Medical Specialty:
Neurology
Sample Name: Glioma - 2
Description: Headache. Right frontal lobe glioma.
(Medical Transcription Sample Report)
CC: Headache
HX: 37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.
PMH: 1)s/p tonsillectomy. 2)s/p elective abortion.
FHX: Mother with breast CA, MA with "bone cancer." AODM both sides of family.
SHX: Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.
MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.
CN: unremarkable.
Motor: full strength with normal muscle bulk and tone.
Sensory: unremarkable.
Station/Gait: unremarkable.
Reflexes: unremarkable.
Gen. Exam: unremarkable.
COURSE: MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.
Keywords: neurology, frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma,