ImranzamanML/Clinical_Documents_on_Syndromes_Disease

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Gen exam: unremarkable.

COURSE:

MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH

FT4, CRP

ESR

GS

PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.

She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.
EXAM:

MRI OF THE RIGHT ANKLE

CLINICAL:

Pain.

FINDINGS:

The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.

IMPRESSION

: NORMAL MRI OF THE RIGHT ANKLE.
EXAM:

Lexiscan Nuclear Myocardial Perfusion Scan.

INDICATION:

Chest pain.

TYPE OF TEST:

Lexiscan, unable to walk on a treadmill.

INTERPRETATION:

Resting heart rate of 96, blood pressure of 141/76. EKG

normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted.

SUMMARY:

1. Nondiagnostic Lexiscan.

2. Nuclear interpretation as below.

NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:

Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68.

IMPRESSION:

1. Normal nuclear myocardial perfusion scan.

2. Ejection fraction 41% by gated SPECT.
PREOPERATIVE DIAGNOSIS:

Low back pain.

POSTOPERATIVE DIAGNOSIS:

Low back pain.

PROCEDURE PERFORMED:

1. Lumbar discogram L2-3.

2. Lumbar discogram L3-4.

3. Lumbar discogram L4-5.

4. Lumbar discogram L5-S1.

ANESTHESIA:

IV sedation.

PROCEDURE IN DETAIL:

The patient was brought to the Radiology Suite and placed prone onto a radiolucent table. The C-arm was brought into the operative field and AP

left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained. We then proceeded to prepare the low back with a Betadine solution and draped sterile. Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space. A metallic marker was then placed laterally and a needle entrance point was determined. A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP

oblique and lateral fluoroscopic projections. A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus. We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.

A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.
PREOPERATIVE DIAGNOSIS:

Acute cholecystitis.

POSTOPERATIVE DIAGNOSIS:

Gen exam: unremarkable.

COURSE:

MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH

FT4, CRP

ESR

GS

PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.

She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.

EXAM:

MRI OF THE RIGHT ANKLE

CLINICAL:

Pain.

FINDINGS:

The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.

IMPRESSION

: NORMAL MRI OF THE RIGHT ANKLE.

EXAM:

Lexiscan Nuclear Myocardial Perfusion Scan.

INDICATION:

Chest pain.

TYPE OF TEST:

Lexiscan, unable to walk on a treadmill.

INTERPRETATION:

Resting heart rate of 96, blood pressure of 141/76. EKG

normal sinus rhythm, nonspecific ST-T changes, left bundle branch block. Post Lexiscan 0.4 mg injected intravenously by standard protocol. Peak heart rate was 105, blood pressure of 135/72. EKG remains the same. No symptoms are noted.

SUMMARY:

1. Nondiagnostic Lexiscan.

2. Nuclear interpretation as below.

NUCLEAR MYOCARDIAL PERFUSION SCAN WITH STANDARD PROTOCOL:

Resting and stress images were obtained with 10.4, 32.5 mCi of tetrofosmin injected intravenously by standard protocol. Myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake. There is no evidence of reversible or fixed defect. Gated SPECT revealed mild global hypokinesis, more pronounced in the septal wall possibly secondary to prior surgery. Ejection fraction calculated at 41%. End-diastolic volume of 115, end-systolic volume of 68.

IMPRESSION:

1. Normal nuclear myocardial perfusion scan.

2. Ejection fraction 41% by gated SPECT.

PREOPERATIVE DIAGNOSIS:

Low back pain.

POSTOPERATIVE DIAGNOSIS:

Low back pain.

PROCEDURE PERFORMED:

1. Lumbar discogram L2-3.

2. Lumbar discogram L3-4.

3. Lumbar discogram L4-5.

4. Lumbar discogram L5-S1.

ANESTHESIA:

IV sedation.

PROCEDURE IN DETAIL:

The patient was brought to the Radiology Suite and placed prone onto a radiolucent table. The C-arm was brought into the operative field and AP

left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained. We then proceeded to prepare the low back with a Betadine solution and draped sterile. Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space. A metallic marker was then placed laterally and a needle entrance point was determined. A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP

oblique and lateral fluoroscopic projections. A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus. We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.

A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.

PREOPERATIVE DIAGNOSIS:

Acute cholecystitis.

POSTOPERATIVE DIAGNOSIS: