Medical Specialty:

Sample Name: CT Brain: Subdural hematoma

Description: CT of Brain - Subacute SDH.
(Medical Transcription Sample Report)

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.

Keywords: radiology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis,