 9, 2008 at 11:04 am

MRA Neck Dictation

leave a comment »

Indication: [x].

Technique: An MRA of the neck was performed using 2D and 3D time-of-flight techniques without the use of gadolinium.

Comparison: [x]

Findings: No hemodynamically significant stenosis of the common carotid, carotid bifurcation, or internal carotid arteries is seen. The extracranial portions of the vertebral basilar system are preserved without stenosis. No aneurysmal dilatation or dissection is seen.

Impression: Normal MRA of the neck.

Written by lmwong

April 9, 2008 at 11:03 am

MRA Head Dictation

leave a comment »

Indication: [x]

Technique: An MRA of the head was performed using 3D time-of-flight technique without the use of gadolinium.

Comparison: [x]

Findings: The anterior and posterior cerebral circulations are patent. No hemodynamically significant stenosis, anuerysmal dilatation or dissection is seen. No focal anuerysm is identified.

Impression: Normal MRA of the head.

Written by lmwong

April 9, 2008 at 11:02 am

Brain MRI Dictation

leave a comment »

Indication: [x]

Technique: An MRI of the brain was performed utilizing the following sequences: [x]

Comparison: [x]

Findings: The ventricles and sulci are normal in size and configuration. There is no acute infarct or intracerebral hemorrhage. No extra-axial blood or fluid collection is present. No intracranial mass is identified. The brainstem, posterior fossa and cervical medullary junction are preserved. Normal intracranial intravascular flow voids are seen. The orbits, periorbital and paracavernous spaces are normal. No abnormality of the skull base or calvarium is identified.

Impression: Normal MRI of the brain.

Written by lmwong

April 9, 2008 at 11:02 am

C-Spine CT Dictation

leave a comment »

Indication: Neck injury.

Technique: Multiple contiguous 3 mm axial images were obtained from the skull base through the thoracic inlet without intravenous contrast. Reformats in the coronal and sagittal planes were also obtained.

Comparison: [x]

Findings: No prevertebral soft tissue swelling is seen. The cervical alignment is maintained without spondylolisthesis. No acute fracture is identified. The vertebral body and disk space heights are preserved. The odontoid process is intact.

Impression: [x]

Written by lmwong

April 9, 2008 at 11:01 am

Posted in ct, neck, neuro, sample dictation

Petrous Temporal Bone CT Dictation

leave a comment »

Indication: [x]

Technique: A CT of the petrous temporal bone was obtained utilizing multiple contiguous 1 mm axial and coronal images without the use of intravenous contrast. Sagittal and coronal reformats were also obtained.

Comparison: [x]

Findings: The external auditory canals, tympanic membranes, and osseous labyrinths are normal bilaterally. There is no evidence of erosion of the ossicles, scutum, or tegmen tympani. The mastoid air cells are well-pneumatized and well aerated. No suspicious osseous lesion or fracture is identified.

Impression: Normal petrous temporal bone CT.

Written by lmwong

April 9, 2008 at 11:00 am

Neck Soft Tissue CT Dictation

leave a comment »

Indication: [x]

Technique: Contiguous 3mm axial images were obtained from the skull base to the thoracic inlet following the administration of intravenous contrast.

Comparison: [x]

Findings: The nasopharynx, oropharynx and hypopharynx are normal. No cervical mass or collection is seen. No aerodigestive tract mass is identified. The parotid, submandibular and thyroid glands are normal. No lymphadenopathy is identified. The osseous structures are intact.

Impression: Normal neck CT.

Written by lmwong

April 9, 2008 at 11:00 am

Posted in ct, neck, neuro, sample dictation

Facial CT Dictation

leave a comment »

Indication: Facial injury.

Technique: A facial CT was performed utilizing contiguous 3 mm axial images with reformats in the coronal and sagittal planes. No intravenous contrast was administered.

Comparison: [x]

Findings: The paranasal sinuses are well-developed and aerated. There is no mucosal disease or air-fluid level. The cribriform plate appears intact. The nasal septum is not deviated. No osseous lesion or fracture is visualized.

Impression: Normal facial CT.

Written by lmwong

April 9, 2008 at 10:59 am

Head CT Dictation

leave a comment »

Indication: [x]

Technique: Multiple contiguous 5 mm axial images were obtained from the skull base to the vertex without the use of intravenous contrast.

Comparison: [x]

Findings: The ventricles and sulci are within normal limits. No intracranial hemorrhage or extra-axial fluid collection is identified. There is no evidence of acute territorial infarct, focal mass lesion or midline shift. The osseous structures are intact. The paranasal sinuses are well-aerated.

Impression: Normal head CT.

Written by lmwong

April 9, 2008 at 10:58 am

Posted in ct, head, neuro, sample dictation

L Spine xray Dictation

leave a comment »

Indication: [x].
Technique: 4 views of the lumbosacral spine.
Comparison: [x]
Findings: The vertebral body and disc space heights are preserved. The spinal alignment is maintained without evidence of spondylolisthesis. No acute fracture is identified. The SI joints are unremarkable.
Impression: Unremarkable examination of the lumbosacral spine.

Written by lmwong

April 9, 2008 at 10:57 am

Paranasal Sinus Xray Dictation

leave a comment »

Indication: [x]
Technique: [x] views of the paranasal sinuses.
Comparison: No priors available for comparison.
Findings: The paranasal sinuses are grossly clear. No fluid levels are identified. No expansile or destructive osseous lesions are seen. There is no gross evidence of fracture.
Impression: No radiographic evidence of acute sinusitis

Written by lmwong

April 9, 2008 at 10:57 am

Thoracic Spine xray Dictation

leave a comment »

Indication: [x]
Technique: [x] views of the thoracic spine.
Comparison: [x]
Findings: The vertebral body and disc space heights are preserved. The spinal alignment is maintained without evidence of spondylolithesis. No acute fracture is identified. No lytic or blastic lesions are seen.
Impression: Unremarkable examination of the thoracic spine.

Written by lmwong

April 9, 2008 at 10:56 am

C-spine xray Dictation

leave a comment »

Indication: [x].
Technique: Four views of the cervical spine.
Comparison: [x]
Findings: The cervical spine is visualized from C1-T1. No prevertebral soft tissue swelling is seen. The cervical alignment is maintained without spondylolisthesis. No acute fracture is identified. The vertebral body and disk space heights are preserved. The odontoid process is intact.
Impression: Unremarkable examination of the C-spine.

Written by lmwong

April 9, 2008 at 10:53 am

Stereotatic Biopsy Dictation

leave a comment »

CLINICAL HISTORY: [x] year old woman referred for stereotactic core biopsy of a cluster of indeterminate microcalcifications in the [left or right] breast noted on recent mammography at [place and date].

Technique: [x] breast stereotactic core biopsy. Unilateral [digital] mammography. Specimen radiography. Dated [x].

PROCEDURE: Preliminary grid localizing film confirms a [x] cm cluster of microcalcifications in the [location within the breast].

Following universal protocol, patient and site verification was performed with a “time out” prior to the procedure.
After obtaining informed consent, the patient was positioned prone on the stereotactic table and the target was localized with digital images. A [x] approach was used. The skin was cleansed with Chloraprep. Cutaneous and deeper subcutaneous anesthesia was achieved using [x] cc of 1% Lidocaine and [x] cc’s of 1% Lidocaine containing epinephrine respectively. A small scalpel incision was made. A 9 gauge ATEC probe was inserted and its accurate position confirmed with pre and post fire images on the first pass. A total of [x] core biopsy specimens were obtained.

[#of radiographs] specimen radiographs revealed calcification in [x] cores. Cores containing radiographically evident calcium were sent in one container of formalin and cores not containing radiographically evident calcium were sent in another container of formalin for pathologic analysis, results pending. A [x] clip was [x] deployed to mark the biopsy site.

Post procedure cranial caudal and medial lateral projections disclose the clip to be at the target site. There [ are or are no ] residual microcalcifications noted at the biopsy site.

Following the procedure, the wound was cleansed and compressed. Steri strips and sterile gauze were applied and the patient was given post biopsy instructions. She left the department in good condition. Dr. [x] was in attendance during the entire procedure.

CONCLUSION: Status post stereotactic core biopsy of [right/left]

Written by lmwong

April 7, 2008 at 9:41 pm

Ultrasound Core Biopsy Dictation

leave a comment »

CLINICAL HISTORY: [x] year old woman referred for ultrasound-guided biopsy of a mass in the [right/left] breast.
The lesion was noted on previous ultrasound performed at [x] on [date]. Recent mammogram performed at [x] on [date] [demostrated/failed to demonstrate] the lesion.

Technique: [x] breast ultrasound guided core biopsy dated [x].

PROCEDURE:
Preliminary ultrasound evaluation of the [right/left] breast with special attention to the area of [sonographic/mammographic/palpable] concern, confirms the presence of a [x] x [x] cm mass at the [x] o’clock position, approximately [x] cm from the nipple, at a depth of [x] cm from the skin.

Following universal protocol, patient and site verification was performed with a “time out” prior to the procedure.
Informed consent was obtained. The patient was positioned in the supine oblique position, and the lesion was localized with real-time sonography. The skin was cleansed with Chloraprep. [x] cc’s of 1% Lidocaine was used for local anesthesia. A [lateral/medial/oblique] approach to the target was used. An 18-gauge needle, secured to a spring-loaded device, was advanced to the preselected target. A total of [x] biopsy specimens were obtained, with pre- and post-fire images documenting needle placement for each pass. Specimens were sent for pathologic analysis, results pending.

Following the procedure, the wound was cleansed and compressed. Steri-strips and sterile gauze were applied and the patient was given post-biopsy instructions. The patient tolerated the procedure well and left the department in good condition.

Dr. [x] was in attendance during the entire procedure.

IMPRESSION

Ultrasound-guided core biopsy of [right/left] breast mass. Pathology pending.

Written by lmwong

April 7, 2008 at 9:40 pm

Mammogram Needle Localization

leave a comment »

CLINICAL HISTORY: [x] year old woman referred for needle-wire localization of a [mass/cluster of calcifications] in the [right/left] breast [x] noted on previous mammogram performed at [x] on [x].

PROCEDURE: Following a universal protocol, patient and site verification was performed with a “time out” prior to the procedure. Preliminary mammographic views of the [right/left] breast confirm the presence of a [x] cm [mass/cluster
of calcifications] in the [x], approximately [x] cm
from the nipple.

Informed consent was obtained. A localizing grid film was obtained. The skin was cleansed with ChloraPrep. [x] cc of 1% Lidocaine was used for local anesthesia. Using a [lateral/medial/superior/inferior] approach, a
[x] needle/wire assembly was used to localize the target. Post-localization mammographic views disclosed the target to be[ant/post/med/lat] to the [reinforced segment of the wire/distal portion of the needle].
Labeled films were sent with the patient to the OR.
The patient tolerated the procedure well and left the department in good condition.

A surgical specimen submitted for radiography
demonstrates the targeted [mass/calcifications] to be within the specimen. The [x] wire is intact. Dr. [x] was notified of these findings at the time of surgery.

IMPRESSION:
Needle/wire localization and documented surgical excision of [left/right] breast [x]
[mass/microcalcifications].

Written by lmwong

April 7, 2008 at 9:39 pm

Ultrasound Needle Localization Dictation

leave a comment »

CLINICAL HISTORY: [x] year old woman referred for needle localization of a mass in the [right/left] breast.
The lesion was noted on previous ultrasound performed at [x] on [x]. Recent mammogram performed at [x] on [x] revealed [x].

Technique: Needle localization under ultrasound guidance, specimen radiography

PROCEDURE: Following universal protocol, patient and site verification was performed with a “time out” prior to the procedure. Preliminary ultrasound of the [right/left] breast with special attention to the area of sonographic concern, confirms the presence of a [x] x [x] cm mass at the [x] o’clock axis, [x] cm from the nipple.

Informed consent was obtained. The patient was positioned in the supine oblique position. The skin was cleansed. 0.2 cc 1% Lidocaine was used for local anesthesia. Using a [lateral/medial/superior/inferior] approach, a [x] needle/wire assembly was used to localize the target under real-time sonographic guidance.
A post-localization mammographic view was obtained, and sent with the patient to the OR.

The patient tolerated the procedure well and left the department in good condition.

A surgical specimen submitted for radiography demonstrates the targeted lesion to be within the specimen. The [x] wire is intact. Dr. [x] was notified of these findings at the time of surgery.

IMPRESSION: Ultrasound-guided needle localization and documented excision [left/right] breast mass .

Written by lmwong

April 7, 2008 at 9:39 pm

Right Unilateral Mammogram (s/p left mastectomy) Dictation

leave a comment »

CLINICAL HISTORY: [x] year old woman status post left mastectomy for carcinoma in [x]. The patient is now referred for follow up right mammogram. [x]

TECHNIQUE: Unilateral right mammogram dated [x]

COMPARISON: [x]

FINDINGS:
The right breast is [almost entirely fatty.;
composed of scattered fibroglandular densities.;
heterogeneously dense, which may lower the sensitivity of mammography.;
extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient.]

No mammographically suspicious mass or suspicious cluster of calcifications are seen in the right breast.

IMPRESSION:
No mammographic evidence of malignancy in the right breast.

RECOMMENDATION:
Unilateral right mammogram in one year.

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: Benign findings]

Written by lmwong

April 7, 2008 at 9:37 pm

Left Unilateral Mammogram (s/p right mastectomy) Dictation

leave a comment »

CLINICAL HISTORY: [x] year old woman status post right mastectomy for carcinoma in [x]. The patient is now referred for follow up left mammogram. [x].

TECHNIQUE: Unilateral left mammogram dated [x]

COMPARISON: [x]

FINDINGS:

The left breast is [almost entirely fatty.;
composed of scattered fibroglandular densities.;
heterogeneously dense, which may lower the sensitivity of mammography.;
extremely dense, which decreases the sensitivity of mammography. This makes physical examination relatively more important in this patient. ].

No mammographically suspicious mass or suspisious cluster of calcifications are seen in the left breast.

IMPRESSION:
No mammographic evidence of malignancy in the left breast. [x]

RECOMMENDATION:
Follow up left mammogram in one year. [x]

Findings and recommendations were discussed with the patient and she received a written record summarizing this report.

[BIRADS 2: benign findings]

Written by lmwong

April 7, 2008 at 9:36 pm

Diagnostic Mammogram After Recall Dictation

leave a comment »

Indication: [x] year old woman underwent screening mammography, [x], recalled for additional imaging of the [x] breast.

Technique: [x] unilateral mammogram, [x] breast sonogram

Comparison: [x]

Findings: [x]

Impression: [x]

Recommendation: [x]

These findings and recommendations were discussed with the patient and she received written record summarzing this report.

BIRADS [x]

Written by lmwong

April 7, 2008 at 9:35 pm

Follow

Get every new post delivered to your Inbox.

Join 151 other followers