46 years Female (DOB:10/18/1969)Reason: persistent right temporal headaches; evaluate for mass or vascular changes History: persistent right temporal headachesPROVIDER/ATTENDING NAME: NICOLE M LEONG NICOLE M LEONG The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses demonstrate small air-fluid levels.. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.
1.There is no evidence for intracranial mass or other intracranial lesion that would explain the patient's headaches2.There were air-fluid levels present in the maxillary sinuses. The possibility of acute sinusitis cannot be excluded. Another possibility is that this represents retained secretions due to other cause. Patient reportedly has a history of allergic retinitis and sinusitis.