ImranzamanML/Clinical_Documents_on_Syndromes_Disease

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HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.

COURSE:

Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.

In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD

4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.

She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.
CC:

Low Back Pain (LBP) with associated BLE weakness.

HX:

This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE

on 12/6/95; then down the LLE

on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE

but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC.

MEDS:

SLNTC

Coumadin 4mg qd, Propranolol, Procardia XL

Altace, Zaroxolyn.

PMH:

1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN

5) Amaurosis Fugax, OD

8/95 (Mayo Clinic evaluation--TEE (-)

but Carotid Doppler (+) but "non-surgical" so placed on Coumadin).

FHX:

Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.

SHX:

retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.

EXAM:

BP130.56, HR68, RR16, Afebrile.

MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.

CN: Unremarkable.

MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-

Hip abductors 3+/3+

Hip adductors 5/5, Knee flexors & extensors 4/4-

Ankle flexion 4-/4-

Tibialis Anterior 2/2-

Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.

SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.

COORD: Normal FNF-RAM. Slowed HKS due to weakness.

Station: No pronator drift. Romberg testing not done.

Gait: Unable to stand.

Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.

Rectal: normal rectal tone, guaiac negative stool.

GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.

COURSE:

WBC 11.6, Hgb 13.4, Hct 38%

Plt 295. ESR 40 (normal 0-14)

CRP 1.4 (normal <0.4)

INR 1.5, PTT 35 (normal)

Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left

compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.
EXAM:

HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.

COURSE:

Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.

In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD

4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.

She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later.

CC:

Low Back Pain (LBP) with associated BLE weakness.

HX:

This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE

on 12/6/95; then down the LLE

on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE

but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC.

MEDS:

SLNTC

Coumadin 4mg qd, Propranolol, Procardia XL

Altace, Zaroxolyn.

PMH:

1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN

5) Amaurosis Fugax, OD

8/95 (Mayo Clinic evaluation--TEE (-)

but Carotid Doppler (+) but "non-surgical" so placed on Coumadin).

FHX:

Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.

SHX:

retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.

EXAM:

BP130.56, HR68, RR16, Afebrile.

MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.

CN: Unremarkable.

MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-

Hip abductors 3+/3+

Hip adductors 5/5, Knee flexors & extensors 4/4-

Ankle flexion 4-/4-

Tibialis Anterior 2/2-

Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.

SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.

COORD: Normal FNF-RAM. Slowed HKS due to weakness.

Station: No pronator drift. Romberg testing not done.

Gait: Unable to stand.

Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.

Rectal: normal rectal tone, guaiac negative stool.

GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.

COURSE:

WBC 11.6, Hgb 13.4, Hct 38%

Plt 295. ESR 40 (normal 0-14)

CRP 1.4 (normal <0.4)

INR 1.5, PTT 35 (normal)

Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left

compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.

EXAM: