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12_Neurology.txt

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+CC:
+
+ Confusion and slurred speech.
+
+HX 
+
+ (primarily obtained from boyfriend): This 31 y/o RHF experienced a "flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found "passed out" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.
+
+She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.
+
+PMH:
+
+ Migraine Headache.
+
+FHX: 
+
+ Unremarkable.
+
+SHX: 
+
+Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.
+
+ROS:
+
+ Irregular menses.
+
+EXAM: 
+
+BP118/66.  HR83. RR 20. T36.8C.
+
+MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.
+
+CN: Flattened right nasolabial fold only.
+
+Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.
+
+Sensory: withdrew to noxious stimulation in all 4 extremities.
+
+Coordination: difficult to assess.
+
+Station: Right pronator drift.
+
+Gait: unremarkable.
+
+Reflexes: 2/2BUE
+
+ 3/3BLE
+
+ Plantars were flexor bilaterally.
+
+General Exam: unremarkable.
+
+INITIAL STUDIES:
+
+ CBC
+
+ GS
+
+ UA
+
+ PT
+
+ PTT
+
+ ESR
+
+ CRP
+
+ EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).
+
+COURSE: 
+
+MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV
+
+ ANA
+
+ Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.
+
+She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.
+
+In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.

1490_Radiology.txt

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+GENERAL EVALUATION:
+
+Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.
+
+BIOMETRY:
+
+BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:

1492_Radiology.txt

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+GENERAL EVALUATION:
+
+Fetal Cardiac Activity: Normal at 140 BPM
+
+Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.
+
+Uterus: Normal,Cervix:

1494_Radiology.txt

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+GENERAL EVALUATION: 
+
+Twin B,Fetal Cardiac Activity: Normal at 166 BPM
+
+Fetal Lie: Longitudinal, to the maternal right.
+
+Fetal Presentation: Cephalic.
+
+Placenta: Fused, posterior placenta, Grade I to II.
+
+Uterus: Normal,Cervix: Closed.
+
+Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.
+
+BIOMETRY:
+
+BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:

1497_Radiology.txt

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+EXAM: 
+
+ Transvaginal ultrasound.
+
+HISTORY: 
+
+ Pelvic pain.
+
+FINDINGS: 
+
+ The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.
+
+The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.
+
+IMPRESSION:
+
+1.  No evidence for torsion.
+
+2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.

1498_Radiology.txt

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+EXAM: 
+
+ OB Ultrasound.
+
+HISTORY:
+
+  A 29-year-old female requests for size and date of pregnancy.
+
+FINDINGS: 
+
+ A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute.  Placenta is located posteriorly, grade 0 without previa.  Cervical length is 4.2 cm.  There is normal amniotic fluid index of 12.2 cm.  There is a 4-chamber heart.  There is spontaneous body/limb motion.  The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.
+
+BIOMETRIC DATA:
+
+BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.
+
+ESTIMATED DATE OF DELIVERY: 
+
+ Month DD
+
+ YYYY.
+
+Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.
+
+IMPRESSION: 
+
+ Single live intrauterine gestation without complications as described.

1499_Radiology.txt

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+EXAM: 
+
+ Bilateral lower extremity ultrasound for deep venous thrombus.
+
+REASON FOR EXAM: 
+
+ Lower extremity edema bilaterally.
+
+TECHNIQUE: 
+
+ Colored, grayscale, and Doppler imaging is all employed.
+
+FINDINGS: 
+
+ This examination is limited.  There is prominent edema bilaterally and there is large body habitus.  These two limit assessment especially of the right lower extremity.
+
+As visualized, there is no gross evidence of DVT.  The right leg grayscale images are limited.  No obvious clot identified on the color flow or Doppler images.  The left leg is better visualized than the right, but again is limited.  No definite clot is seen.
+
+IMPRESSION: 
+
+ Limited study secondary to body habitus and edema.  No obvious DVT as visualized.

1503_Radiology.txt

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+REASON FOR EXAM: 
+
+ Followup for fetal growth. 
+
+ 
+
+INTERPRETATION: 
+
+ Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. 
+
+FETAL BIOMETRY:  
+
+BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  
+
+The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  
+
+A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2.
+
+ 
+
+IMPRESSION: 
+
+ Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.

1505_Radiology.txt

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+HISTORY OF PRESENT ILLNESS: 
+
+ I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology.  Please see also my cardiovascular consultation dictated separately.  But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.  She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.
+
+I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent.  I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear.  The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction.  The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.
+
+PROCEDURE: 
+
+ The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself.  She received 20 cc of viscous lidocaine for topical oral anesthetic effect.  She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect.  The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition.  This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout.  She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.
+
+FINDINGS: 
+
+ Normal left ventricular size and systolic function.  LVEF of 60%.  Mild left atrial enlargement.  Normal right atrial size.  Normal right ventricular size and systolic function.  No left ventricular wall motion abnormalities identified.  The four pulmonary veins are identified.  The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage.  No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves.  The mitral valve is seen.  There is mild mitral regurgitation with two jets.  No mitral stenosis.  Four pulmonary veins were identified without reversible pulmonary venous flow.  There are three cusps of the aortic valve seen.  No aortic stenosis.  There is trace aortic insufficiency.  There is trace pulmonic insufficiency.  The pulmonary artery is seen and is within normal limits.  There is trace to mild tricuspid regurgitation.  Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study.  E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds.  The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm.  The intra-atrial septum is identified as are the SVC and IVC
+
+ and these are within normal limits.  The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale.  No pericardial effusion.  There is mild nonmobile descending aortic atherosclerosis seen.
+
+IMPRESSION:
+
+1.  Normal left ventricular size and systolic function.  Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.
+
+2.  Mild left atrial enlargement.
+
+3.  Intracardiac thrombus identified at the base of the left atrial appendage.
+
+4.  Mild mitral regurgitation with two jets.
+
+5.  Mild nonmobile descending aortic atherosclerosis.
+
+Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.
+
+These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.

1507_Radiology.txt

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+EXAM: 
+
+ Ultrasound Abdomen.
+
+ 
+
+REASON FOR EXAM: 
+
+ Elevated liver function tests.
+
+ 
+
+INTERPRETATION: 
+
+ The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration.  The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed.  There is dilatation of the common bile duct up to 1 cm.  There is also dilatation of the pancreatic duct that measures up to 3 mm.  There is caliectasis in the right kidney.  The bladder is significantly distended measuring 937 cc in volume.  The caliectasis in the right kidney may be secondary to back pressure from the distended bladder.  The aorta is normal in caliber.
+
+ 
+
+IMPRESSION:
+
+1.  Dilated common duct as well as pancreatic duct as described.  Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass.  The findings could reflect changes of cholecystectomy.  
+
+2.  Significantly distended bladder with probably resultant caliectasis in the right kidney.  Clinical correlation recommended.

1511_Radiology.txt

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+CLINICAL INDICATIONS: 
+
+ MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.
+
+DESCRIPTION OF PROCEDURE: 
+
+ The transesophageal echocardiogram was performed after getting verbal and a written consent signed.  Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  There were no complications.  The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.
+
+FINDINGS:
+
+1.  Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.
+
+2.  Mitral valve is calcified and thick.  No vegetation seen.  There is mild-to-moderate MR present.  There is mild AI present also.
+
+3.  Tricuspid valve and pulmonary valve are structurally normal.
+
+4.  There is a mild TR present.
+
+5.  There is no clot seen in the left atrial appendage.  The velocity in the left atrial appendage was 0.6 m/sec.
+
+6.  Intraatrial septum was intact.  There is no clot or mass seen.
+
+7.  Normal LV and RV systolic function.
+
+8.  There is thick raised calcified plaque seen in the thoracic aorta and arch.
+
+SUMMARY:
+
+1.  There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  Calculated aortic valve area was 0.6 sq. cm.
+
+2.  Normal LV systolic function.
+

1513_Radiology.txt

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+TESTICULAR ULTRASOUND
+
+REASON FOR EXAM:  
+
+Left testicular swelling for one day.
+
+FINDINGS:  
+
+The left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  The right epididymis measures up to 9 mm.  There is a hydrocele on the right side.  Normal flow is seen within the testicle and epididymis on the right.
+
+The left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  The left testicle shows normal blood flow.  The left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  There is mild scrotal wall thickening.  A hydrocele is seen on the left side.
+
+IMPRESSION:
+
+1.  Hypervascularity of the left epididymis compatible with left epididymitis.
+
+2.  Bilateral hydroceles.

1516_Radiology.txt

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+REASON FOR EXAM: 
+
+ Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.
+
+PREOPERATIVE DIAGNOSIS:  
+
+Atrial valve replacement.
+
+POSTOPERATIVE DIAGNOSES:
+
+  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.
+
+PROCEDURES IN DETAIL: 
+
+ The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.
+
+Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.
+
+The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.
+
+INTERPRETATION: 
+
+ The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.
+
+The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.
+
+The right atrium and right ventricle were both normal in size.
+
+Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.
+
+No AIC.
+
+Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.
+
+Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.
+
+The aorta and aortic arch were unremarkable.  No dissection.
+
+IMPRESSION:
+
+1.  Mildly dilated left atrium.
+
+2.  Mild-to-moderate regurgitation.
+
+3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended.

1524_Radiology.txt

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+INDICATIONS:  
+
+Chest pain, hypertension, type II diabetes mellitus.
+
+PROCEDURE DONE:
+
+  Dobutamine Myoview stress test.
+
+STRESS ECG RESULTS:
+
+  The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes.  Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion.  The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality.  The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate.  The blood pressure increased from 130/80 to 160/70.  A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion.  No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.
+
+MYOCARDIAL PERFUSION IMAGING:
+
+  Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview.  Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview.  The lung heart ratio is 0.36.  Myocardial perfusion images were normal both at rest and with stress.  Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.
+
+CONCLUSIONS:
+
+1.  Stress test is negative for dobutamine-induced myocardial ischemia.
+
+2.  Normal left ventricular size, regional wall motion, and ejection fraction.

1530_Radiology.txt

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+EXAM: 
+
+ Single frontal view of the chest.
+
+HISTORY: 
+
+ Atelectasis.  Patient is status-post surgical correction for ASD.
+
+TECHNIQUE: 
+
+ A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.
+
+FINDINGS:
+
+  Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  Sternotomy wires are noted.  They appear in appropriate placement.  There are no focal areas of consolidation to suggest pneumonia.  Once again seen is minimal amount of bilateral basilar atelectasis.  The cardiomediastinal silhouette appears to be within normal limits at this time.  No evidence of any pneumothoraces or pleural effusions.
+
+IMPRESSION:
+
+1.  There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.
+
+2.  Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.
+
+3.  Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.

1534_Radiology.txt

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+INDICATION FOR STUDY: 
+
+ Elevated cardiac enzymes, fullness in chest, abnormal EKG
+
+ and risk factors.
+
+MEDICATIONS:
+
+  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.
+
+BASELINE EKG: 
+
+ Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.
+
+EXERCISE RESULTS:
+
+1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.
+
+2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.
+
+NUCLEAR PROTOCOL:  
+
+Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.
+
+NUCLEAR RESULTS:
+
+1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.
+
+2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.
+
+IMPRESSION:
+
+1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.
+
+2.  Mild hypertensive cardiomyopathy with an EF of 48%.
+
+3.  Poor exercise capacity due to cardiovascular deconditioning.
+
+4.  Suboptimally controlled blood pressure on today's exam.

1535_Radiology.txt

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+PROCEDURE: 
+
+ Radiofrequency thermocoagulation of bilateral lumbar sympathetic chain.
+
+ANESTHESIA: 
+
+ Local sedation.
+
+VITAL SIGNS: 
+
+ See nurse's notes.
+
+COMPLICATIONS: 
+
+ None.
+
+DETAILS OF PROCEDURE:  
+
+INT was placed.  The patient was in the operating room in the prone position with the back prepped and draped in a sterile fashion.  The patient was given sedation and monitored.  Lidocaine 1.5% for skin wheal was made 10 cm from the midline to the bilateral L2 distal vertebral body.  A 20-gauge, 15 cm SMK needle was then directed using AP and fluoroscopic guidance so that the tip of the needle was noted to be along the distal one-third and anterior border on the lateral view and on the AP view the tip of the needle was inside the lateral third of the border of the vertebral body.  At this time a negative motor stimulation was obtained.  Injection of 10 cc of 0.5% Marcaine plus 10 mg of Depo-Medrol was performed. Coagulation was then carried out for 90oC for 90 seconds.  At the conclusion of this, the needle under fluoroscopic guidance was withdrawn approximately 5 mm where again a negative motor stimulation was obtained and the sequence of injection and coagulation was repeated.  This was repeated one more time with a 5 mm withdrawal and coagulation.
+
+At that time, attention was directed to the L3 body where the needle was placed to the upper one-third/distal two-thirds junction and the sequence of injection, coagulation, and negative motor stimulation with needle withdrawal one time of a 5 mm distance was repeated.  There were no compilations from this.  The patient was discharged to operating room recovery in stable condition.

1538_Radiology.txt

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+EXAM: 
+
+ Cervical, lumbosacral, thoracic spine flexion and extension.
+
+HISTORY: 
+
+ Back and neck pain.
+
+CERVICAL SPINE
+
+FINDINGS:  
+
+AP
+
+ lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.

1539_Radiology.txt

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+PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION
+
+This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.
+
+The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.

1540_Radiology.txt

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+EXAM: 
+
+ Right foot series.
+
+REASON FOR EXAM:  
+
+Injury.
+
+FINDINGS: 
+
+ Three images of the right foot were obtained.  On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  Fractures in these bones cannot be completely excluded.  There is soft tissue swelling seen overlying the calcaneus within this region.
+
+IMPRESSION: 
+
+ Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  Recommend correlation with site of pain in addition to conservative management and followup imaging.  A phone call will be placed to the emergency room regarding these findings.

1542_Radiology.txt

@@ -0,0 +1,19 @@
+EXAM:
+
+  Nuclear medicine lymphatic scan.
+
+REASON FOR EXAM: 
+
+ Left breast cancer.
+
+TECHNIQUE: 
+
+ 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.
+
+FINDINGS:  
+
+There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.
+
+IMPRESSION:  
+
+Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.

1544_Radiology.txt

@@ -0,0 +1,29 @@
+INDICATION: 
+
+ Lung carcinoma.
+
+Whole body PET scanning was performed with 11 mCi of 18 FDG. Axial, coronal and sagittal imaging was performed over the neck, chest abdomen and pelvis.
+
+FINDINGS:
+
+There is normal physiologic activity identified in the myocardium, liver, spleen, ureters, kidneys and bladder.
+
+There is abnormal FDG-avid activity identified in the posterior left paraspinal region best seen on axial images 245-257 with an SUV of 3.8, no definite bone lesion is identified on the CT scan or the bone scan dated 08/14/2007 (It may be purely lytic).
+
+Additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the CT scan with an SUV of 18.1, the adjacent atelectasis as likely post obstructive in nature.
+
+Additionally, although there is no definite lesion identified on CT 
+
+ there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an SUV of 5.0. The spiculated density seen in the right upper lobe on the CT scan does not demonstrate FDG activity on this PET scan.
+
+There is a hypermetabolic lymph node identified in the aorta pulmonary window with an SUV of 3.7 in the mediastinum.
+
+IMPRESSION:
+
+No prior PET scans for comparison, there is a large lesion identified in the area of the left hilum with an SUV of 18.1 likely causing the obstructive atelectasis seen on the CT scan.
+
+There is a tiny satellite area of hypermetabolic FDG in the left upper lobe adjacent to the pleura with an SUV of 5.0.
+
+There is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion. However no lesion is identified on bone scan or CT scan.
+
+There is a hypermetabolic lymph node identified. The aorta pulmonary window with a corresponding finding on CT scan with an SUV of 3.7.

1545_Radiology.txt

@@ -0,0 +1,19 @@
+EXAM:
+
+  Nuclear medicine tumor localization, whole body.
+
+HISTORY: 
+
+ Status post subtotal thyroidectomy for thyroid carcinoma, histology not provided.
+
+FINDINGS: 
+
+ Following the oral administration of 4.3 mCi Iodine-131, whole body planar images were obtained in the anterior and posterior projections at 24, 48, and 72 hours.
+
+There is increased uptake in the left upper quadrant, which persists throughout the examination.  There is a focus of increased activity in the right lower quadrant, which becomes readily apparent at 72 hours.  Physiologic uptake in the liver, spleen, and transverse colon is noted.  Physiologic urinary bladder uptake is also appreciated.  There is low-grade uptake in the oropharyngeal region.
+
+IMPRESSION:  
+
+Iodine-avid foci in the right lower quadrant and left upper quadrant medially suspicious for distant metastasis.  Anatomical evaluation, i.e.
+
+ CT is advised to determine if there are corresponding mesenteric lesions.  Ultimately (provided that the original pathology of the thyroid tumor with iodine-avid) PET scanning may be necessary.  No evidence of iodine added locoregional metastasis.

1547_Radiology.txt

@@ -0,0 +1,19 @@
+INDICATIONS:
+
+  Previously markedly abnormal dobutamine Myoview stress test and gated scan.
+
+PROCEDURE DONE:
+
+  Resting Myoview perfusion scan and gated myocardial scan.
+
+MYOCARDIAL PERFUSION IMAGING:
+
+  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD
+
+ YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.
+
+CONCLUSIONS:
+
+  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD
+
+ YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.

1550_Radiology.txt

@@ -0,0 +1,8 @@
+DIAGNOSIS:  
+
+Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.
+
+INDICATION: 
+
+ To evaluate for coronary artery disease.
+

1551_Radiology.txt

@@ -0,0 +1,31 @@
+FINDINGS:
+
+There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.
+
+There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.
+
+The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).
+
+There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.
+
+The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).
+
+There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).
+
+There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).
+
+There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).
+
+Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).
+
+There are no pathological cysts or soft tissue masses.
+
+IMPRESSION:
+
+Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.
+
+Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.
+
+Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.
+
+Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.

1560_Radiology.txt

@@ -0,0 +1,31 @@
+EXAM:
+
+MRI LEFT SHOULDER
+
+CLINICAL:
+
+This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.
+
+FINDINGS:
+
+Examination was performed on 9/1/05.
+
+There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).
+
+Normal infraspinatus tendon.
+
+There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.
+
+There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.
+
+There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.
+
+Normal superior, middle and inferior glenohumeral ligaments.
+
+There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).
+
+Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.
+
+IMPRESSION:
+
+  There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon.  There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion.

1567_Radiology.txt

@@ -0,0 +1,27 @@
+EXAM: 
+
+ MRI orbit/face/neck with and without contrast; MR angiography of the head,CLINICAL HISTORY: 
+
+ 1-day-old female with facial mass.
+
+TECHNIQUE:
+
+1.  Multisequence, multiplanar images of the orbits/face/neck were obtained with and without contrast.  0.5 ml Magnevist was used as the intravenous contrast agent.
+
+2.  MR angiography of the head was obtained using a time-of-flight technique.
+
+3.  The patient was under general anesthesia during the exam.
+
+FINDINGS:
+
+  MRI orbits/face/neck:  There is a pedunculated mass measuring 5.7 x 4.4 x 6.7 cm arising from the patient's lip on the right side.  The mass demonstrates a heterogeneous signal.  There is also heterogeneous enhancement which may relate to a high vascular tumor given the small amount of contrast for the exam.  The origin of the mass from the upper lip demonstrates intact soft tissue planes.
+
+Limited evaluation of the head demonstrates normal appearing midline structures.  Incidental note is made of a small arachnoid cyst within the anterior left middle cranial fossa.  The mastoid air cells on the right are opacified; while the left demonstrates appropriate aeration.
+
+MR angiography of the head:  Angiography is limited such that the vessel feeding the mass cannot be identified with certainty.  The right external carotid artery is noted to be asymmetrically larger than the left, the phenomenon likely related to provision of feeding vessels to the mass.  There is no carotid stenosis.
+
+IMPRESSION:
+
+1.  The mass arising from the right upper lip measures 5.7 x 4.4 x 6.7 cm with a heterogeneous appearance and enhancement pattern.  Hemangioma should be considered in the differential diagnosis as well as other mesenchymal neoplasms.
+
+2.  MR angiography is suboptimal such that feeding vessels to the mass cannot be identified with certainty.

1569_Radiology.txt

@@ -0,0 +1,39 @@
+CC:
+
+ Found unresponsive.
+
+HX: 
+
+  39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with "stiff straight arms" and a "strange breathing pattern." A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.
+
+PMH:
+
+ 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:
+
+ Imuran, Prednisone, Mestinon, Mannitol, DPH
+
+ IV NS
+
+FHX/SHX:
+
+ Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.
+
+EXAM:
+
+ 35.8F, 99BPM
+
+ BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE)
+
+ or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.
+
+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.

1570_Radiology.txt

@@ -0,0 +1,87 @@
+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.

1575_Radiology.txt

@@ -0,0 +1,32 @@
+EXAM:
+
+  MRI Head W&WO Contrast.
+
+REASON FOR EXAM:
+
+  Dyspnea.
+
+COMPARISON:
+
+  None. 
+
+TECHNIQUE:
+
+  MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist).  
+
+INTERPRETATION: 
+
+ There are no abnormal/unexpected foci of contrast enhancement.  There are no diffusion weighted signal abnormalities.  There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal.  The ventricles and sulci are prominent, but proportionate.  Per T2 weighted sequence, there is no hyperdense vascularity.  There are no calvarial signal abnormalities.  There is no significant mastoid air cell fluid.  No significant sinus mucosal disease per MRI.
+
+IMPRESSION:
+
+1.  No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses.  
+
+2.  No evidence for acute infarction. 
+
+3.  Mild, scattered, patchy, chronic small vessel ischemic disease changes. 
+
+4.  Diffuse cortical volume loss, consistent with patient's age. 
+
+5.  Preliminary report was issued at the time of dictation.  
+

1576_Radiology.txt

@@ -0,0 +1,53 @@
+EXAM:
+
+MRI LEFT FOOT
+
+CLINICAL:
+
+ A 49-year-old female with ankle pain times one month, without a specific injury. Patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.
+
+FINDINGS:
+
+Received for second opinion interpretations is an MRI examination performed on 05/27/2005.
+
+There is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.
+
+There is edema of the subcutis adipose space posterior to the Achilles tendon. Findings suggest altered biomechanics with crural fascial strains.
+
+There is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. There is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. The study has been performed with the foot in neutral position. Confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.
+
+There is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.
+
+Normal peroneal tendons.
+
+There is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. Normal extensor hallucis longus and extensor digitorum tendons.
+
+Normal Achilles tendon. There is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the Achilles tendon.
+
+Normal distal tibiofibular syndesmotic ligamentous complex.
+
+Normal lateral, subtalar and deltoid ligamentous complexes.
+
+There are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.
+
+Normal plantar fascia. There is no plantar calcaneal spur.
+
+There is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.
+
+Normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.
+
+The metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.
+
+IMPRESSION:
+
+Tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.
+
+Minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.
+
+Edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.
+
+Mild tendinosis of the tibialis anterior tendon with mild tendon thickening.
+
+Normal plantar fascia and no plantar fasciitis.
+
+Venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.

1579_Radiology.txt

@@ -0,0 +1,21 @@
+EXAM:
+
+MRI LEFT KNEE WITHOUT CONTRAST
+
+CLINICAL:
+
+Left knee pain.
+
+FINDINGS:
+
+Comparison is made with 10/13/05 radiographs.
+
+There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.
+
+Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.
+
+IMPRESSION:
+
+Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.
+
+Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.

1580_Radiology.txt

@@ -0,0 +1,59 @@
+EXAM:
+
+MRI RIGHT FOOT
+
+CLINICAL:
+
+Pain and swelling in the right foot.
+
+FINDINGS: 
+
+Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.
+
+There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.
+
+There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.
+
+Normal plantar calcaneonavicular spring ligament.
+
+Normal talonavicular articulation.
+
+There is minimal synovial fluid within the peroneal tendon sheaths.
+
+Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.
+
+There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.
+
+There is edema extending along the deep surface of the extensor digitorum brevis muscle.
+
+Normal anterior, subtalar and deltoid ligamentous complex.
+
+Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.
+
+The Lisfranc’s ligament is intact.
+
+The Achilles tendon insertion has been excluded from the field-of-view.
+
+Normal plantar fascia and intrinsic plantar muscles of the foot.
+
+There is mild venous distention of the veins of the foot within the tarsal tunnel.
+
+There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.
+
+Normal deltoid ligamentous complex.
+
+Normal talar dome and no occult osteochondral talar dome defect.
+
+IMPRESSION:
+
+Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.
+
+Small ganglion intwined within the bifurcate ligament.
+
+Interstitial edema of the short plantar calcaneocuboid ligament.
+
+Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.
+
+Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.
+
+Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.

1584_Radiology.txt

@@ -0,0 +1,49 @@
+CC:
+
+ Right shoulder pain.
+
+HX: 
+
+This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.
+
+She had been taking Naprosyn with little relief.
+
+PMH: 
+
+1) Catamenial Headaches. 2) Allergy to Macrodantin.
+
+SHX/FHX:
+
+ Smokes 2ppd cigarettes.
+
+EXAM: 
+
+Vital signs were unremarkable.
+
+CN: unremarkable.
+
+Motor: full strength throughout. Normal tone and muscle bulk.
+
+Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.
+
+Coord/Gait/Station: Unremarkable.
+
+Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.
+
+Plantar responses were flexor bilaterally. Rectal exam: normal tone.
+
+IMPRESSION:
+
+ C-spine lesion.
+
+COURSE: 
+
+MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV
+
+ but 1+ sharps and fibrillations in the right biceps (C5-6)
+
+ brachioradialis (C5-6)
+
+ triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.
+
+The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.

1586_Radiology.txt

@@ -0,0 +1,55 @@
+CC:
+
+ Left third digit numbness and wrist pain.
+
+HX: 
+
+This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.
+
+SHX/FHX:
+
+ 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.
+
+EXAM: 
+
+Vital signs unremarkable.
+
+MS:
+
+ A & O to person, place, time. Fluent speech without dysarthria.
+
+CN II-XII: 
+
+Unremarkable,MOTOR:
+
+ 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.
+
+SENSORY:
+
+ Decreased PP in third digit of left hand only (palmar and dorsal sides).
+
+STATION/GAIT/COORD:
+
+ Unremarkable.
+
+REFLEXES: 
+
+1+ throughout, plantar responses were downgoing bilaterally.
+
+GEN EXAM: 
+
+Unremarkable.
+
+Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.
+
+CLINICAL IMPRESSION: 
+
+Left Carpal Tunnel Syndrome,EMG/NCV: 
+
+Unremarkable.
+
+MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.
+
+COURSE:
+
+ The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.

1589_Radiology.txt

@@ -0,0 +1,23 @@
+EXAM:
+
+MRI SPINAL CORD CERVICAL WITHOUT CONTRAST
+
+CLINICAL:
+
+Right arm pain, numbness and tingling.
+
+FINDINGS:
+
+Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.
+
+At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.
+
+At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.
+
+At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.
+
+A specific abnormality is not identified at the C7-T1 level.
+
+IMPRESSION:
+
+Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.

1590_Radiology.txt

@@ -0,0 +1,87 @@
+CC: 
+
+Sensory loss.
+
+HX: 
+
+25y/o RHF began experiencing pruritus in the RUE
+
+ above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.
+
+MEDS:
+
+ None.
+
+PMH:
+
+ Unremarkable.
+
+FHX: 
+
+GF with CAD
+
+ otherwise unremarkable.
+
+SHX:
+
+ Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.
+
+EXAM:
+
+  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.
+
+CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.
+
+MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.
+
+Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.
+
+Coord: Intact FNF
+
+ HKS and RAM
+
+ bilaterally.
+
+Station: No pronator drift. Romberg's test not documented.
+
+Gait: Unsteady wide-based. Able to TT and HW. Poor TW.
+
+Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.
+
+Gen. Exam: Unremarkable.
+
+COURSE:
+
+ CBC
+
+ GS
+
+ PT
+
+ PTT
+
+ ESR
+
+ FT4, TSH
+
+ ANA
+
+ Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte)
+
+ Glucose 55mg/dl, Protein 46mg/dl (normal 15-45)
+
+ CSF IgG 7.5mg/dl (normal 0.0-6.2)
+
+ CSF IgG index 1.3 (normal 0.0-0.7)
+
+ agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.
+
+She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.
+
+MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes)
+
+ Glucose 57, Protein 51 (elevated)
+
+ cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE
+
+ loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.

1599_Radiology.txt

@@ -0,0 +1,29 @@
+FINDINGS:
+
+There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).
+
+There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.
+
+Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.
+
+There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.
+
+There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.
+
+There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.
+
+Normal flow within the carotid arteries and circle of Willis.
+
+Normal calvarium, central skull base and temporal bones.  There is no demonstrated calvarium metastases.
+
+IMPRESSION:
+
+Severe generalized cerebral atrophy.
+
+Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.
+
+Remote lacunar infarction in the right cerebellar hemisphere.
+
+Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.
+
+No demonstrated calvarial metastases.

1601_Radiology.txt

@@ -0,0 +1,75 @@
+CC: 
+
+Fall with subsequent nausea and vomiting.
+
+HX: 
+
+This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He "knew what he wanted to say, but could not say it."
+
+His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.
+
+On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.
+
+He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM
+
+ he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.
+
+MEDS:
+
+ None.
+
+PMH:
+
+ 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.
+
+2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.
+
+FHX:
+
+ No neurologic disease in family.
+
+SHX:
+
+ Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.
+
+EXAM: 
+
+BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.
+
+MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as "up" or "down". He comprehended speech, but could not repeat or write.
+
+CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.
+
+Motor: 5/5 strength with normal muscle bulk and tone.
+
+Sensory: no abnormalities noted.
+
+Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE
+
+Gait: ND.
+
+Station: No truncal ataxia, but he had a slight RUE upward drift.
+
+Reflexes 2/2 BUE
+
+ 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.
+
+Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.
+
+HEENT: atraumatic normocephalic skull. No carotid bruitts.
+
+COURSE:
+
+ PT
+
+ PTT
+
+ CBC
+
+ GS
+
+ UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.
+
+He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.
+
+His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.

1602_Radiology.txt

@@ -0,0 +1,73 @@
+CC:
+
+ Lethargy.
+
+HX:
+
+ This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP
+
+ SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.
+
+He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.
+
+MEDS ON ADMISSION:
+
+ Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.
+
+PMH:
+
+ 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT
+
+ then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.
+
+FHX:
+
+ HTN and multiple malignancies of unknown type.
+
+SHX:
+
+ Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.
+
+EXAM: 
+
+7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.
+
+MS: Somnolent, but opened eyes to loud voices and would follow most commands.
+
+CN: Pupils 2.5/3.0 and "equally reactive to light." Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.
+
+MOTOR: Moved 4 extremities well.
+
+Sensory/Coord/Gait/Station/Reflexes: not done.
+
+Gen EXAM: Penil ulcerations.
+
+EXAM:
+
+ 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.
+
+MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.
+
+CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.
+
+MOTOR: Grade 5- strength on the right side.
+
+Sensory: no loss of sensation on PP/VIB/PROP testing.
+
+Coord: reduced speed and accuracy on right FNF and right HKS movements.
+
+Station: RUE pronator drift.
+
+Gait: not done.
+
+Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.
+
+Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.
+
+COURSE:
+
+ The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.
+
+The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.
+
+He never returned for follow-up.

1603_Radiology.txt

@@ -0,0 +1,61 @@
+CC:
+
+ Sudden onset blindness.
+
+HX:
+
+ This 58 y/o RHF was in her usual healthy state, until 4:00PM
+
+ 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to "severe blurring" enroute to a local ER
+
+ but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.
+
+PMH:
+
+ 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD
+
+ relieved with NSAIDs.
+
+FHX/SHX:
+
+ Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.
+
+Unremarkable FHx.
+
+MEDS:
+
+ none.
+
+EXAM:
+
+ Vitals: 36.9C.  HR 93.  BP 151/93.  RR 22.  98% O2Sat.
+
+MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.
+
+CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.
+
+Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.
+
+Sensory: Withdrew to PP in all extremities.
+
+Gait: ND.
+
+Reflexes: 2+/2+ throughout UE
+
+ 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.
+
+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.

1608_Radiology.txt

@@ -0,0 +1,15 @@
+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.

1614_Radiology.txt

@@ -0,0 +1,33 @@
+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.

1617_Radiology.txt

@@ -0,0 +1,31 @@
+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.

1623_Radiology.txt

@@ -0,0 +1,31 @@
+PREOPERATIVE DIAGNOSIS:
+
+  Acute cholecystitis.
+
+POSTOPERATIVE DIAGNOSIS:
+
+  Acute gangrenous cholecystitis with cholelithiasis.
+
+OPERATION PERFORMED: 
+
+ Laparoscopic cholecystectomy with cholangiogram.
+
+FINDINGS:  
+
+The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.
+
+COMPLICATIONS:  
+
+None.
+
+EBL: 
+
+ Scant.
+
+SPECIMEN REMOVED: 
+
+ Gallbladder with stones.
+
+DESCRIPTION OF PROCEDURE:  
+
+The patient was prepped and draped in the usual sterile fashion under general anesthesia.  A curvilinear incision was made below the umbilicus.  Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  Once this complete, insufflation was begun.  Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  Once all four ports were placed, the right upper quadrant was then explored.  The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  This was taken down using Bovie cautery to free up visualization of the gallbladder.  The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  The cystic duct and cystic artery were serially clipped and transected.  The gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  Adequate hemostasis with Bovie cautery was achieved.  The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  Next, the right upper quadrant was copiously irrigated out using the suction irrigator.  Once this was complete, the additional ports were able to be removed.  The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion.  All skin incisions were injected using Marcaine 1/4 percent plain.  The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique.  The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.

1624_Radiology.txt

@@ -0,0 +1,79 @@
+CC:
+
+ HA and vision loss.
+
+HX: 
+
+71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.
+
+FHX:
+
+ HTN
+
+ stroke, coronary artery disease, melanoma.
+
+SHX:
+
+ Quit smoking 15 years ago.
+
+MEDS:
+
+ Lanoxin, Capoten, Lasix, KCL
+
+ ASA
+
+ Voltaren, Alupent MDI
+
+PMH: 
+
+CHF
+
+ Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.
+
+EXAM: 
+
+35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS
+
+ Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e.
+
+ fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.
+
+LAB:
+
+ CBC
+
+ PT/PTT
+
+ General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL
+
+ glucose 58mg/DL
+
+ RBC 2800/mm3, WBC 1/mm3. ANA
+
+ RF
+
+ TSH
+
+ FT4 were WNL.
+
+IMPRESSION:
+
+ CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.
+
+COURSE:
+
+ The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS
+
+ RAPD OS
+
+ bilateral optic disk pallor (OS > OD)
+
+ CN3 palsy and bilateral temporal field loss, OS >> OD . ESR
+
+ CRP
+
+ MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) 
+
+ The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS
+
+ elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92.

1629_Radiology.txt

@@ -0,0 +1,5 @@
+HYPERFRACTIONATION
+
+This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours).  The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors.  The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.
+
+During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.

1630_Radiology.txt

@@ -0,0 +1,23 @@
+EXAM: 
+
+ Five views of the right knee.
+
+HISTORY: 
+
+ Pain.  The patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.
+
+TECHNIQUE:
+
+  Five views of the right knee were evaluated.  There are no priors for comparison.
+
+FINDINGS: 
+
+ Five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations.  There are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia.  There is also appearance of a high-riding patella suggestive of patella alta.
+
+IMPRESSION:
+
+1.  No evidence of any displaced fractures, dislocations, or subluxations.
+
+2.  Growth arrest lines seen in the distal femur and proximal tibia.
+
+3.  Questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.

1632_Radiology.txt

@@ -0,0 +1,37 @@
+EXAM: 
+
+ Screening full-field digital mammogram.
+
+HISTORY:
+
+  Screening examination of a 58-year-old female who currently denies complaints.  Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  The patient's sister was also diagnosed with breast cancer at the age of 59.
+
+TECHNIQUE: 
+
+ Standard digital mammographic imaging was performed.  The examination was performed with iCAD Second Look Version 7.2.
+
+COMPARISON: 
+
+ Most recently obtained __________.
+
+FINDINGS: 
+
+ The right breast is again smaller than the left.  There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  A few benign-appearing microcalcifications are present.
+
+No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  The skin is stable.  No enlarged axillary lymph node is seen.
+
+IMPRESSION:
+
+1.  No significant interval changes are seen.  No mammographic evidence of malignancy is identified.
+
+2.  Annual screening mammography is recommended or sooner if clinical symptoms warrant.
+
+BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:
+
+1.  A certain percentage of cancers, probably 10% to 15%
+
+ will not be identified by mammography.
+
+2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.
+
+3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.