Consult - History and Phy.
Sample Name: MCA Aneurysm
Description: Patient with sudden onset dizziness and RUE clumsiness. Giant Left MCA Aneurysm.
(Medical Transcription Sample Report)
HX: This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.
PMH: HTN for many years
MEDS: Vasotec and Dyazide
SHX/FHX: ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92)
EXAM: BP158/92, HR91, RR16
CN: no deficits noted
Motor: no weakness or abnormal tone noted
Sensory: no deficits noted
Reflexes: 3+ throughout. Plantars down-going bilaterally.
Gen exam: unremarkable
STUDIES: WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.
MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.
3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.
COURSE: The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.
Keywords: consult - history and phy., mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral,