Sample Name: Acute Intracerebral Hemorrhage
Description: MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).
(Medical Transcription Sample Report)
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.
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).
COORDINATION: dysmetric FNF and HKS movements (left worse than right).
STATION: RUE pronator drift and Romberg sign present.
GAIT: shuffling and bradykinetic.
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).
Keywords: radiology, acute intracerebral hemorrhage, colace, coumadin, digoxin, echocardiogram, ecotrin, hct, hemorrhage, intracerebral, kcl, lasix, mri, mri scan, mri brain, bone cancer, dementia, generalized weakness, lethargy, lightheadedness, numbness, presyncope, procardia sr, stroke, generalized weakness and lightheadedness, weakness and lightheadedness, hand numbness, heart disease, weighted images, scan,