Sample Type / Medical Specialty: Neurology
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
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: neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis,