Sample Type / Medical Specialty: Neurology
Sample Name: Limbic Encephalitis
Description: Patient with a 1-year history of progressive anterograde amnesia
(Medical Transcription Sample Report)
CC: Rapidly progressive amnesia.
HX: This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.
PMH: 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.
FHX/SHX: Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.
ROS: Unremarkable. No history of cancer.
MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.
Motor: Full strength throughout with normal muscle tone and bulk.
Sensory: Intact to LT/PP/PROP
Station: No pronator drift, truncal ataxia or Romberg sign.
Reflexes: 3+ throughout with downgoing plantar responses bilaterally.
Gen Exam: unremarkable.
IMPRESSION: Limbic encephalitis secondary to cancer of unknown origin.
He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .
Keywords: neurology, mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory,