25 years Male (DOB:8/30/1990)Reason: communicating hydrocephalus, autism, shunt , new headaches evaluate for changes History: new headaches, aggressive behaviorPROVIDER/ATTENDING NAME: DAVID M. FRIM DAVID M. FRIM The exam is degraded by metal artifact which obscures partial visualization of left hemisphere orbits and paranasal sinuses.The patient status post left-sided ventriculostomy tube placement. The ventriculostomy tube courses in the left frontal lobe into the left lateral ventricle with tip in the third ventricle. It is stable compared to the previous exam.Patient is status post right-sided craniotomy. The patient is status post right anterior temporal lobectomy and There is a defect present along the anterior aspect of the right middle frontal gyrusThe visualized portions of the paranasal sinuses are clear to the extent of visualization possible. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.
1.The exam is limited due to metal artifact. This would obscure more subtle abnormalities. To the extent of visualization there is a no evidence for acute intracranial hemorrhage, mass effect or edema.2.The patient status post ventriculostomy tube placement. The lateral ventricles are not enlarged and are stable compared to the prior exam.3.The patient is status post right-sided craniotomy for right frontal and temporal lobe surgery.