Sample Name: CT Brain - Hemangioma
Description: CT Brain: Midbrain hemangioma
(Medical Transcription Sample Report)
CC: Horizontal diplopia.
HX: This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.
PMH: 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.
FHX: HTN, Colon CA, and a daughter with unknown type of "dystonia."
SHX: Denied Tobacco/ETOH/illicit drug use.
MEDS: Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.
EXAM: BP216/108 HR72 RR14 Wt81.6kg T36.6C
CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.
Coord: mild "ataxia" of RAM (left > right)
Station: no pronator drift or Romberg sign
Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion)
No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993.
Keywords: neurology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal,