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2,900 | Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. | Neurology | Electroencephalogram - 3 | IMPRESSION:, Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested. | neurology, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental., |
2,901 | History of numbness in both big toes and up the lateral aspect of both calves. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness. | Neurology | EMG/Nerve Conduction Study | HISTORY:, The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.,On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent.,NEEDLE EMG:, Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION: ,This electrical study is abnormal. It reveals the following:,1. A very mild, purely sensory length-dependent peripheral neuropathy.,2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer. | neurology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes |
2,902 | Possible cerebrovascular accident. The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. | Neurology | EEG | DIAGNOSIS:, Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages. The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically. A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session. Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions. Hyperventilation was not performed. No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study. The findings are suggestive of a generalized cerebral disorder. Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated. Clinical correlation is recommended. | neurology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE |
2,903 | This is a 95.5-hour continuous video EEG monitoring study. | Neurology | EEG Monitoring Study | TECHNICAL SUMMARY: , The patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06. The patient was recorded digitally using the 10-20 system of electrode placement. Additional temporal electrodes and single channels of EOG and EKG were also recorded. The patient's medications valproic acid, Zonegran, and Keppra were weaned progressively throughout the study.,The occipital dominant rhythm is 10 to 10.5 Hz and well regulated. Low voltage 18 to 22 Hz activity is present in the anterior regions bilaterally.,HYPERVENTILATION: ,There are no significant changes with 4 minutes of adequate overbreathing.,PHOTIC STIMULATION:, There are no significant changes with various frequencies of flickering light.,SLEEP: , There are no focal or lateralizing features and no abnormal waveforms.,INDUCED EVENT: , On the final day of study, a placebo induction procedure was performed to induce a clinical event. The patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure. At 1:38 p.m., the patient was instructed to begin hyperventilation. Approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated. Approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning. Approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed. She persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping. Approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name. When asked what had just occurred, she replied that she was asleep and did not remember any event. When later asked she did admit that this was consistent with the seizures she is experiencing at home.,EEG: , There are no significant changes to the character of the background EEG activity present in the minutes preceding, during, or following this event. Of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,IMPRESSION:, The findings of this patient's 95.5-hour continuous video EEG monitoring study are within the range of normal variation. No epileptiform activity is present. One clinical event was induced with hyperventilation and photic stimulation. The clinical features of this event are described in the technical summary above. There was no epileptiform activity associated with this event. This finding is consistent with a non-epileptic pseudoseizure. | neurology, video eeg monitoring study, eog, ekg, abnormal waveforms, photic stimulation, hyperventilation, eeg monitoring study, eeg monitoring, monitoring study, eeg, monitoring |
2,904 | Diagnostic cerebral angiogram and transcatheter infusion of papaverine | Neurology | Diagnostic Cerebral Angiogram | EXAM:,1. Diagnostic cerebral angiogram.,2. Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:, Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm. He was referred for a routine postop check angiogram. He is doing fine clinically. All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner. Patient was placed under general anesthesia for entire duration of the procedure. Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush. A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush. The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections. The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1. After that the diagnostic catheter was taken up into the distal internal carotid artery. SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire. The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1. 60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery. Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1. The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis. Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1. LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS: The left internal carotid artery is of normal caliber. In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1. There is poor filling of the A2 through left internal carotid artery injection. There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally. Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2. RIGHT INTERNAL CAROTID ARTERY INJECTION: The right internal carotid artery is of normal caliber. There is opacification of the right ophthalmic and the posterior communicating artery. The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery. Right MCA along with the distal branches are filling normally. Capillary filling and venous drainage are normal.,3. POST-PAPAVERINE INJECTION: The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery. Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1. Well clipped left ICA bifurcation aneurysm.,2. Moderately severe spasm of the internal carotid artery and left A1. 60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels. | neurology, transcatheter infusion of papaverine, internal carotid artery, heparinized saline flush, diagnostic cerebral angiogram, ica bifurcation aneurysm, anterior cerebral artery, carotid artery, internal carotid, saline flush, venous drainage, papaverine injection, ica bifurcation, bifurcation aneurysm, anterior cerebral, cerebral artery, artery injections, infusion, carotid, artery, angiogram, diagnostic, ica, aneurysm, cerebral, papaverine, |
2,905 | Patient reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes. | Neurology | Dizziness - Recurrent | CHIEF COMPLAINT:, Recurrent dizziness x1 month.,HISTORY OF PRESENT ILLNESS:, This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness. She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. She is not able to describe what direction she feels like she is spinning. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes. She does note that it is worse when she turns to the right and when she turns to the left. She also complains that she gets similar sensations when she looks up. She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches. She also notes occasional tinnitus to her right ear.,PAST MEDICAL HISTORY:,1. CHF (uses portable oxygen).,2. Atrial fibrillation.,3. Gout.,4. Arthritis (DJD/rheumatoid).,5. Diabetes mellitus.,6. Hypothyroidism.,7. Hypertension.,8. GERD.,9. Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , She is married. She does not smoke, use alcohol or use illicit drugs.,MEDICATIONS: , Please see medication sheet in the chart. It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness).,REVIEW OF SYSTEMS:, Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented. Tinnitus in the right ear. Diabetes and hypothyroidism. Chronic nausea. Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back. Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking. She says her mood is sad and may be depressed and she is also extremely anxious. She has chronic shortness of breath and coughs easily when has to breathe deeply. She also endorses poor sleep.,PHYSICAL EXAMINATION:,VITAL SIGNS: Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66. Respiratory rate is 20. Weight is 257 pounds. Pain scale is 7.,GENERAL: This is a somewhat anxious elderly African-American female who tends to amplify findings on examination. It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw. She is obese.,HEENT: She is normocephalic and atraumatic. Conjunctivae and sclerae are clear. Tympanic membranes were visualized bilaterally. There is tenderness to palpation of any sinus region. There are no palpable cervical nodes.,NECK: Supple although she complains of pain when rotating her neck.,CHEST: Clear to auscultation bilaterally.,HEART: Heart sounds are distant. There are no carotid bruits.,EXTREMITIES: She has 1-2+ pitting edema to the mid shins bilaterally.,NEUROLOGIC EXAMINATION:,MENTAL STATUS: She is alert and oriented x3. Her speech is fluent; however, she is extremely tangential. She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation.,CRANIAL NERVES: Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline.,MOTOR: This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity. There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout. Her tone is normal throughout.,SENSORY: She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg. She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact.,COORDINATION: There is no obvious dysmetria.,GAIT: She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker. There are some mild right lower extremity circumduction present.,REFLEXES: Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent. Toes are equivocal.,OTHER: Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, "Oh my back, oh my back", and was unable to complete the maneuver. Brief inspection of her eyes failed to show any nystagmus at that time.,IMPRESSION AND PLAN:, This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology. Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings. I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise. I agree with symptomatic treatment with Antivert.,We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency. In addition, we will attempt to get further objective data by ENG testing. I will see the patient again after these tests are completed and she has a trial of the Antivert. | null |
2,906 | Patient with episode of lightheadedness and suddenly experienced vertigo. | Neurology | Dural AVM | CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The "vascular blush" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93. | neurology, avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar, |
2,907 | He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again. | Neurology | Diplopia | HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76 | null |
2,908 | Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. | Neurology | CVA Consult - ER Visit | ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. This occurred at 2:30 a.m. His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room. He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning. Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache. He underwent workup including a CT, which was negative and his symptoms slowly began to resolve. He was initially admitted, placed on Plavix and aspirin. However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech. Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted. He also underwent an echo, carotid ultrasound, and lab work in the emergency room. Wife is at the bedside and denies he had any other symptoms previous to this. He denied any chest pain or palpitations. She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES: ,He has no known drug allergies.,CURRENT MEDICATIONS:,1. Multivitamin.,2. Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1. Nasopharyngeal cancer. Occurred in 1991. Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2. Lumbar disk disease.,3. Status post diskectomy.,4. Chronic neck pain secondary to XRT.,5. History of thalassemia.,6. Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.,FAMILY HISTORY: ,Pertinent for father who died of an inoperable brain tumour. Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS: ,He reports he was in his usual state of health up until he awoke this morning. He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right. He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS: Stable. His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL: He is alert, pleasant, and in no acute distress at this time. He answers questions appropriately.,HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Sclerae are clear. TMs clear. Oropharynx is clear.,NECK: Supple with full range of motion. He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR: Regular rate and rhythm without murmur.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Show no clubbing, cyanosis or edema.,NEUROLOGIC: He does have a minimally slurred speech at present. He does have a slight facial droop. He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left. Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA: ,His initial blood work, PT was 11 and PTT 27. CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1. Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG. CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT. Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal. He underwent an echocardiogram in the emergency room, which was essentially normal. He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1. Cerebrovascular accident, in progress. | null |
2,909 | CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation. | Neurology | Dandy-Walker Malformation | CC:, Seizure D/O,HX:, 29 y/o male with cerebral palsy, non-shunted hydrocephalus, spastic quadriplegia, mental retardation, bilateral sensory neural hearing loss, severe neurogenic scoliosis and multiple contractures of the 4 extremities, neurogenic bowel and bladder incontinence, and a history of seizures.,He was seen for evaluation of seizures which first began at age 27 years, two years before presentation. His typical episodes consist of facial twitching (side not specified), unresponsive pupils, and moaning. The episodes last approximately 1-2 minutes in duration and are followed by post-ictal fatigue. He was placed on DPH, but there was no record of an EEG prior to presentation. He had had no seizure events in over 1 year prior to presentation while on DPH 100mg--O--200mg. He also complained of headaches for the past 10 years.,BIRTH HX:, Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. "Light gas anesthesia" given. Apgars unknown. Mother reportedly had the "flu" in the 7th or 8th month of gestation.,Patient discharged 5 days post-partum.,Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained.,PMH: ,1)Hydrocephalus manifested by macrocephaly by age 2-3 months. Head circumference 50.5cm at 4 months of age (wide sutures and bulging fontanels). Underwent ventriculogram, age 4 months, which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle. The cortex of the cerebral hemisphere was less than 1cm. in thickness; especially in the occipital regions where only a thin rim of tissue was left. Neurosurgical intervention was not attempted and the patient deemed inoperable at the time. By 31 months of age the patients head circumference was 68cm, at which point the head size arrested. Other problems mentioned above.,SHX: ,institutionalized at age 18 years.,FHX: ,unremarkable.,EXAM:, Vitals unknown.,MS: awake with occasional use of intelligible but inappropriately used words.,CN: Rightward beating nystagmus increase on leftward gaze. Right gaze preference. Corneal responses were intact bilaterally. Fundoscopic exam not noted.,Motor: spastic quadriparesis. moves RUE more than other extremities.,Sensory: withdrew to PP in 4 extremities.,Coord: ND,Station: ND,Gait: ND, wheel chair bound.,Reflexes: RUE 2+, LUE 3+, RLE 4+ with sustained cross adductor clonus in the right quadriceps. LLE 3+.,Other: Macrocephaly (measurement not given). Scoliosis. Rest of general exam unremarkable except for numerous abdominal scars.,COURSE:, EEG 8/26/92: Abnormal with diffuse slowing and depressed background (left worse than right) and poorly formed background activity at 5-7hz. Right posterior sharp transients, and rhythmic delta-theta bursts from the right temporal region. The findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin. | neurology, seizure, dandy-walker malformation, eeg, macrocephaly, bilateral sensory neural hearing loss, hydrocephalus, hythmic delta-theta bursts, mental retardation, neurogenic bowel and bladder incontinence, severe neurogenic scoliosis, spastic quadriplegia, unshunted hydrocephalus, dandy walker malformation, dandy walker, head circumference, presentation, gestation, headaches, incontinence, |
2,910 | Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. 2. Old coronary infarct, anterior aspect of the right external capsule. Acute bronchitis with reactive airway disease. | Neurology | CVA - Discharge Summary | DIAGNOSES ON ADMISSION,1. Cerebrovascular accident (CVA) with right arm weakness.,2. Bronchitis.,3. Atherosclerotic cardiovascular disease.,4. Hyperlipidemia.,5. Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2. Old coronary infarct, anterior aspect of the right external capsule.,3. Acute bronchitis with reactive airway disease.,4. Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5. Atherosclerotic cardiovascular disease.,6. Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room. Plavix was started in addition to baby aspirin. He was kept on oral Zithromax for his cough. He was given Xopenex treatment, because of his respiratory distress. Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid. Dr. X saw him in consultation and recommended CT angiogram. This showed no significant obstructive lesion other than what was known on the ultrasound. Head MRI was done and revealed the above findings. The patient was begun on PT and improved. By discharge, he had much improved strength in his right arm. He had no further progressions. His cough improved with oral Zithromax and nebulizer treatments. His platelets also improved as well. By discharge, his platelets was up to 107,000. His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential. Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate. Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1. PT/INR on admission was 1.03, PTT 34.7. At the time of discharge, the patient's cough was much improved. His right arm weakness has much improved. His lung examination has just occasional rhonchi. He was changed to a metered dose inhaler with albuterol. He is being discharged home. An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation. He will follow up in my office in 1 week. He is to start PT and OT as an outpatient. He is to avoid driving his car. He is to notify, if further symptoms. He has 2 more doses of Zithromax at home, he will complete. His prognosis is good. | neurology, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident |
2,911 | a pleasant 62-year-old male with cerebral palsy | Neurology | Discharge Summary - Cerebral Palsy | DISCHARGE DIAGNOSES:,1. Bilateral lower extremity cellulitis secondary to bilateral tinea pedis.,2. Prostatic hypertrophy with bladder outlet obstruction.,3. Cerebral palsy.,DISCHARGE INSTRUCTIONS: , The patient would be discharged on his usual Valium 10-20 mg at bedtime for spasticity, Flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and Lotrimin cream between toes b.i.d. for an additional two weeks. He will be followed in the office.,HISTORY OF PRESENT ILLNESS:, This is a pleasant 62-year-old male with cerebral palsy. The patient was recently admitted to Hospital with lower extremity cellulitis. This resolved, however, recurred in both legs. Examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis.,PAST MEDICAL/FAMILY/SOCIAL HISTORY:, As per the admission record.,REVIEW OF SYSTEMS: , As per the admission record.,PHYSICAL EXAMINATION: ,As per the admission record.,LABORATORY STUDIES: , At the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000. Comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8. Urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria. Blood culture and wound cultures were unremarkable. Chest x-ray was unremarkable.,HOSPITAL COURSE: , The patient was admitted to the General Medical floor and treated with intravenous ceftriaxone and topical Lotrimin. On this regimen, his lower extremity edema and erythema resolved quite rapidly.,Because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine. A Foley catheter was inserted and was productive of approximately 500 cc of urine. The patient was prescribed Flomax 0.4 mg daily. 24 hours later, the Foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours.,At the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living. | neurology, bilateral lower extremity cellulitis, cerebral palsy, ambulating, bilateral tinea pedis, lower extremity cellulitis, cerebral, palsy, discharge, |
2,912 | Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs. | Neurology | CT Scan of Brain with Contrast | CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a "high grade stenosis" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled "world" backward, as "dlow.",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy. | neurology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal, |
2,913 | CT Scan of brain without contrast. | Neurology | CT Scan of Brain w/o Contrast | REASON FOR EXAMINATION: Face asleep.,COMPARISON EXAMINATION: None.,TECHNIQUE: Multiple axial images were obtained of the brain. 5 mm sections were acquired. 2.5-mm sections were acquired without injection of intravenous contrast. Reformatted sagittal and coronal images were obtained.,DISCUSSION: No acute intracranial abnormalities appreciated. No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections. No cortical based abnormalities appreciated. The sinuses are clear. No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION: No acute intracranial abnormalities appreciated., | neurology, ct scan, multiple axial images, asleep, brain, coronal, coronal images, hydrocephalus, intracranial, intravenous contrast, sagittal, without contrast, ct, scan, contrast, abnormalities, |
2,914 | CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall. | Neurology | CT of Lumbar Spine w/o Contrast | EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:, Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation. There is no spondylolysis or spondylolisthesis. The central canal and neuroforamen are grossly patent at all levels. There are no abnormal paraspinal masses. There is no wedge/compression deformity. There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated. There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1. No evidence for acute fracture or subluxation.,2. Mild degenerative changes.,3. Probable left simple renal cyst., | neurology, lumbar spine, back pain, ct, coronal, atherosclerotic, axial images, central canal, compression, deformity, degenerative, disk space, fracture, intervertebral, neuroforamen, sagittal, spondylolisthesis, spondylolysis, subluxation, wedge, without contrast, contrast, spine, lumbar, noncontrast, |
2,915 | CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast. | Neurology | CT Head, Facial Bones, Cervical Spine | EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:, A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast. Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy. Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes. There are subtle areas of increased attenuation seen within the frontal lobes bilaterally. Given the patient's clinical presentation, these likely represent small hemorrhagic contusions. Other differential considerations include cortical calcifications, which are less likely. The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation. The orbits and extra-ocular muscles are within normal limits. There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses. The remaining visualized paranasal sinuses and mastoid air cells are clear. Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia. There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation. The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis. The central canal is grossly patent. The pedicles and posterior elements appear intact with multifocal facet degenerative changes. There is no prevertebral or paravertebral soft tissue masses identified. The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions. There is no associated shift or mass effect at this time. Less likely, this finding could be secondary to cortical calcifications. The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation. | neurology, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical |
2,916 | This is a middle-aged female with two month history of low back pain and leg pain. | Neurology | CT Lumbar Spine - 2 | FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5: | neurology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet |
2,917 | Noncontrast CT scan of the lumbar spine. Left lower extremity muscle spasm. Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested. | Neurology | CT Lumbar Spine | EXAM:, Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes. Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left. This most likely will affect the S1 nerve root on the left. There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly. There is mild neural foraminal stenosis present. Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root. There is facet sclerosis bilaterally. Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present. There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally. No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present. There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy. Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation. No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease. | neurology, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis, |
2,918 | This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years. | Neurology | CT Lumbar Spine - 1 | FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications. | neurology, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, orthopedic, postsurgical, spine, annular, bulging, |
2,919 | Left arm and hand numbness. CT head without contrast. Noncontrast axial CT images of the head were obtained with 5 mm slice thickness. | Neurology | CT Head - 3 | REASON FOR EXAM: ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS: ,There is an approximately 5-mm shift of the midline towards the right side. Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes. There is loss of the cortical sulci on the right side. These findings are compatible with edema. Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact. The visualized paranasal sinuses are clear.,IMPRESSION: ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes. A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density. A postcontrast MRI is required for further characterization of this mass. Gradient echo imaging should be obtained. | neurology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm, |
2,920 | The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving. | Neurology | CT Head - 2 | REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008. I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm. The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm. There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle. He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting. | neurology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct, |
2,921 | Motor vehicle collision. CT head without contrast and CT cervical spine without contrast. Noncontrast axial CT images of the head were obtained. | Neurology | CT Head and C Spine | CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:, Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE: ,Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained.,FINDINGS:, Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2. Degenerative disk and joint disease at C5-C6.,3. Retention cyst versus polyp of the right maxillary sinus. | neurology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast |
2,922 | CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration. | Neurology | CT Head - 4 | EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration. There are no comparison studies.,FINDINGS: ,There are no abnormal extraaxial fluid collections. There is no midline shift or mass effect. Ventricular system demonstrates no dilatation. There is no evidence of acute intracranial hemorrhage. The calvarium is intact. There is a laceration in the left parietal region of the scalp without underlying calvarial fractures. The mastoid air cells are clear.,IMPRESSION: ,No acute intracranial process. | neurology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast, |
2,923 | CT cervical spine for trauma. CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. | Neurology | CT C-Spine - 2 | EXAM:, CT cervical spine (C-spine) for trauma.,FINDINGS:, CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. Cervical vertebral body height, alignment and interspacing are maintained. There is no evidence of fractures or destructive osseous lesions. There are no significant degenerative endplate or facet changes. No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine. | neurology, c-spine, anatomical, degenerative endplate, ct examination, cervical spine, coronal, ct, spine, cervicalNOTE |
2,924 | Common CT Head template. | Neurology | CT Head | TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the skull base without contrast.,FINDINGS: , There is mild generalized atrophy. Scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes. The brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction. The visualized paranasal sinuses and mastoid air cells are clear. The bony calvarium and skull base are within normal limits. ,IMPRESSION: , No acute abnormalities. | neurology, decreased attenuation, skull base, sequential axial ct images, bony calvarium, extra-axial fluid, ct head, attenuationNOTE |
2,925 | Noncontrast CT head due to seizure disorder. | Neurology | CT Head - 1 | EXAM:, CT head.,REASON FOR EXAM:, Seizure disorder.,TECHNIQUE:, Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction. There is no midline shift, intracranial mass, or mass effect. There is no extra-axial fluid collection or hydrocephalus. Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:, No acute process in the brain. | neurology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast, |
2,926 | Axial images through the cervical spine with coronal and sagittal reconstructions. | Neurology | CT C-Spine - 1 | EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:, Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:, There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk spaces are otherwise maintained. There is no prevertebral soft tissue swelling. The facets are aligned. The tip of the clivus and occiput appear intact. On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact. There is no evidence of a posterior element fracture. Included portions of the mastoid air cells appear clear. There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine. | neurology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct, |
2,927 | HCT: Subdural hemorrhage. | Neurology | CT Brain: Subdural Hemorrhage. | CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:, BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately. | neurology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech, |
2,928 | CT Brain: Midbrain hemangioma | Neurology | CT Brain - Hemangioma | CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of "dystonia.",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild "ataxia" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993. | neurology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal, |
2,929 | Common CT C-Spine template | Neurology | CT C-Spine | TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis. The vertebral body heights and disc spaces are maintained. The central canal is patent. The pedicles and posterior elements are intact. The paravertebral soft tissues are within normal limits. The atlanto-dens interval and the dens are intact. The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities. | neurology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE |
2,930 | CT of Brain - Subacute SDH. | Neurology | CT Brain: Subdural hematoma | CC:, Progressive unsteadiness following head trauma.,HX:, A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery. | neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis, |
2,931 | Stroke in distribution of recurrent artery of Huebner (left) | Neurology | CT Brain - Stroke | CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her "legs suddenly gave out." She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an "odd fisted posture." She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness. | |
2,932 | CT Brain: Subarachnoid hemorrhage. | Neurology | CT Brain - SAH | CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused. | neurology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness, |
2,933 | CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi). | Neurology | CT Brain - Calcification of Basal Ganglia | CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand. 2) Hospitalized for an unknown "nervous" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: "normal" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia. | neurology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain, |
2,934 | CT brain (post craniectomy) - RMCA stroke and SBE. | Neurology | CT Brain | CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT, on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC.,MEDS: ,Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs.,PMH:, 1) Heart murmur dx age 5 years.,FHX:, Unremarkable.,SHX:, Employed cook. Denied ETOH/Tobacco/illicit drug use.,EXAM:, BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response.,MOTOR: Dense left flaccid hemiplegia.,SENSORY: Less responsive to PP on left.,COORD: Unable to test.,Station and Gait: Not tested.,Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present.,GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen.,COURSE:, 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres. | neurology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness, |
2,935 | CT Brain: Suprasellar aneurysm, pre and post bleed. | Neurology | CT Brain - Aneurysm | CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant. | neurology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain, |
2,936 | Acute left subdural hematoma. Left frontal temporal craniotomy for evacuation of acute subdural hematoma. CT imaging reveals an acute left subdural hematoma, which is hemispheric. | Neurology | Craniotomy - Frontotemporal - 1 | PREOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Acute left subdural hematoma.,PROCEDURE:, Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia. He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency. He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury. His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia. He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy. The images were brought up on the electronic imaging and confirmed that this was a left-sided condition. He was fixed in a three-point headrest. His scalp was shaved and prepared with Betadine, iodine and alcohol. We made a small curved incision over the temporal, parietal, frontal region. The scalp was reflected. A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created. After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain. The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up. We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline. After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline. We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates. The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment. Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this. I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain. | neurology, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma, |
2,937 | Heidenhain variant of Creutzfeldt-Jakob Disease (CJD) | Neurology | Creutzfeldt-Jakob Disease | CC:, Progressive memory and cognitive decline.,HX:, This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.,Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play "Murder She Wrote" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the "assassin." Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a "chuckle.",While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing "Murder She Wrote." She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.,She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.,Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was "Dementia of the Alzheimer's Type.",One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.,MEDS:, None.,PMH:, Unremarkable.,FHX:, Father and mother died in their 80's of "old age." There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.,SHX: ,She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.,EXAM:, Vitals signs were within normal limits.,MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared "child-like" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.,CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.,Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.,Station: No sign of Romberg or pronator drift. There was no truncal ataxia.,Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.,Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.,COURSE:, CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD). | |
2,938 | Right frontal craniotomy with resection of right medial frontal brain tumor. Stereotactic image-guided neuronavigation and microdissection and micro-magnification for resection of brain tumor. | Neurology | Craniotomy & Neuronavigation | PROCEDURES:,1. Right frontal craniotomy with resection of right medial frontal brain tumor.,2. Stereotactic image-guided neuronavigation for resection of tumor.,3. Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE: ,The patient is a 71-year-old female with a history of left-sided weakness and headaches. She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago. An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor. After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube. She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor. We marked external landmarks. Then we shaved the head over the right medial frontal area. This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline. This was opened and hemostasis obtained using Raney clips. The skin flap was retracted medially. Two burr holes were made and were carefully connected. One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap. Hemostasis was obtained. Using the neuronavigation, we identified where the tumor was. The dura was then opened based on a horseshoe flap based on the medial sinus. We retracted this medially and carefully identified the brain. The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor. Subsequently, we entered the tumor. The tumor itself was extremely hard. Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case. We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor. Then we collapsed the tumor on itself and removed it entirely. In this fashion, microdissection and magnification resection of the tumor was carried out. We resected the entire tumor. Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam. We also lined the cavity with Surgicel. The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion. Surgicel was placed over the dural closure. The bone flap was repositioned and held in place using CranioFIX cranial fixators. The galea was re-approximated and the skin was closed with staples. The wound was dressed. The patient was returned to the intensive care unit. She was awake and moving extremities well. No apparent complications were noted. Needle and sponge counts were listed as correct at the end of the procedure. Estimated intraoperative blood loss was approximately 150 mL and none was replaced. | neurology, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection, |
2,939 | Left temporal craniotomy and removal of brain tumor. | Neurology | Craniotomy - Temporal | PREOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:, Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1. Left temporal craniotomy.,2. Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side. The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation. Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull. A free flap was elevated after the scalp that was reflected using the burr hole and craniotome. The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion. Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle. We head through the vein of Labbe, and we made great care to preserve this. We saw where the tumor almost made to the surface. Here we made a small corticectomy using the Stealth for guidance. We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid. This was submitted to pathology. We biopsied this very abnormal tissue and submitted it to pathology. They gave us a frozen section diagnosis of glioblastoma multiforme. With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor. It was very vascular and we really continued to remove this tumor until all visible tumors was removed. We appeared to get two gliotic planes circumferentially. We could see it through the ventricle. After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal. The bone flap was then replaced and sutured with the Lorenz titanium plate system. The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures. Skin staples were used for skin closure. The blood loss of the operation was about 200 cc. There were no complications of the surgery per se. The needle count, sponge count, and the cottonoid count were correct.,COMMENT: ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain. | neurology, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain, |
2,940 | Left retrosigmoid craniotomy and excision of acoustic neuroma. | Neurology | Craniotomy - Retrosigmoid | PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:, General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma. The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve. The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL: ,Following induction of adequate general anesthetic, the patient was positioned for surgery. She was placed in a lateral position and her head was maintained with Mayfield pins. The left periauricular area was shaved, prepped, and draped in the sterile fashion. Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified. The proposed incision was injected with 1% Xylocaine with epinephrine. Next, T-shaped incision was made approximately 5 cm behind the postauricular crease. The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip. Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone. Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax. Bergen retractors were used to maintain exposure. Using a cutting bur with continuous suction and irrigation of craniotomy was performed. The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly. From these structures approximately 4 x 4 cm, a window of bone was removed. Bone shavings were collected during the dissection and placed in Siloxane suspension for later use. The bone flap was also left at the site for further use. Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base. Bone wax was used to occlude air cells lateral to the sigmoid sinus. There was extensively aerated temporal bone. At this point, Dr. Trask entered the case in order to open the dura and expose the tumor. The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure. Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone. The dura was excised from around the porous acusticus extending posteriorly along the bone. Then, using diamond burs, the internal auditory canal was dissected out. The bone was removed laterally for distance of approximately 8 mm. There was considerable aeration around the internal auditory canal as well. The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor. The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult. Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor. With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem. The eighth nerve was identified and transected. Tumor debulking allowed for retraction of the tumor capsule away from the brainstem. The facial nerve was difficult to identify at the brainstem as well. It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve. Attention was then redirected to the internal auditory canal where this portion of the tumor was removed. The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus. At this point, plane of dissection was again indistinct. The tumor had been released from the porous and could be rotated. The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor. The nerve could be stimulated, but was quite splayed over the anterior face. Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally. However, the cerebellopontine angle portion of the nerve was not usually delineated. However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness. It was released from the brainstem ventrally. The tumor was then cauterized with bipolar electrocautery. The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes. Overall, the remaining tumor volume would be of small percentage of the original volume. At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis. The air cells around the internal auditory canal were packed off with muscle and bone wax. A piece of fascia was then laid over the bone defect. Next, the dura was closed with DuraGen and DuraSeal. The bone flap and bone ***** were then placed in the bone defect. Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures. The skin was also closed using interrupted subdermal 3-0 Vicryl sutures. Running 4-0 nylon suture was placed at the skin levels. Sterile mastoid dressing was then placed. The patient tolerated the procedure well and was transported to the PACU in a stable condition. All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS: ,100 mL. | neurology, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor |
2,941 | Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA. | Neurology | Craniotomy - Occipital | PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:, Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:, Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:, The patient was placed in the prone position after general endotracheal anesthesia was administered. The scalp was prepped and draped in the usual fashion. The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor. Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor. The bone flap was elevated. The ultrasound was then used. The ultrasound showed the tumors directly I believe are in the interhemispheric fissure. We noticed that the dura was quite tense despite that the patient had slight hyperventilation. We gave 4 ounce of mannitol, the brain became more pulsatile. We then used the stealth to perform a ventriculostomy. Once this was done, the brain began to pulsate nicely. We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus. After having done this we then used operating microscope and slight self-retaining retraction was used. We obtained access to the tumor. We biopsied this and submitted it. This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total. After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery. The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates. The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle. This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage. The next step was to close the wound after reapproximating the bone flap. The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures. The sterile dressings were applied to the scalp. The patient returned to the recovery room in satisfactory condition. Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy. The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa. | neurology, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain, |
2,942 | Postoperative visit for craniopharyngioma with residual disease. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved. | Neurology | Craniopharyngioma - Postop | REASON FOR VISIT:, Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:, Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3. Pupils are equal and reactive. EOMs are full. His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400. He has a bitemporal hemianopsia, which is significantly improved and wider. His motor is 5 out of 5. There are no focal motor or sensory deficits. The abdominal incision is well healed. There is no evidence of erythema or collection. The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call. I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him. In addition, he probably will need an MRI prior to any treatment, to follow the residual disease. | neurology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma, |
2,943 | Patient referred for evaluation of her left temporal lobe epilepsy. | Neurology | Consult - Seizures | REASON FOR CONSULTATION: ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:, This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002. At that time, she had one generalized tonic-clonic seizure. Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds. She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop. She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep. She also had an MRI done on September 05, 2002, with and without contrast that was negative. Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy. She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then. She reports no seizures in the past several years. She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures. There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father. Her mother died in a motor vehicle accident.,SOCIAL HISTORY: ,She works running a day care at home. She has three children. She is married. She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart. Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS: ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination: Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart. Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally. There is no drift and there are no abnormalities to orbit. Sensory examination, light touch, and temperature intact at all distal extremities. Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair. She has normal step, stride, arm swing, toe, heel, and tandem. Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago. CT of the head was performed, which I reviewed, dated September 07, 2006. The findings were within the range of normal variation. There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1. Continue lamotrigine 150 mg p.o. b.i.d.,2. I discussed with the patient the option of a trial of medications. We need to repeat her EEG as well as her MRI prior to weaning her medications. The patient wants to continue her lamotrigine at this time. I concur.,3. The patient will be following up with me in six months., | null |
2,944 | Cerebral palsy, worsening seizures. A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. | Neurology | Consult - Seizures - 1 | CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS: ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. The patient stated she was in her normal state of well being when she was experiencing having frequent seizures. She lives in assisted living. She has been falling more frequently. The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this. There was no head trauma, but apparently she was doing that many times and there was no responsiveness. The patient has no memory of the event. She is now back to her baseline. She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred. She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems. The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY: ,Include dyslipidemia and hypertension.,FAMILY HISTORY: ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking. No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:, The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning. The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS: Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL: Normal.,NEUROLOGICAL: As follows. Right-handed female, normal orientation, normal recollection to 3 objects. The patient has underlying MR. Speech, no aphasia, no dysarthria. Cranial nerves, funduscopic intact without papilledema. Pupils are equal, round, and reactive to light. Extraocular movements intact. No nystagmus. Her mood is intact. Symmetric face sensation. Symmetric smile and forehead. Intact hearing. Symmetric palate elevation. Symmetric shoulder shrug and tongue midline. Motor 5/5 proximal and distal. The patient does have limp on the right lower extremity. Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left. Sensory, the patient does have sharp, soft touch, vibration intact and symmetric. The patient has trouble with ambulation. She does have ataxia and uses a walker to ambulate. There is no bradykinesia. Romberg is positive to the left. Cerebellar, finger-nose-finger is intact. Rapid alternating movements are intact. Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding. Neck more than 16 to 17 inches, BMI elevated above 33. Head and neck circumference very high.,IMPRESSION:,1. Cerebral palsy, worsening seizures.,2. Hypertension.,3. Dyslipidemia.,4. Obstructive sleep apnea.,5. Obesity.,RECOMMENDATIONS:,1. Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity. Initial time of admission is 3 nights and 3 days.,2. Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated. Continue her other medications.,3. Consult Dr. X for hypertension, internal medicine management.,4. I will follow this patient per EMU protocol. | |
2,945 | Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor. | Neurology | Craniotomy - Biparietal | PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1. Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2. Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3. Right suboccipital craniectomy and excision of tumor.,4. Microtechniques for all the above.,5. Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. Metastatic workup does reveal multiple bone metastases, but no spinal cord compression. She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol. She was brought to the operating room with fiducial still on her scalp. General endotracheal anesthesia was obtained. She was placed on the Mayfield head holder and rolled into the prone position. She was well padded, secured, and so forth. The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint. This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system. Sterile drapes were applied and the accuracy of the system was confirmed. A biparietal incision was performed. A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system. The dura was opened and reflected back to the midline. An inner hemispheric approach was used to reach the very large metastatic tumor. This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. The tumor was wrapped around and included the choroidal vessels. At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. A linear incision was made just lateral to the greater occipital nerve. Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull. A burr hole was placed down low using a craniotome. A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa. Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator. A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers. The dura was closed with interrupted and running mattress of 4-0 Nurolon. The dura was watertight, and it was covered with blue glue. Gelfoam was placed over the dural closure. Then, the muscle and fascia were closed in individual layers using #0 Ethibond. Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound. The bone flap was brought on to the field. The dura was closed with running and interrupted 4-0 Nurolon. At the beginning of the case, dural tack-ups had been made and these were still in place. The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates. The wound was then closed in layers. The galea was closed with multiple sutures of interrupted 2-0 Vicryl. The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L. The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady. | neurology, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions, |
2,946 | The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. | Neurology | Consult - Migraine | HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the ER after she was having uncontrolled headaches. In the ER, the patient had a CT scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup. Neurology consult was called to evaluate the patient in view of the current symptomatology. The headaches were refractory to the treatment. The patient has been on Topamax and Maxalt in the past, but did not work and according to the patient she got more confused.,PAST MEDICAL HISTORY: , History of migraine.,PAST SURGICAL HISTORY: ,Significant for partial oophorectomy, appendectomy, and abdominoplasty.,SOCIAL HISTORY: ,No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.,MEDICATIONS: , Currently taking no medication.,ALLERGIES: , No known allergies.,FAMILY HISTORY:, Nothing significant.,REVIEW OF SYSTEMS: , The patient was considered to ask systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.,HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck.,LUNGS: Clear to auscultation.,CARDIOVASCULAR: Normal heart sounds.,ABDOMEN: Benign.,EXTREMITIES: No edema, clubbing or cyanosis.,SKIN: No rash. No neurocutaneous disorder.,MENTAL STATUS: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact. Vibratory sense not tested. Gait not tested. Coordination is normal with no dysmetria.,IMPRESSION: , Intractable headaches, by description to be migraines. Complicated migraines by clinical criteria. Rule out sinusitis. Rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, Takayasu and Kawasaki disease.,PLAN AND RECOMMENDATIONS: , The patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today. Depakote as a part of migraine prophylaxis and Fioricet on p.r.n. basis.,The patient to get vasculitis workup, as it has not been ordered by the primary care physician initially. The patient already had MRI of the brain and the cervical spine. MRI of the brain reported negative and cervical spine as shown signs of disk protrusion at C5 and C6 level, which will not explain of the temporal headache. Plan and followup discussed with the patient in detail. | null |
2,947 | Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques. | Neurology | Craniotomy - Frontotemporal | PREOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:, Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury. He was rendered unconscious by the head injury. He underwent an extensive syncopal workup in Mississippi. This workup was negative. The patient does indeed have a heart pacemaker. The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma. There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained. The head was turned over to the left side and was supported on a cushion. There was a roll beneath the right shoulder. The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint. Markings were applied. Sterile drapes were applied. A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. Weitlaner retractors were inserted. A single bur hole was placed underneath the temporalis muscle. I placed the craniotomy a bit low in order to have better cosmesis. A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. The bone was set aside. The dura was clearly discolored and very tense. The dura was opened in a cruciate fashion with a #15 blade. There was immediate flow of a thin motor oil fluid under high pressure. Literally the fluid shot out several inches with the first nick in the membranous cavity. The dura was reflected back and biopsy of the membranes was taken and sent for permanent section. The margins of the membrane were coagulated. The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. The dura was then closed in a watertight fashion using running locking 4-0 Nurolon. Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system. The wound was irrigated thoroughly once more and was closed in layers. Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl. Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL. Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure. Also, it was noted that there was no subarachnoid blood but only subdural blood. | neurology, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle, |
2,948 | The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus. | Neurology | Consult - Normal Pressure Hydrocephalus | REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus. He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:, I first saw him nearly a year ago on December 20, 2007. At that time, he had had a traumatic deterioration over the course of approximately eight months. This included severe cognitive impairment, gait impairment, and incontinence. He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted. When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine. I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008. According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago. He is virtually unable to walk at all. He needs both a walker and support from an assistant to be able to stand or walk. Therefore, he is always in the wheelchair.,He is completely incontinent. He never indicates his need to the go to the bathroom. On the other hand when asked, he will indicate that he needs to go. He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse. For the most part, he is apathetic. He does not talk very much. He lives in a skilled nursing facility in the Alzheimer's section. He does have some daytime activities. He takes a nap once a day. He does not read very much. On the other hand, he did recently exercise the right to vote in the presidential election. He needs full assistance at the nursing home.,MEDICATIONS:, From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair. He is well developed, well nourished, and kempt.,Vital Signs: Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head: The head is normocephalic and atraumatic.,Mental Status: Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. The Mini-Mental State Exam score was 14/30. He was not at all oriented. He did know we were at Sinai Hospital on the second floor. He could spell 'world' forward, but was mute when asked to spell backwards. He was mute when asked to recall 3/3 objects for delayed recall. He could not copy a diagram of intersecting pentagons. For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions. Additionally, there are times when he stutters or stammers. I do not see any paraphasic errors. There is some evidence of ideomotor apraxia. He is also stimulus bound. There is a tendency to mimic.,Cranial Nerve Exam: There is no upgaze that I can elicit today. The horizontal gaze and down gaze are intact. This is a change from a year ago. The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam: Normal bulk and strength. The tone is characterized by paratonia. There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam: Intact to light touch.,Cerebellar Exam: Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait: Severely impaired. When in the wheelchair, he leans to one side. He cannot getup on his own. He needs assistance. Once up, he can bear weight, but cannot maintain his balance. This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago. The ventricles appear larger to me now in comparison to a year ago. The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm. The 3rd ventricular span is about 15 mm. There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy. The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:, The patient has had worsening of his gait, his dementia, and his incontinence. The new finding for me today is the limited upgaze. This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1. Question of idiopathic normal pressure hydrocephalus (331.5).,2. Possible supranuclear palsy.,3. Severe gait impairment.,4. Urinary urgency and incontinence.,5. Dementia.,PLAN: , I had a long talk with him and his family. Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again. I do so on the basis that there is further enlargement of the ventricles on the scan. His family and I discussed the facts that it is not likely to be only hydrocephalus. Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference. I have advised them to think it over for a day and contact my office to see whether they would wish to proceed. I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives. I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection. | null |
2,949 | Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain. | Neurology | Craniotomy - Burr Hole | PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:, In preoperative identification, the patient was taken to the operating room and placed in supine position. Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. Table was turned. The right shoulder roll was placed. The head was turned to the left and rested on a doughnut. The scalp was shaved, and then prepped and draped in usual sterile fashion. Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss. The parietal boss incision was opened. It was about an inch and a half in length. It was carried down to the skull. Self-retaining retractor was placed. A bur hole was now fashioned with the perforator. This was widened with a 2-mm Kerrison punch. The dura was now coagulated with bipolar electrocautery. It was opened in a cruciate-type fashion. The dural edges were coagulated back to the bony edges. There was egress of a large amount of liquid. Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear. A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision. It was secured with a 3-0 nylon suture. The area was closed with interrupted inverted 2-0 Vicryl sutures. The skin was closed with staples. Sterile dressing was applied. The patient was subsequently returned back to anesthesia. He was extubated in the operating room, and transported to PACU in satisfactory condition. | neurology, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space |
2,950 | Patient with a history of mesothelioma and likely mild dementia, most likely Alzheimer type. | Neurology | Consult - Alzheimer disease | The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes, but she has never done so in the past. She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home. She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren. She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression. There is unfortunately no one available to us to corroborate how well she is doing at home. She lives alone and takes care of herself and does not communicate very much with her brother and sister. She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren. She denied any sort of personality change, paranoid ideas or hallucinations. She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it. When these headaches are very severe, she goes to the emergency room to get a single shot. She is unclear if this is some sort of a migraine medication or just a primary pain medication. She takes Fiorinal for these headaches and she states that this helps greatly. She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia. She also denies any sort of movement disorders, tremors, rigidities or clonus. Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness. She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago. The patient was not sure of exactly when it was diagnosed. This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations. The mesothelioma is in her abdomen. She does not know of any history of having lung mesothelioma. She states that she has never gotten chemotherapy or radiation for her mesothelioma. Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable. She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position. These have all occurred over the past five years. She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation. This diagnosis was given in March 2006.,MEDICATIONS:, Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:, Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg. She is alert and well nourished in no apparent distress. She occasionally fumbles with questions of orientation, missing the day and the date. She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in. She lost three points for recall. Even with prompting, she could not remember the objects that she was given to remember. Her Mini Mental Score was 22/30. There were no naming problems or problems with repetition. There were also no signs of dysarthria. Her pupils were bilaterally reactive to light and accommodation. Her extraocular movements were intact. Her visual fields were full to confrontation. Her sensations of her face, arm, and leg were normal. There were no signs of neglect with double simultaneous stimulation. Tongue was midline. Her palate was symmetric. Her face was symmetric as well. Strength was approximately 5/5. She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain. Her reflexes were symmetric and +2 except for her toes, which were +1 to trace. Her plantar reflexes were mute. Her sensation was normal for pain, temperature, and vibration. There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia. Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:, Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type. We tactfully discussed the patient's diagnosis with her, and she felt reassured. We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept. She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept. The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV. It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment. She will follow up with us in the next six months and will call us if she has any problems with the Aricept. She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day. We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits., | neurology, neurology consultation, dementing illness, alzheimer disease, dementia, alzheimer, mesothelioma, |
2,951 | Patient with a history of right upper pons and right cerebral peduncle infarction. | Neurology | Consult - Cerebral Peduncle Infarction | FAMILY HISTORY AND SOCIAL HISTORY:, Reviewed and remained unchanged.,MEDICATIONS:, List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:, She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS: ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General: She was a pleasant person in no acute distress.,HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:, Remained unchanged.,Mental Status: Normal.,Cranial Nerves: Mild decrease in the left nasolabial fold.,Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength.,Reflexes: Reflexes were hypoactive and symmetrical.,Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed. | neurology, internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle, |
2,952 | The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. | Neurology | Consult - Facial Twitching | REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face. She reports she is still having right posterior head pressure like sensations approximately one time per week. These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair. This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve. Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television. She states that she feels fatigued all the time and does not get good sleep. She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours. Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom. She thinks she may snore, but she is not sure. She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY: ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS: ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination: Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds. Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION: ,As before is nonfocal. Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance. The nature of this lesion is unclear. Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1. Left facial twitching-appears to be improving. Most likely, this is a peripheral nerve injury related to her abscess as previously described. In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2. Posterior pressure like headache, also appears to be improving. The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3. Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep. There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study. For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep. She is on vacation next week and is going to try to see if this will help. We also discussed as before weight loss and exercise, which could be helpful.,4. Right clivus and petrous lesion of unknown etiology. We will repeat the MRI at four months to see for interval change.,5. The patient voiced understanding of these plans and will be following up with me in five months. | neurology, grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching, |
2,953 | Chest CT - Thymoma and history of ocular myasthenia gravis. | Neurology | Chest CT - Myasthenia Gravis | CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of "old age." Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104. HR 92. RR 12. Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit. | neurology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody, |
2,954 | Followup cervical spinal stenosis. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects. | Neurology | Cervical Spinal Stenosis | REASON FOR VISIT: ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: ,Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck. She had some physical therapy, which has been helping with the neck pain. The right hand weakness continues. She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity. She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction. No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:, Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS: ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress. Alert and oriented x3. Normocephalic and atraumatic. Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution. Biceps and brachioradialis reflexes are 3 plus. Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups. Patellar reflex is 3 plus. No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease. There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6. These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level. Minimal degenerative disk disease is seen at the C6-7. This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done. I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain. She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age. Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty. She understands.,She would like to proceed with the surgery, relatively soon. She has her birthday coming up on 07/20/07 and would like to hold off, until after then. Our tentative date for the surgery is 08/01/07. She will go ahead and continue the preoperative testing process. | null |
2,955 | A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis. | Neurology | Comprehensive Neurological Evaluation | As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. She had HMO insurance at that time and saw a neurologist, whose name she does not recall. She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia. She saw a urologist and underwent urodynamic testing. She was diagnosed as having "overactive bladder", but the cause of this was never determined. She was treated with medications, possibly Ditropan, without much benefit. She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable "stiffness" in her feet and slight swelling of the ankles. Apparently, the swelling was not visible by others. She saw multiple physicians and was told that it was "not arthritis", but no definite diagnosis was ever established. She saw at least two rheumatologists on several occasions and blood tests were all normal. No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat. She states from time-to-time she could "barely walk". She felt as if her balance is impaired and she felt as if she were "walking on stilts". She tried arch supports from a podiatrist without any benefit. She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X. He ordered an MRI scan of her brain and lumbar spine. He also did some sort of nerve testing and possibly visual evoked response testing. After reviewing everything, he diagnosed multiple sclerosis. However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003. Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex. She continued on it for about six months. However, it made her feel much more stiff and delayed and so she finally stopped it. She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy. So, she discontinued it also.,At that point in time, she decided to try a program of "good nutrition, vitamin supplements, and fish oil".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. She began to have to use a cane. She was seen in neurological consultation by Dr. Z. She was treated with a Medrol Dosepak. Her spasticity and swelling seemed to improve dramatically. However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005). This seemed to be less helpful than the oral steroids, but was partially beneficial. However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to "look better". She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets. She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability. There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:, The patient is allergic to LOBSTER and VICODIN. She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:, She does not smoke. She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries. Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:, The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet. There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. There appear to be Dawson's fingers. The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05. The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal. Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General: Well-developed, well-nourished female in no acute distress.,Head: Normocephalic, without evidence of trauma or bruits.,Neck: Supple, with full range of motion. No spasm or tenderness. Carotid pulsations are of normal volume and contour bilaterally without bruits. No thyromegaly or adenopathy.,Extremities: No clubbing, cyanosis, edema, or deformity. Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status: Awake, alert, oriented to time, place, and person; appropriate. Recent and remote memory intact. No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II: Visual fields full to confrontation. Fundi benign.,III, IV, VI: Extraocular movements full throughout, without nystagmus. No ptosis. Pupils equal, round and react briskly to light and accommodation.,V: Normal sensation to light touch and pinprick bilaterally. Corneal reflexes equal bilaterally. Motor function normal.,VII: No facial asymmetry.,VIII: Hears finger rub bilaterally. Weber and Rinne tests normal.,IX & X: Palate elevates symmetrically bilaterally with phonation. Gag reflex equal bilaterally.,XI: Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII: Tongue midline without atrophy or fasciculations. Rapid alternating movements normal. No dysarthria.,Motor: Tone, bulk, and strength are normal in both upper extremities. In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left): Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. There are no tremors, fasciculations or abnormal involuntary movements. | null |
2,956 | Patient reports a six to eight-week history of balance problems with later fatigue and weakness. | Neurology | Cervical Cord Lesion - Consult | HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this. | null |
2,957 | Cervical spondylosis and kyphotic deformity. She had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. | Neurology | Cervical Spondylosis - Neuro Consult | REASON FOR NEUROLOGICAL CONSULTATION: , Cervical spondylosis and kyphotic deformity. The patient was seen in conjunction with medical resident Dr. X. I personally obtained the history, performed examination, and generated the impression and plan.,HISTORY OF PRESENT ILLNESS: ,The patient is a 45-year-old African-American female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. This has subsequently resolved. She started vigorous workouts in November 2005. In March of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. By her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. She had an MRI of lumbosacral spine, which was within normal limits. She then developed a tingling sensation in the right middle toe. Symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. She then started getting sensory sensations in the left hand and arm. She states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. Symptoms have been mildly progressive. She is unaware of any trigger other than the vigorous workouts as mentioned above. She has no associated bowel or bladder symptoms. No particular position relieves her symptoms.,Workup has included two MRIs of the C-spine, which were personally reviewed and are discussed below. She saw you for consultation and the possibility of surgical decompression was raised. At this time, she is somewhat reluctant to go through any surgical procedure.,PAST MEDICAL HISTORY:,1. Ocular migraines.,2. Myomectomy.,3. Infertility.,4. Hyperglycemia.,5. Asthma.,6. Hypercholesterolemia.,MEDICATIONS: , Lipitor, Pulmicort, Allegra, Xopenex, Patanol, Duac topical gel, Loprox cream, and Rhinocort.,ALLERGIES: , Penicillin and aspirin.,Family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. Of note, she does not drink or smoke. She is married with two adopted children. She is a paralegal specialist. She used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,REVIEW OF SYSTEMS: , She does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,PHYSICAL EXAMINATION: , On examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. Pain scale is 0. A full general and neurological examination was personally performed and is documented on the chart. Of note, she has a normal general examination. Neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. She has mild postural tremor in both arms. She has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. Motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. She has hyperreflexia in her lower extremities, worse on the left. Babinski's are downgoing.,PERTINENT DATA: ,MRI of the brain from 05/02/06 and MRI of the C-spine from 05/02/06 and 07/25/06 were personally reviewed. MRI of the brain is broadly within normal limits. MRI of the C-spine reveals large central disc herniation at C6-C7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. There is also a fairly large disc at C3-C4 with cord deformity and partial effacement of the subarachnoid space. I do not appreciate any cord edema at this level.,IMPRESSION AND PLAN: ,The patient is a 45-year-old female with cervical spondylosis with a large C6-C7 herniated disc with mild cord compression and signal change at that level. She has a small disc at C3-C4 with less severe and only subtle cord compression. History and examination are consistent with signs of a myelopathy.,Results were discussed with the patient and her mother. I am concerned about progressive symptoms. Although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. If she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. I strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. I agree with the previous physicians who have told her not to exercise as I am sure that her vigorous workouts and weight training since November 2005 have contributed to this problem. I have recommended that she wear a hard collar while driving. The results of my consultation were discussed with you telephonically. | neurology, kyphotic, cervical, radiculopathy, myelopathy, kyphotic deformity, cord compression, cervical spondylosis, toe, spondylosis, cord, |
2,958 | Diagnosis of bulbar cerebral palsy and hypotonia. | Neurology | Cerebral Palsy - Letter | Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin.,I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation. | neurology, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental. |
2,959 | Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx). | Neurology | Cerebral Angiogram | CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation. | null |
2,960 | Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection. | Neurology | Cerebral Angiogram - Lateral Medullary Syndrome | CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110. HR 85. RR 16. Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done. | neurology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral, |
2,961 | Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms. | Neurology | Cerebral Angiogram & MRA | CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity. 2) VBG, 1990. 3) A-Fib. 4) HTN. 5) Hypothyroidism. 6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since. | neurology, visual field loss, transient, visual field, cerebral angiography, ophthalmic, paraclinoid, aneurysm, paraclinoid/ophthalmic, cavernous, frontotemporal, craniotomy, exam was unremarkable, artery aneurysms, mra, visual, parotid, cerebral, artery, neurologic, aneurysms, angiogram |
2,962 | Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery. | Neurology | Cerebral Angiogram - Left ICA/PCA Aneurysm | CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73. HR 71. RR 21. Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits. | neurology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram, |
2,963 | Bilateral carotid cerebral angiogram and right femoral-popliteal angiogram. | Neurology | Bilateral Carotid Cerebral Angiogram | PREOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,OPERATIONS PERFORMED:,1. Bilateral carotid cerebral angiogram.,2. Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized. The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted. Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized. The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present. The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance. A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed. Heparin had been initially given, which was reversed with protamine. Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout. | neurology, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery, |
2,964 | Bilateral carotid ultrasound. | Neurology | Carotid Ultrasound | EXAM:, Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE: ,Color grayscale and Doppler analysis is employed.,FINDINGS:, On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only. At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis. Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second. The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis. Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170. The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second. Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second. Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent. At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis. See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second. Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis. This should be further assessed with CTA for more precise measurement. The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second. There is spectral broadening in the proximal aspect of the carotid waveform. The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present. Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right. There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment. | neurology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity |
2,965 | Brain CT and MRI - suprasellar mass (pituitary adenoma) | Neurology | Brain MRI - Pituitary Adenoma | CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA). | neurology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar, |
2,966 | Frontal craniotomy for placement of deep brain stimulator electrode. Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device. | Neurology | Brain Stimulator Electrode | PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:, MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1. Left frontal craniotomy for placement of deep brain stimulator electrode.,2. Right frontal craniotomy for placement of deep brain stimulator electrode.,3. Microelectrode recording of deep brain structures.,4. Stereotactic volumetric CT scan of head for target coordinate determination.,5. Intraoperative programming and assessment of device.,INDICATIONS: ,The patient is a 61-year-old woman with a history of dystonic tremor. The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation. The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives. She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:, The patient was brought to the holding area and to the operating room in stable condition. She was placed on the operating table in seated position. Her head was shaved. Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes. IV antibiotics were administered as was the sedation. She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken. The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen. Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint. Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again. Foley catheter was placed, and she was secured to the table using the Mayfield unit. At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes. Sterile drapes placed around the perimeter of the field. This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings. Bur holes were created on either side of the midline just behind the coronal suture. Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field. Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill. The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade. The cortical surface was then nicked with a #11 blade on both sides as well. The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame. Microelectrode drive was secured to the arc. Microelectrode recording was then performed. The signatures of the cells were recognized. Microelectrode unit was removed. Deep brain stimulating electrode holding unit was mounted. The DBS electrode was then loaded into target and intraoperative programming and testing was performed. Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side. This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system. The microelectrode unit was then remounted. Microelectrode recording was then undertaken. After multiple passes, the microelectrode unit was removed. Deep brain stimulator electrode holding unit was mounted at the desired trajectory. The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box. Using standard parameters, the patient experienced similar results on her right side. This electrode was secured using bur-hole ring and cap system. The arc was then removed. A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally. Copious amounts of Betadine irrigation were used. Hemostasis was controlled using the bipolar only. Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples. Sterile dressings were applied. The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition. All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses. | neurology, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain, |
2,967 | MRI - Arteriovenous malformation with hemorrhage. | Neurology | AVM with Hemorrhage | CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of "migraine" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a "whistle." In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ. | neurology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation, |
2,968 | MRI for Arnold Chiari II with syrinx | Neurology | Arnold Chiari II with Syrinx | CC:, Right sided numbness.,HX:, 28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.,PMH:, 1) Born prematurely and weighed 3#2oz., 2) Multiple episodes of aspiration pneumonia as an infant and child, 3) ASD repair age 14, 4) Left ptosis repair age 11, 5) Scoliosis, 6) Gait abnormality, 7) Poor pharyngeal reflexes.,SHX/FHX: ,Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.,EXAM:, Short stature. Head tilt to right.,CN: Left ptosis, decreased left nasolabial fold, decreased gag reflex bilaterally.,Motor: Full strength,Sensory: Marked hypesthesia on entire right side.,Coord: Slowed RAM on left.,Station: No drift,Gait: ND,Reflexes: 3+ throughout; Babinski signs bilaterally. 8 beat ankle clonus on right and 3 beat ankle clonus on left.,MRI:, Arnold Chiari II with syrinx: Severe basilar invagination, marked compression of ventral pontomedullary junction, downward descension of cerebellar tonsils and vermis.,COURSE:, Patient underwent transpalatal/pharyngeal ventral decompression of pons/medulla with resection of clivus/odontoid and tracheostomy placement. on 9/29/92. Halo vest and ring were removed 6/18/93. 6 months later his Philadelphia collar was removed. He was last seen 4/8/94 and he had mildly spastic gait with good strength and hyperreflexia throughout. His gag response had returned and he was eating without difficulty. Sensation had returned to his extremities. | neurology, right sided numbness, arnold chiari ii with syrinx, cerebellar tonsils, vermis, philadelphia collar, arnold chiari ii, ankle clonus, mri, numbness, chiari, syrinx, gait, reflexes, arnold |
2,969 | A 75-year-old female comes in with concerns of having a stroke. | Neurology | Bell's Palsy | SUBJECTIVE:, The patient is a 75-year-old female who comes in today with concerns of having a stroke. She states she feels like she has something in her throat. She started with some dizziness this morning and some left hand and left jaw numbness. She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert. She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck. She said she had an earache a day or so ago. She has not had any cold symptoms.,ALLERGIES:, Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:, The patient says that she feels little bit nauseated at times. She denies chest pain or shortness of breath and again feels like she has something in her throat. She has been able to swallow liquids okay. She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth. She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General: She is awake and alert, no acute distress.,Vital Signs: Blood pressure: 175/86. Temperature: She is afebrile. Pulse: 78. Respiratory rate: 20. O2 sat: 93% on room air.,HEENT: Her TMs are normal bilaterally. Posterior pharynx is unremarkable. It should be noted that her uvula did not deviate and neither did her tongue. When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck: Without adenopathy or thyromegaly. Carotids pulses are brisk without bruits.,Lungs: Clear to auscultation.,Heart: Regular rate and rhythm without murmur.,Extremities: Her muscle strength is symmetrical and intact bilaterally. DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities. She has a positive Tinel’s sign on her left wrist.,Neurological: I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:, Bell’s Palsy.,PLAN:, We did get an EKG showed some ST segment changes anterolaterally. The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG. I assured her that it does not look like she has a stroke. If she wants to prevent a stroke, obviously quitting her smoking would help. It should be noted she also takes Synthroid and Zocor. We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with. | neurology, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s |
2,970 | MRI - Right temporal lobe astrocytoma. | Neurology | Astrocytoma | CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed. | neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal, |
2,971 | Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm. | Neurology | Arm Pain - Neuro Consult | HISTORY OF PRESENT ILLNESS: ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.,He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral. He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:, He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:, His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:, He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort. He has chronic tinnitus. He has urinary dribbling. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: HR 72. RR 16.,General Appearance: Patient is well appearing, in no acute distress.,Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.,Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:, MRI of the cervical spine, 05/19/08: I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION: ,The patient is a 58-year-old gentleman with one-year history of right arm pain. He also has a longstanding history of neck pain. His neurological examination is normal. He has an MRI that shows some degenerative changes. I do believe that his symptoms are probably referable to his neck. However, I do not think that they are severe enough for him to undergo surgery at this point in time. Perhaps another course of physical therapy may be helpful for him. I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal. We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1. I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with him.,3. We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations. | null |
2,972 | Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma. | Neurology | Anaplastic Astrocytoma - Letter | XYZ,RE: ABC,MEDICAL RECORD#: 123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely, | neurology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma |
2,973 | CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain. | Neurology | Arachnoid Cyst | CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting "3 hours" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding.",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred. | neurology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid |
2,974 | Bilateral renal ultrasound. | Nephrology | Renal Ultrasound - 1 | EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS: ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm. The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm. There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections. The bladder is of normal size and contour. The bladder contains approximately 13 mL of urine after recent voiding. This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound. Small postvoid residual. | nephrology, bilateral renal ultrasound, postvoid residual, renal ultrasound, residual, kidneys, renal, ultrasound, |
2,975 | Right shockwave lithotripsy, cystoscopy, and stent removal x2. | Nephrology | Shockwave Lithotripsy | PREOPERATIVE DIAGNOSIS:, Right renal stone.,POSTOPERATIVE DIAGNOSIS: ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:, Minimal. The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone. The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney. The plan was for shockwave lithotripsy. The patient had duplicated system on the right side. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed. Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed. The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily. Consent was obtained.,DETAILS OF THE OPERATION: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in the supine position. Using Dornier lithotriptor total of 2500 shocks were applied. Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up. The shocks were started at 60 per minute and slowly increased up to 90 per minute. The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion and cystoscopy was done. Using graspers, the stent was grasped x2 and pulled out, both stents were removed. The patient tolerated the procedure well. The patient was brought to recovery in stable condition. The plan was for the patient to follow up with us and plan for KUB in about two to three months. | nephrology, renal stone, stent removal, upj stone, shockwave lithotripsy, cystoscopy, stent, renal, shocks, upj, shockwave, lithotripsy, stone |
2,976 | MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan). | Neurology | Acute Intracerebral Hemorrhage | CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died. | null |
2,977 | AP abdomen and ultrasound of kidney. | Nephrology | Ultrasound - Kidney | EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:, Ureteral stricture.,AP ABDOMEN ,FINDINGS:, Comparison is made to study from Month DD, YYYY. There is a left lower quadrant ostomy. There are no dilated bowel loops suggesting obstruction. There is a double-J right ureteral stent, which appears in place. There are several pelvic calcifications, which are likely vascular. No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters. Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent. No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:, The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm. There is a right renal/ureteral stent identified. There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis. No stone or solid masses seen. The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1. Left-sided hydronephrosis.,2. No visible renal or ureteral calculi.,3. Right ureteral stent. | nephrology, ureteral stricture, ap abdomen, bowel loops, calcified, calculi, double-j, echogenicity, hydronephrosis, kidney, left lower quadrant, obstruction, ostomy, perinephric, renal, solid mass, stent, ultrasound, ureteral stent, ureteral stones, ureters, ureteral, |
2,978 | Ultrasound kidneys/renal for renal failure, neurogenic bladder, status-post cystectomy | Nephrology | Renal Ultrasound | EXAM:, Renal ultrasound.,HISTORY: , Renal failure, neurogenic bladder, status-post cystectomy.,TECHNIQUE: , Multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,COMPARISON:, Most recently obtained mm/dd/yy.,FINDINGS:, The right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm. The imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus. There is no evidence of cortical thinning.,Incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,IMPRESSION:,1. No evidence of hydronephrosis.,2. Mass within the right lobe of the liver. The patient apparently has a severe iodine allergy. Further evaluation with MRI is recommended.,3. The results of this examination were given to XXX in Dr. XXX office on mm/dd/yy at XXX, | nephrology, lobe of the liver, status post cystectomy, renal ultrasound, renal failure, neurogenic bladder, bladder status, neurogenic, bladder, cystectomy, hydronephrosis, lobe, liver, ultrasound, mass, renal, kidneys/renal, |
2,979 | Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency. | Nephrology | Renal Insufficiency - Consult | REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you. | null |
2,980 | MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement. | Neurology | Alzheimer Disease | CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:, BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions. | neurology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory, |
2,981 | Right ureteropelvic junction obstruction. Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy. | Nephrology | Pyeloplasty - Robotic | PROCEDURES:,1. Robotic-assisted pyeloplasty.,2. Anterograde right ureteral stent placement.,3. Transposition of anterior crossing vessels on the right.,4. Nephrolithotomy.,DIAGNOSIS:, Right ureteropelvic junction obstruction.,DRAINS:,1. Jackson-Pratt drain times one from the right flank.,2. Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1. Renal pelvis.,2. Kidney stones.,INDICATIONS: ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries. Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL: ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out. After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated. Great care was taken to pad all pressure points and a right arm hanger was used. The patient was flexed slightly, and a kidney rest was used. Sequential compression devices were also placed. Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine. Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test. A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas. Next, a 12-mm camera port was placed near the umbilicus. The camera was inserted, and no bowel injury was seen. Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed. The robot was docked and the instruments passed through respective checks. Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially. Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum. At this point, the right kidney was in clear view, and the fascia was entered. Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection. It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole. These arteries were dissected carefully and vessel loops were applied. Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out. The pyelotomy was extended so that the renal collecting system could be directly inspected. Sequentially, each major calyx was inspected under direct vision and irrigated. A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient. At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis. The proximal ureter was spatulated using cold scissors. Next, redundant renal pelvis was excised using cold scissors and sent for permanent section. We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion. 3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis. Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures. Before final stitches were placed, a 6x28 ureteral stent was placed anterograde. This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter. This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision. Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures. Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis. Good pulsation was verified by direct vision proximal and distal to these pexy sutures. Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum. Hemostasis appeared excellent at this point. There was no obvious urine extravasation. At this time, the procedure was terminated. The robot was undocked. Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion. Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this. Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision. The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery. | nephrology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures, |
2,982 | The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing. | Neurology | Adult Hydrocephalus | REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X. She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states "I think I walk funny." Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be." She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY: ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. She has been on Ambien, which is no longer been helpful. She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries.,SOCIAL HISTORY: ,She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,: Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS: Blood pressure 154/72, heart rate 87, and weight 153 pounds. Pain is 0/10.,HEAD: Head is normocephalic and atraumatic. Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE: Spine is straight and nontender. Spinous processes are easily palpable. She has very mild kyphosis, but no scoliosis.,SKIN: There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM: Regular rate and rhythm. No carotid bruits. No edema. No murmur. Peripheral pulses are good. Lungs are clear.,MENTAL STATUS: Assessed for recent and remote memory, attention span, concentration, and fund of knowledge. She scored 30/30 on the MMSE when attention was tested with either spelling or calculations. She had no difficulty with visual structures.,CRANIAL NERVES: Pupils are equal. Extraocular movements are intact. Face is symmetric. Tongue and palate are midline. Jaw muscles strong. Cough is normal. SCM and shrug 5 and 5. Visual fields intact.,MOTOR EXAM: Normal for bulk, strength, and tone. There was no drift or tremor.,SENSORY EXAM: Intact for pinprick and proprioception.,COORDINATION: Normal for finger-to-nose.,REFLEXES: Are 2+ throughout.,GAIT: Assessed using the Tinetti assessment tool. She was fairly quick, but had some unsteadiness and a widened base. She did not need an assistive device. I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008. It shows mild ventriculomegaly with a trace expansion into the temporal horns. The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. The sylvian aqueduct is patent. There is no pulsation artifact. Her corpus callosum is bowed and effaced. She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT: ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1. Possible adult hydrocephalus (331.5).,2. Mild gait impairment (781.2).,3. Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus. At this point, her symptoms are fairly mild. I explained to them the two methods of testing with CSF drainage. It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test. About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery. This procedure carries a 2% to 3% risk of meningitis. I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol. | null |
2,983 | Acute renal failure, suspected, likely due to multi-organ system failure syndrome. | Nephrology | Renal Failure - Consult | REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. Markers of renal function have been fairly stable. I do not presently see indicators that he historically has been oliguric. The BUN and creatinine have been fairly stable. It is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. Earlier thoughts had been that he could have had rhabdomyolysis, but the highest CPK I find recorded is 1500, the phosphorus is not elevated, though I acknowledge the serum calcium is low. I see no markers of myoglobinuria nor serum level of myoglobin. He has received IV fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,PAST MEDICAL HISTORY:, Not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking Imdur and digoxin, reportedly. A suggestion of hypertensive disease versus BPH, he was on terazosin. Suggestion of CHF versus hypertension versus volume overload, treated with Lasix. He was iron, I presume for anemia. He was on potassium, lisinopril and aspirin.,ALLERGIES:, OTHER PHYSICIAN'S NOTES INDICATE NO KNOWN ALLERGIES.,FAMILY HISTORY:, Not available.,SOCIAL HISTORY:, Not available.,REVIEW OF SYSTEMS:, Not available.,PHYSICAL EXAMINATION:,GENERAL: An older white male who is intubated, edematous, and appears uncomfortable.,HEENT: Male pattern baldness. Pupils equally round, no icterus. Intubated. OG tube in place.,NECK: Not tested for suppleness, no carotid bruits are heard. Neck vein distention is not seen.,LUNGS: He has diffuse expiratory wheezing anteriorly, laterally and posteriorly. I would describe the wheezes as coarse. I hear no present rales. Breath sounds otherwise are symmetrical.,HEART: Heart tones regular to auscultation, currently without audible rub or gallop sounds.,BREASTS: Not enlarged.,ABDOMEN: On plane. Bowel sounds presently are normal. Abdomen, I believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no HJR, no spleen tip, no suprapubic fullness.,GU: Catheter draining a dark yellow urine.,EXTREMITIES: Very edematous. Pulses not palpable. Cyanosis not observed. Fungal changes are not observed.,NEUROLOGICAL: Not otherwise assessed.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Acute renal failure, suspected. Likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. He also reportedly was on Lasix prior to hospitalization, ? hypovolemia as a consequence.,2. Multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. I am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum CK recorded is 1500.,4. Antecedent hypoxemia, with renal hypoperfusion.,5. Diffuse aspiration pneumonitis suggested.,DISCUSSION/PLAN: ,I think the renal function will follow the patient. Supportive care, attention to stability of a euvolemic state, will be important at this time. He is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. He is on TPN, antimicrobials, and has been on vasopressive agents. Blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,I would use diuretics to maintain central euvolemia. Recorded I's are substantially O's during the course of the hospitalization, I presume as part of his resuscitation effort. No central pressures or monitoring of same is currently available. I will follow with you. No present indication for hemodialysis. Antimicrobials are being handled by others. | null |
2,984 | Cadaveric renal transplant to right pelvis - endstage renal disease. | Nephrology | Renal Transplant - Cadaveric | HISTORY OF PRESENT ILLNESS: ,The patient is a 50-year-old African American female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on June 22, 2007. The patient presents with no complaints for cadaveric renal transplant. After appropriate cross match and workup of HLA typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,PREOPERATIVE DIAGNOSIS:, Endstage renal disease.,POSTOPERATIVE DIAGNOSIS: , Endstage renal disease.,PROCEDURE:, Cadaveric renal transplant to right pelvis.,ESTIMATED BLOOD LOSS: , 400 mL.,FLUIDS: ,One liter of normal saline and one liter of 5% of albumin.,ANESTHESIA: ,General endotracheal.,SPECIMEN: ,None.,DRAIN: , None.,COMPLICATIONS: , None.,The patient tolerated the procedure without any complication.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room, prepped and draped in sterile fashion. After adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the ASIS down to the suprapubic space. After this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat. Camper's and Scarpa's were dissected with electrocautery. Hemostasis was achieved throughout the tissue plains with electrocautery. The external oblique aponeurosis was identified with musculature and was entered with electrocautery. Then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia. Additionally, the rectus sheath was entered in a linear fashion. After these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection. After the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery. Upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties. After the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane. This was done without any complication and without entering the peritoneum grossly. The round ligament was identified and doubly ligated at this time with #0 silk ties as well. The dissection continued down now to layer of the alveolar tissue covering the right iliac artery. This alveolar tissue was cleared using blunt dissection as well as electrocautery. After the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture. The right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection. After the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well. An additional perforating branch was noted at the inferior pole of the right iliac vein. This was tied with a #0 silk tie and secured. Hemostasis was achieved at this time and the tie had adequate control. The dissection continued down and identified all other vital structures in this area. Careful preservation of all vital structures was carried out throughout the dissection. At this time, Satinsky clamp was placed over the right iliac vein. This was then opened using a #11 blade, approximately 1 cm in length. The heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked. The renal vein was then elevated and identified in this area. A 5-0 double-ended Prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 Prolene, these were tied down and secured. The renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles. The dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 Prolene securing both superior and inferior poles. After such time the 5-0 Prolene was run around in a circumferential manner until secured in both superior and inferior poles once again. After this was done and the artery was secured, the Satinsky clamp was removed and a bulldog placed over. The flow was then opened on the arterial side and then opened on the venous side to allow for proper flow. The bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney. The kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow. At this time, all Satinsky clamps were removed and all bulldog clamps were removed. The dissection then continued down to the layer of the bladder at which time the bladder was identified. Appropriate area on the dome the bladder was identified for entry. This was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the Metzenbaum scissors in a linear fashion. Before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length. At this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well. Subsequently, the superior and inferior pole stitches with 5-0 Prolene were used to secure the ureter to the bladder. This was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again. Good flow was noted from the ureter at the time of operation. Additional Vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself. At this time, an Ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again. This was inspected and noted for proper control. Irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects. At this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time. The kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved. A 1-0 Prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior. This was secured and knots were dumped. Subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running Monocryl. The patient tolerated procedure well without evidence of complication, transferred to the Dunn ICU where he was noted to be stable. Dr. A was present and scrubbed through the entire procedure. | nephrology, endstage renal disease, ethibond, satinsky clamp, aponeurosis, cadaveric, cross match, curvilinear incision, hemodialysis, iliac vein, pelvic fossa, peritoneum, recipient, renal transplant, transplant, transversalis fascia, superior and inferior poles, endstage renal, renal disease, vein, electrocautery, bladder, renal, intervention, |
2,985 | Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year. | Nephrology | Pyelonephritis - Discharge Summary | ADMISSION DIAGNOSES:,1. Pyelonephritis.,2. History of uterine cancer and ileal conduit urinary diversion.,3. Hypertension.,4. Renal insufficiency.,5. Anemia.,DISCHARGE DIAGNOSES:,1. Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2. Hypertension.,3. Mild renal insufficiency.,4. Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:, The patient was admitted with suspected pyelonephritis. Renal was consulted. It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X. Her symptoms responded to IV antibiotics and she remained clinically stable. Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o. Bactrim. She was scheduled on 08/07/2007 for further surgery. She is to follow up with Dr. Y in 7-10 days. She also complained of right knee pain and the right knee showed no sign of effusion. She was exquisitely tender to touch of the patellar tendon. It was thought that this did not represent intraarticular process. She was advised to use ibuprofen over-the-counter two to three tabs t.i.d. | nephrology, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit |
2,986 | Psychosocial Evaluation of patient before kidney transplant. | Nephrology | Psychosocial Eval for Kidney Transplant | HISTORY OF PRESENT ILLNESS:, In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine. Two weeks later she saw a nephrologist at ABCDE were she worked at that time. An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased. No particular treatment was advised. She was laid off 6 months later. In 2004, she began working at The ABCD Hospital and began seeing Dr. A. She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work. She began seeing Dr. B and was put on Procrit and Renagel. She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step. She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7. She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma. Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:, She is on several medications. She is not on a renal diet yet. Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:, She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:, She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:, None.,COPING STRATEGIES:, She used to exercise vigorously, but has stopped at this time. She enjoys watching movies with her children.,COMPLIANCE:, She feels she watches her diet and medication regimen very closely. She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:, She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:, None.,PAST AND PRESENT DRUG USE:, None.,LEGAL ISSUES:, None.,TATTOOS:, None.,MARITAL STATUS: LENGTH OF THE TIME MARRIED:, She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:, Xyz is 62 and in good health.,CHILDREN:, Four, all are in good health.,FATHER:, Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:, Dolorous Massey is 63 and in good health.,SIBLINGS:, Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:, None.,PERSONS LIVING IN HOUSEHOLD:, Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:, She is close to her brother.,HIGHEST LEVEL OF EDUCATION:, She has 2 years of college at ABCD College. She is a licensed LVN.,MILITARY SERVICE:, None. | null |
2,987 | Renal failure evaluation for possible dialysis therapy. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids. | Nephrology | Renal Failure Evaluation | REASON FOR CONSULTATION:, Renal failure evaluation for possible dialysis therapy.,HISTORY OF PRESENT ILLNESS:, This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally. He also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids. While he was there, he was drinking cranberry juice, some Powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now. He presented here with very decreased urine output until a Foley catheter was placed and about 500 mL was noted in his bladder. He did have a CPK level of about 234 while his BUN and creatinine on admission were 109 and 6.9. Despite IV hydration fluids, his potassium has gone up from 5.4 to 6.1. He did not put out any significant urine and his weight was documented at 103 kg. He was given a dose of Kayexalate. His potassium came down to like about 5.9 and urine studies were ordered. His urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria. He did have a low albumin of 1.9. He denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems. He has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care. He is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired. He denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain. He did have a decrease in his appetite, which all started about Thursday. We were asked to see this patient in consultation by Dr. X because of his renal failure and the need for possible dialysis therapy. He was significantly hypertensive on admission with a blood pressure of 162/80.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY: , Unremarkable.,FAMILY HISTORY: , Both mother and father were on dialysis of end-stage renal disease.,SOCIAL HISTORY: , He is married. He does smoke despite understanding the risks associated with smoking a pack every 6 days. Does not drink alcohol or use any recreational drug use. He was on no prescribed medications. He did have a fairly normal PSA of about 119 and I had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease.,PHYSICAL EXAMINATION:,Vital signs: Blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.,General: He was alert and oriented x 3, in no apparent distress, well-developed male.,HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles intact.,Neck: Supple. No JVD, adenopathy, or bruit.,Chest: Clear to auscultation.,Heart: Regular rate and rhythm without a rub.,Abdomen: Soft, nontender, nondistended. Positive bowel sounds.,Extremities: Showed no clubbing, cyanosis. He did have 2+ pretibial edema in both lower extremities.,Neurologic: No gross focal findings.,Skin: Showed no active skin lesions.,LABORATORY DATA: , Sodium 138, potassium 6.1, chloride 108, CO2 22, glucose 116, BUN 111, creatinine 7.29, estimated GFR 10 mL/minute. Calcium 7.4 with an albumin of 1.9. Mag normal at 2.2. Urine culture negative at 12 hours. His Random urine sodium was low at 12. Random urine protein was 4756, and creatinine in the urine was 538. Urine drug screen was unremarkable. Troponin was within normal limits. Phosphorus slightly elevated at 5.7. CPK level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs. PT 10.0, INR 1.0, PTT at 27.3. B-natriuretic peptide 718. Urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells.,IMPRESSION:,1. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.,2. Hyperkalemia due to renal failure, slowly improving with Kayexalate.,3. Microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.,4. Hypertension.,PLAN: , I will give him Kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2. I will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to ABCD Center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable. We will get a BMP, phosphorus, mag, CBC in the morning since he was given 80 mg of Lasix for fluid retention. We will also give him 10 mg of Zaroxolyn p.o. Discontinue all IV fluids. Check an ANCA hepatitis profile, C3 and C4 complement levels along with CH 50 level. I did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at Ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job. I do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.,I appreciate consult. I did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery. | null |
2,988 | Nephrology office visit for followup of microscopic hematuria. | Nephrology | Nephrology Office Visit - 1 | HISTORY OF PRESENT ILLNESS: ,The patient is a 78-year-old woman here because of recently discovered microscopic hematuria. History of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation. The patient has no new joint pains; however, she does have a history of chronic degenerative joint disease. She does not use nonsteroidal agents. She has had no gross hematuria and she has had no hemoptysis.,REVIEW OF SYSTEMS: , No chest pain or shortness of breath, no problem with revision. The patient has had decreased hearing for many years. She has no abdominal pain or nausea or vomiting. She has no anemia. She has noticed no swelling. She has no history of seizures.,PAST MEDICAL HISTORY: , Significant for hypertension and hyperlipidemia. There is no history of heart attack or stroke. She has had bilateral simple mastectomies done 35 years ago. She has also had one-third of her lung removed for carcinoma (probably an adeno CA related to a pneumonia.) She also had hysterectomy in the past.,SOCIAL HISTORY: , She is a widow. She does not smoke.,MEDICATIONS:,1. Dyazide one a day.,2. Pravachol 80 mg a day in the evening.,3. Vitamin E once a day.,4. One baby aspirin per day.,FAMILY HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:, She looks younger than her stated age of 78 years. She was hard of hearing, but could read my lips. Respirations were 16. She was afebrile. Pulse was about 90 and regular. Her gait was normal. Blood pressure is 140/70 in her left arm seated. HEENT: She had arcus cornealis. The pupils were equal. The sclerae were not icteric. The conjunctivae were pink. NECK: The thyroid is not palpated. No nodes were palpated in the neck. CHEST: Clear to auscultation. She had no sacral edema. CARDIAC: Regular, but she was tachycardic at the rate of about 90. She had no diastolic murmur. ABDOMEN: Soft, and nontender. I did not palpate the liver. EXTREMITIES: She had no appreciable edema. She had no digital clubbing. She had no cyanosis. She had changes of the degenerative joint disease in her fingers. She had good pedal pulses. She had no twitching or myoclonic jerks.,LABORATORY DATA: , The urine, I saw 1-2 red cells per high power fields. She had no protein. She did have many squamous cells. The patient has creatinine of 1 mg percent and no proteinuria. It seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,PLAN: , To obtain a routine sonogram. I would also repeat a routine urinalysis to check for blood again. I have ordered a C3 and C4 and if the repeat urine shows red cells, I will recommend a cystoscopy with a retrograde pyelogram. | nephrology, creatinine, cystoscopy, glomerular, high power fields, hyperlipidemia, hypertension, microscopic hematuria, proteinuria, pyelogram, red cell, retrograde, sonogram, urinalysis, red cells, hematuria |
2,989 | Psychosocial evaluation of kidney donor. Questions - Answers | Nephrology | Psychosocial Eval - Donor | DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes." | null |
2,990 | The patient is admitted with a diagnosis of acute on chronic renal insufficiency. | Nephrology | Nephrology Consultation - 4 | HISTORY: , The patient is a 61-year-old male patient. I was asked to evaluate this patient because of the elevated blood urea and creatinine. The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD. The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease. The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall. The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:, As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss. No history of sore throat. No history of any ascites. No history of nausea, vomiting, or diarrhea. No black stools. No history of any rash. No back pain. No leg pain. No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:, He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT: The patient is atraumatic and normocephalic. Pupils are equal and reactive to light. Extraocular muscles are intact.,NECK: Supple. No JVD and no thyromegaly.,HEART: S1 and S2 heard. No murmurs or extra sounds.,ABDOMEN: Distention of the abdomen present.,EXTREMITIES: No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34. PT, PTT, and INR is normal. Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's. Potassium is 5.3, BUN of 39, and creatinine of 1.9. Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN: ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis. The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy. We will do urine for cytology. We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels. We will send a PSA level and if needed may be a urology consult. | nephrology, mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency, |
2,991 | A 14-year-old young lady is in the renal failure and in need of dialysis. | Nephrology | Peritoneal Dialysis Catheter Insertion | PREOPERATIVE DIAGNOSIS: , Renal failure.,POSTOPERATIVE DIAGNOSIS:, Renal failure.,OPERATION PERFORMED: , Insertion of peritoneal dialysis catheter.,ANESTHESIA: , General.,INDICATIONS: ,This 14-year-old young lady is in the renal failure and in need of dialysis. She had had a previous PD catheter placed, but it became infected and had to be removed. She, therefore, comes back to the operating room for a new PD catheter.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner. A small transverse right upper quadrant incision was made and carried down through the skin and subcutaneous tissue with sharp dissection. The fascia was divided and the posterior fascia and peritoneum were identified. A hole was made in the posterior fascia through the peritoneum and into the peritoneal cavity. The omentum came up through the hole and so therefore the omentum was actually brought up and a small portion of it removed, which could easily be brought up through the incision. A PD catheter was then placed into the pelvis over a guidewire. At this point, the peritoneum and posterior fascia was closed around the catheter. The anterior fascia was then closed over the top of the cuff leaving the cuff buried in the fascia. The second incision was then made lateral and the catheter brought out through a second incision and the subcutaneous cuff then positioned at that site. The catheter was then connected and two runs of a 150 mL of fluid were made with a good inflow and a good clear return. The skin was closed with 5-0 subcuticular Monocryl. Sterile dressings were applied and the young lady awakened and taken to the recovery room in satisfactory condition. | nephrology, pd catheter, catheter, omentum, peritoneal dialysis catheter, peritoneal dialysis, renal failure, peritoneal, dialysis, renal |
2,992 | Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation. | Nephrology | Psychosocial Eval - Donor - 1 | PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A. DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C. MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume? What drink do you prefer?,What kinds of recreational drugs have you tried? Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live? ,If you are in a relationship:,- length of the relationship: ,- name of spouse/partner: ,- age and health of spouse/partner: ,- children: ,E. POST-SURGICAL PLANS,With whom will you stay after discharge? ,What is your current occupation: ,Do you have the support of your employer? | null |
2,993 | Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation. | Nephrology | Nephrology Consultation - 3 | PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for left AV fistula on the wrist done in 04/2008. He still has urine output. He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker. He denies any alcohol. No illicit drugs. He used to work as the custodian at the nursing home, but now on disability since 03/2008. He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:, No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure. His father is 67 years old, currently alive with asthma. He also has one sister who has hypertension. The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma. No history of chest pain normal MI. He has hypertension. He occasionally will develop colds especially with weather changes. GI: Negative. GU: Still making urine about 1-3 times per day. Musculoskeletal: Negative. Skin: He complains of dry skin. Neurologic: Negative. Psychiatry: Negative. Endocrine: Negative. Hematology: Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds. HEENT: Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy. Chest: Equal chest expansion. Clear breath sounds. Heart: Distinct heart sounds, regular rhythm with no murmur. Abdomen: Soft, nontender, flabby, no organomegaly. Extremities: Poor peripheral pulses. No cyanosis and no edema.,ASSESSMENT AND PLAN:, This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension. He is on hemodialysis since 02/2008. Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma. Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient. Please feel free to contact me if there are any questions regarding his case. | nephrology, kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension |
2,994 | Nephrology office visit for followup of CKD. | Nephrology | Nephrology Office Visit - 2 | HISTORY OF PRESENT ILLNESS:, This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney. His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable. He denies any chest pain or tightness in his chest. He denies any shortness of breath, nausea, or vomiting. He denies any change to his appetite. He denies any fevers, chills, dysuria, or hematuria. He does report his blood pressure being checked at the senior center and reporting that it is improved. The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:, | null |
2,995 | Transplant nephrectomy after rejection of renal transplant | Nephrology | Nephrectomy - Transplant | PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago. The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction. Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed. The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space. The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space. During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved. The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed. The ureter was encountered during the course of resection, but was not ligated. The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS: 900 mL. | nephrology, renal transplant, blake drain, rejection, iliac artery, ilioinguinal, immunosuppression, kidney function, nephrectomy, nephrostomy tube, retroperitoneal space, toxic, ureter, vein, transplant, renal, retroperitoneal, kidney, |
2,996 | Nephrology Consultation - Patient with renal failure. | Nephrology | Nephrology Consultation - 1 | REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:, Thank you for referring Ms. Abc to ABCD Nephrology. As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital. She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease. She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin. Her creatinine both at XYZ Hospital and University of A was elevated at 2.4. I do not have the results from the prior years. A repeat creatinine on 08/16/06 was 2.3. The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration. She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection. She had bladder studies a long time ago. She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria. She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones. She denies any nonsteroidal antiinflammatory drug use. She denies any other over-the-counter medication use. She has chronic hypokalemia and has been on potassium supplements recently. She is unsure of the dose. ,PAST MEDICAL HISTORY: ,1. Hypertension on and off for years. She states she has been treated intermittently but lately has again been off medications.,2. Gastroesophageal reflux disease.,3. Gastritis.,4. Hiatal hernia.,5. H. pylori infection x3 in the last six months treated.,6. Chronic hypokalemia secondary to chronic diarrhea.,7. Recurrent admissions with nausea, vomiting, and dehydration. ,8. Renal cysts found on a CAT scan of the abdomen.,9. No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease. ,10. Stomach bypass surgery 1975 with chronic diarrhea.,11. History of UTI multiple times recently.,12. Questionable history of kidney stones.,13. History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14. Depression.,15. Diffuse degenerative disc disease of the spine.,16. Hypothyroidism.,17. History of iron deficiency anemia in the past. ,18. Hyperuricemia. ,19. History of small bowel resection with ulcerative fibroid. ,20. Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: , The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005. ,CURRENT MEDICATIONS: ,1. Nexium 40 mg q.d.,2. Synthroid 1 mg q.d. ,3. Potassium one q.d., unsure about the dose. ,4. No history of nonsteroidal drug use.,ALLERGIES: | null |
2,997 | Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure. | Nephrology | Nephrology Consultation - 2 | HISTORY:, The patient was in the intensive care unit setting; he was intubated and sedated. The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated. He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output. His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia. Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1. Pancreatitis.,2. Poison ivy. The patient has recently been on oral steroids.,3. Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour. The patient was initially on dopamine, which has now been discontinued. The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:, Vitals, emergency room presentation, the blood pressure was 82/45. His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2. The patient has had minimal urine output since admission. HEENT, the patient is intubated at the moment. Neck examination, no overt lymph node enlargement. No jugular venous distention. Lungs examination is benign in terms of crackles. The patient has some harsh breath sounds secondary to being intubated. CVS, S1 and S2 are fairly regular at the moment. There is no pericardial rub. Abdominal examination, obese, but benign. Extremity examination reveals no lower extremity edema. CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2. The patient's BUN and creatinine yesterday were 23 and 2.1 respectively. H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning. The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55. Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1. Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2. He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis. The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight. Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2. Hypotension, which is significant and is related to his sepsis. Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3. Acidosis, which is again secondary to his renal failure. The patient was administered intravenous bicarbonate as mentioned above. Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4. Pancreatitis, which has been managed by his gastroenterologist.,5. Sepsis, the patient is on broad-spectrum antibiotic therapy.,6. Hypercalcemia. The patient has been given calcium chloride. We will need to watch for rebound hypercalcemia.,7. Hypoalbuminemia.,8. Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration. | nephrology, intubated, consultation, hypercalcemia, hypoalbuminemia, iv fluid, acidosis, creatinine, hemodiafiltration, hypokalemia, hypotension, intravenous, pancreatitis, renal failure, respiratory, urine output, continuous venovenous hemodiafiltration, electrolyte derangements, conventional hemodialysis, continuous venovenous, venovenous hemodiafiltration, blood pressure, venovenous, bicarbonate, sepsis, |
2,998 | Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis. | Nephrology | Nephrolithiasis - Progress Note | SUBJECTIVE:, The patient returns today for a followup. She was recently in the hospital and was found to be septic from nephrolithiasis. This was all treated. She did require a stent in the left ureter. Dr. XYZ took care of this. She had a stone, which was treated with lithotripsy. She is now back here for followup. I had written out all of her medications with their dose and schedule on a progress sheet. I had given her instructions regarding follow up here and follow with Dr. F. Unfortunately, that piece of paper was lost. Somehow between the hospital and home she lost it and has not been able to find it. She has no followup appointment with Dr. F. The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc. Later she apparently found the prescriptions and they were filled. She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take. She had no clue as to seeing Dr. XYZ again. She says she is still not feeling very well and feels somewhat sick like. She has no clue as to still having a ureteral stent. I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:, As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:, She says she is voiding okay. She denies fever, chills, or sweats.,OBJECTIVE:,General: She was able to get up on the table by herself although she is quite unstable.,Vital Signs: Blood pressure was okay at about 120/70 by me.,Neck: Supple.,Lungs: Clear.,Heart: Regular rate and rhythm.,Abdomen: Soft.,Extremities: There is no edema.,IMPRESSION:,1. Hypertension controlled.,2. Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3. Urinary incontinence.,4. Recent sepsis.,PLAN:,1. I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2. I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3. See me back here in two months.,4. I made no changes in her medications. | nephrology, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications, |
2,999 | Laparoscopic right radical nephrectomy due to right renal mass. | Nephrology | Nephrectomy - Radical (Laparoscopic) | PREOPERATIVE DIAGNOSIS:, Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:, Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:, 100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA: ,General endotracheal.,DRAINS:, 16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass. This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma. I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy. All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:, After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table. Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia. After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest. All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure. Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage. The abdomen was insufflated in the right outer quadrant. Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy. The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident. We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus. Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed. Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar. There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt. This exposed the retroperitoneum on the right side. The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only. We then identified the ureter and gonadal vein in the retroperitoneum. The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum. Sequential packets of tissue were taken using primarily the LigaSure Atlas device. Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins. We proceeded then and skeletonized the structures into four individual packets. We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland. The adrenal was spared during this procedure. There was no contiguous connection between the renal mass and a right adrenal gland. This plane of dissection was taken down primarily using the LigaSure device. We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring. Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments. The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected. The kidney was then freed within the retroperitoneum. A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction. We extended the lower most trocar site approximately 6 cm to facilitate extraction. The kidney was removed and passed off the table as a specimen for pathology. This was bivalved by pathology, and we reviewed the specimen. | nephrology, renal mass, carter-thomason, endocatch bag, foley catheter, gi stapler, laparoscopic, ligasure, toldt, laparoscopic scissors, nephrectomy, radical nephrectomy, screw-type trocar, umbilicus, upper pole, urethra, carter thomason closure device, laparoscopic right radical nephrectomy, carter thomason closure, carter thomason, renal hilum, kidney, abdomen, endotracheal, radical, oncocytoma, renal, |
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