Sample Name: Astrocytoma
Description: MRI - Right temporal lobe astrocytoma.
(Medical Transcription Sample Report)
CC: Episodic confusion.
HX: This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.
PMH: Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.
MEDS: DPH and ASA
SHX/FHX: 2-4 Beers/day. 1-2 packs of cigarettes per day.
LAB: Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.
Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.
CXR: 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.
EEG: 8/24/92: normal awake and asleep
NEUROPSYCHOLOGICAL TESTING: Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.
COURSE: Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.
Keywords: neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,