Focus on the images. Roy builds your report.

CTA CHEST / ABDOMEN / PELVISRadiologist dictatingIM 850 / 1338

ImageTAAD Case 20 · Apache 2.0

Dictating

EXAM: CTA CHEST, ABDOMEN AND PELVIS (AORTIC DISSECTION PROTOCOL)

HISTORY: Chest pain.

TECHNIQUE: Arterial phase axial acquisition with multiplanar reformats and maximum intensity projection reconstructions. Dose reduction techniques utilized.

COMPARISON: CT chest 03/23/2025.

FINDINGS:

Aorta and branch vessels: Acute dissection arising at the aortic root, extending through the arch, all three major branch vessels, and the descending thoracic aorta. Stanford Type A. The aortic root is aneurysmal, measuring 7.0 cm.

Heart and pericardium: Small simple pericardial effusion. No hemopericardium.

Lungs and pleura: Bilateral lower lobe collapse. Trace simple pleural effusions. No hemothorax.

Mediastinum: No lymphadenopathy or mediastinal mass.

Abdomen and pelvis: Solid organs unremarkable. No free fluid or free air.

IMPRESSION:

1. Acute Stanford Type A aortic dissection arising at a 7.0 cm aneurysmal aortic root.

2. Urgent cardiothoracic surgery consultation recommended.

EXAM: CTA CHEST, ABDOMEN AND PELVIS (AORTIC DISSECTION PROTOCOL)

HISTORY: Chest pain.

TECHNIQUE: Arterial phase axial acquisition with multiplanar reformats and maximum intensity projection reconstructions. Dose reduction techniques utilized.

COMPARISON: CT chest 03/23/2025.

FINDINGS:

Heart and pericardium: Small simple pericardial effusion. No hemopericardium.

Lungs and pleura: Bilateral lower lobe collapse. Trace simple pleural effusions. No hemothorax.

Mediastinum: No lymphadenopathy or mediastinal mass.

Abdomen and pelvis: Solid organs unremarkable. No free fluid or free air.

IMPRESSION:

1. Acute Stanford Type A aortic dissection arising at a 7.0 cm aneurysmal aortic root.

2. Urgent cardiothoracic surgery consultation recommended.

0.0s

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Speak naturally

Dictate findings and instructions in your own words, as if speaking to a colleague. Roy follows your clinical intent without requiring rigid phrases, punctuation, or a prescribed sequence, and lets you correct or refine anything inline as you go, so you can keep your attention on the images without stopping to fix or restructure the report.

Report ready

Dictation

Head CT. Bleed in the right frontal, 3.2 by 2.1 by 1.8 centimeters. No wait, by 2.4 by 2.0.

EXAM: CT HEAD WITHOUT CONTRAST

TECHNIQUE: Axial images of the brain without intravenous contrast.

COMPARISON: None.

FINDINGS:

Brain: Intraparenchymal hematoma in the right frontal lobe measuring 3.2 x 2.4 x 2.0 cm. No midline shift.

Extra-axial: No subarachnoid or subdural hemorrhage.

Ventricles: Normal in size and configuration.

Skull and sinuses: No acute fracture.

IMPRESSION: Intraparenchymal hematoma in the right frontal lobe measuring 3.2 x 2.4 x 2.0 cm.

7.6s

Focus on the positives

Discuss the abnormalities and their implications. Roy completes the appropriate report structure, including a billable header, relevant anatomy, and pertinent negative elements to address the clinical question.

Report ready

Dictation

Portable chest. Left lower lobe pneumonia. Get CT with.

EXAM: PORTABLE CHEST RADIOGRAPH, 1 VIEW

TECHNIQUE: Single AP portable view of the chest.

COMPARISON: None.

FINDINGS:

Lungs: Consolidative opacity in the left lower lobe, consistent with pneumonia.

Pleura: No pleural effusion or pneumothorax.

Heart and mediastinum: Normal cardiomediastinal silhouette.

Bones and soft tissues: No acute osseous abnormality.

IMPRESSION: Left lower lobe pneumonia. Recommend CT chest with contrast.

5.8s

Report your way

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Report ready

Dictation

Gallstones, no wall thickening, negative Murphy's. CBD five millimeters.

Radiologist A

No template available·Succinct reporting style

EXAM: US ABDOMEN RUQ

TECHNIQUE: Grayscale and Doppler ultrasound of the right upper quadrant.

COMPARISON: None.

FINDINGS:

Liver: Normal.

Gallbladder: Gallstones. No wall thickening or pericholecystic fluid. Negative Murphy's.

Common bile duct: 5 mm.

Pancreas: Normal.

Right kidney: Normal echogenicity. No hydronephrosis.

IMPRESSION: Gallstones. No acute cholecystitis.

Radiologist B

Template available·[ ] template field·▾ picklist

EXAM: [LIMITED RIGHT UPPER QUADRANT ULTRASOUND]

TECHNIQUE: Grayscale sonographic evaluation of the right upper quadrant, supplemented with color and spectral Doppler as needed.

COMPARISON: [None.]

FINDINGS:

Liver: [Normal in size, contour, and echogenicity. Antegrade flow is demonstrated in the main portal vein.]

Gallbladder and bile ducts: [There are no gallstones, no gallbladder wall thickening or pericholecystic fluid. Negative sonographic Murphy's sign.] The common bile duct measures [ ] mm.

Pancreas: [The visualized portions are normal in appearance.]

IMPRESSION: [Normal abdominal ultrasound.]

EXAM: [LIMITED RIGHT UPPER QUADRANT ULTRASOUND]

TECHNIQUE: Grayscale sonographic evaluation of the right upper quadrant, supplemented with color and spectral Doppler as needed.

COMPARISON: [None.]

FINDINGS:

Liver: [Normal in size, contour, and echogenicity. Antegrade flow is demonstrated in the main portal vein.]

Gallbladder and bile ducts: [Mobile echogenic foci with posterior acoustic shadowing are present within the gallbladder lumen, consistent with cholelithiasis. There is no gallbladder wall thickening or pericholecystic fluid, and the sonographic Murphy's sign is negative.] The common bile duct measures [5] mm.

Pancreas: [The visualized portions are normal in appearance.]

IMPRESSION: [Cholelithiasis without sonographic evidence of acute cholecystitis. The common bile duct is within normal limits.]

5.5s

Apply clinical guidance

Roy incorporates configured consensus recommendations, guideline language, follow-up recommendations, and relevant MIPS elements when appropriate, mirroring how radiologists think.

Report ready

Dictation

Right lower quadrant pain. No acute finding. Appendix normal. Triple A measures 3.5 centimeters. Left renal simple cyst.

EXAM: CT ABDOMEN AND PELVIS WITH CONTRAST

HISTORY: Right lower quadrant pain

TECHNIQUE: Axial computed tomography of the abdomen and pelvis with intravenous contrast.

COMPARISON: None.

FINDINGS:

Solid organs: Liver, gallbladder, spleen, pancreas and adrenal glands are normal.

Bowel: Normal appendix. No obstruction or inflammatory change.

Kidneys: Simple cyst in the left kidney. No follow-up imaging indicated.

Aorta: Abdominal aortic aneurysm measuring 3.5 cm.

Bladder and pelvic organs: Normal.

Peritoneum: No free fluid or free air.

Bones and soft tissues: No acute osseous abnormality.

IMPRESSION:

No acute abnormality. Normal appendix.

Abdominal aortic aneurysm measuring 3.5 cm. Recommend surveillance imaging in 3 years and vascular surgery consultation per Society for Vascular Surgery guidelines.

7.7s

Bring in clinical information directly

Turn ultrasound worksheets, modality outputs, measurements, summary tables and other technical information into a complete report without manual transcription.

Report ready

Dictation

Pain, increased LFTs. Gallbladder findings are non-specific, question of cholecystitis. Recommend HIDA. Steatohepatitis.

Sonographer worksheet

Arrives with the study

Technologist impression·superseded by dictation

Generated report

Findings merged

EXAM: US ABDOMEN RUQ LIMITED

HISTORY: Pain. Elevated liver function tests.

TECHNIQUE: Grayscale sonographic evaluation of the right upper quadrant supplemented with color and spectral Doppler as needed.

COMPARISON: None.

FINDINGS:

Liver: Hepatomegaly measuring 22.6 cm with hepatic steatosis and thickened main portal vein walls. Hepatopetal portal venous flow.

Gallbladder: Distended gallbladder with a 0.6 cm thickened, edematous wall and trace pericholecystic fluid. Intraluminal echoes without visible shadowing calculi. Positive sonographic Murphy's sign.

Common bile duct: 7.8 mm, dilated.

Right kidney: Measures 11.0 cm. Normal echogenicity. No hydronephrosis.

IMPRESSION:

Steatohepatitis.

Sonographic gallbladder findings are non-specific, possibly due to cholecystitis or hepatic parenchymal disease. Recommend HIDA scan for further evaluation.

Dilated common bile duct.

7.5s

Revise by instruction

Ask Roy to modify, reorganize, correct, add, or remove. You do not have to rebuild the report manually.

Report revised

Dictation

Actually, possible mets include an 8 mm enhancing lesion in the pancreas body and a 4 mm solid nodule in the right lower lobe that I initially missed.

IMPRESSION:

Heterogeneous mass in the left renal upper pole measuring 5.6 cm, highly concerning for renal cell carcinoma.

No metastatic disease.

IMPRESSION:

Heterogeneous mass in the left renal upper pole measuring 5.6 cm, highly concerning for renal cell carcinoma.

8 mm enhancing lesion in the pancreatic body and 4 mm solid nodule in the right lower lobe. Concern for metastatic disease in the pancreas and lungs.

Recommend CT chest with contrast and MRI abdomen with and without contrast.

9.6s

Review, edit, and sign

Roy assists with report creation. He does not replace the radiologist’s interpretation or judgment. You review, edit, and sign every report in your dictation software.

In your dictation software

You review, edit and sign

EXAM: MRI LUMBAR SPINE WITHOUT CONTRAST

HISTORY: Low back pain radiating to the left leg

TECHNIQUE: Multiplanar, multisequence magnetic resonance imaging of the lumbar spine without intravenous contrast.

COMPARISON: None.

FINDINGS:

Alignment: Normal. No spondylolisthesis.

Vertebral bodies: Normal marrow signal. No fracture.

Conus medullaris: Terminates at L1 and is normal.

L4-L5: Broad-based disc bulge with facet arthropathy and ligamentum flavum thickening, resulting in moderate spinal canal stenosis and moderate bilateral neural foraminal narrowing.

L5-S1: Left paracentral disc protrusion compresses the left S1 nerve root.

IMPRESSION:

Moderate spinal canal stenosis at L4-L5.

Left paracentral disc protrusion at L5-S1 compressing the traversing left S1 nerve root.

✓ SignedSigned by the radiologist

5.0s

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