OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: Neurology

Bell's Palsy

Description:

A 75 year-old female comes in with concerns of having a stroke.

SUBJECTIVE:

The patient is a 75 year-old female who comes in today with concerns of having a stroke. She states she feels like she has something in her throat. She started with some dizziness this morning and some left hand and left jaw numbness. She said that she apparently had something about three weeks ago where she was dizzy and had to sit down. She saw Dr. XYZ for that who gave her some Antivert. She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck. She said she had an earache a day or so ago. She has not had any cold symptoms.

ALLERGIES:

Demerol and codeine.

MEDICATIONS:

Lotensin, Lopid, metoprolol, and Darvocet.

REVIEW OF SYSTEMS:

The patient says that she feels little bit nauseated at times. She denies chest pain or shortness of breath and again feels like she has something in her throat. She has been able to swallow liquids okay. She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth. She does say that she occasionally has numbness in her left hand prior to today.

PHYSICAL EXAMINATION:

General:

She is awake and alert, no acute distress.

Vital Signs:

Blood pressure: 175/86.

Temperature:

She is afebrile.

Pulse:

78. Respiratory rate: 20. O2 sat: 93% on room air.

HEENT:

Her TMs are normal bilaterally. Posterior pharynx is unremarkable. It should be noted that her uvula did not deviate and neither did her tongue. When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.

Neck:

Without adenopathy or thyromegaly. Carotids pulses are brisk without bruits.

Lungs:

Clear to auscultation.

Heart:

Regular rate and rhythm without murmur.

Extremities:

Her muscle strength is symmetrical and intact bilaterally. DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities. She has a positive Tinel's sign on her left wrist.

Neurological:

I also took monofilament and she could sense it easily when testing her sensation on her face.

ASSESSMENT:

Bell's Palsy.

PLAN:

We did get an EKG showed some ST segment changes anterolaterally. I assured her that it does not look like she has a stroke. If she wants to prevent a stroke, obviously quitting her smoking would help. It should be noted she also takes Synthroid and Zocor. We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.

  • 350.1, 780.2; G50.0, R55
  • 350.9 780.2; G50.9, R55
  • 351.0, 780.4; G51.0, R42
  • 351.8, 780.4; G51.8, R42

Answer

Subdural hematoma - Craniotomy

Description:

Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.

PREOPERATIVE DIAGNOSIS:

Right chronic subdural hematoma.

POSTOPERATIVE DIAGNOSIS:

Right chronic subdural hematoma.

TYPE OF OPERATION:

Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.

ANESTHESIA:

General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:

100 cc.

OPERATIVE PROCEDURE:

In preoperative identification, the patient was taken to the operating room and placed in supine position. Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. Table was turned. The right shoulder roll was placed. The head was turned to the left and rested on a doughnut. The scalp was shaved, and then prepped and draped in usual sterile fashion. Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss. The parietal boss incision was opened. It was about an inch and a half in length. It was carried down to the skull. Self-retaining retractor was placed. A bur hole was now fashioned with the perforator. This was widened with a 2-mm Kerrison punch. The dura was now coagulated with bipolar electrocautery. It was opened in a cruciate-type fashion. The dural edges were coagulated back to the bony edges. There was egress of a large amount of liquid. Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear. A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision. It was secured with a 3-0 nylon suture. The area was closed with interrupted inverted 2-0 Vicryl sutures. The skin was closed with staples. Sterile dressing was applied. The patient was subsequently returned back to anesthesia. He was extubated in the operating room, and transported to PACU in satisfactory condition.

  • 432.1; I62.03; 61312
  • 432.1; I62.00; 61250
  • 432.0; I62.1; 61154
  • 431; I61.9; 61315

Answer

Migraine without aura

Description:

The patient with gradual onset of a headache problem, located behind both eyes.

CHIEF COMPLAINT:

Headaches.

HEADACHE HISTORY:

The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.

PAST MEDICAL HISTORY:

No significant past medical problems.

PAST SURGICAL HISTORY:

No significant past surgical history.

FAMILY MEDICAL HISTORY:

There is a history of migraine in the family. The condition affects the patient's brother and maternal grandfather.

ALLERGIES:

Codeine.

CURRENT MEDICATIONS:

See chart.

PERSONAL/SOCIAL HISTORY:

Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol.

NEUROLOGIC DRUG HISTORY:

The patient has had no help with the headaches from over-the-counter analgesics.

REVIEW OF SYSTEMS:

ROS General:

Generally healthy. Weight is stable.

ROS Head and Eyes:

Patient has complaints of headaches. Vision can best be described as normal.

ROS Ears Nose and Throat:

The patient notes some sinus congestion.

ROS Cardiovascular:

The patient has no history of any cardiovascular problems and denies any present problems.

ROS Gastrointestinal:

The patient has no history of gastrointestinal problems and denies any present problems.

ROS Musculoskeletal:

No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.

EXAM:

Exam General Appearance:

The patient was alert and cooperative, and did not appear acutely or chronically ill.

Sex and Race:

Male, Caucasian.

Exam Mental Status:

Serial 7's were performed normally. The patient was oriented with regard to time, place and situation.

Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient's affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.

Exam Cranial Nerves:

Sense of smell was intact.

Exam Neck:

Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm. No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.

Exam Back:

Back range of motion was normal in all directions.

Exam Sensory:

Position and vibratory sense was normal.

Exam Reflexes:

Active and symmetrical. There were no pathological reflexes.

Exam Coordination:

The patient's gait had no abnormal components. Tandem gait was performed normally.

Exam Musculoskeletal:

Peripheral pulses palpably normal. There is no edema or significant varicosities. No lesions identified.

IMPRESSION DIAGNOSIS:

Migraine without aura

COMMENTS:

The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.

OTHER TREATMENT:

The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.

RATIONALE FOR TREATMENT PLAN:

The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.

FOLLOW UP INSTRUCTIONS:

The patient was instructed to return to the clinic in 3 weeks.

  • 346.12; G43.001
  • 346.10; G43.009
  • 346.21; G43.819
  • 784.0; G44.1

Answer

Idiopathic hydrocephalus

Description:

The patient is a 79 year-old man with idiopathic hydrocephalus who was found to have large bilateral effusions on a CT scan. The patient's subdural effusions are still noticeable, but they are improving.

REASON FOR CT SCAN:

The patient is a 79 year-old man with idiopathic hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008. I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.

CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm. The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm. There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle. He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.

ASSESSMENT:

The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.

PLAN:

I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting.

  • 331.3, V45.89; G91.0, Z97.8
  • 331.5, V45.81; G91.2, Z95.1
  • 331.4, V44.9; G91.1, Z93.8
  • 331.5, V45.2; G91.2, Z98.2

Answer

New onset seizure

Description:

A 2-1/2 year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.

REASON FOR CONSULTATION:

New-onset seizure.

HISTORY OF PRESENT ILLNESS:

The patient is a 2-1/2 year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone. The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time. Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted. There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.

PAST MEDICAL HISTORY:

Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.

PAST SURGICAL HISTORY:

She has undergone no surgical procedures.

FAMILY MEDICAL HISTORY:

There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.

SOCIAL HISTORY:

Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.

REVIEW OF SYSTEMS:

Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.

PHYSICAL EXAMINATION:

Vital Signs:

Weight was 15.6 kg. She was afebrile. Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.

General:

She was awake, alert, and oriented. She was in no acute distress, only slightly flustered when trying to place the EEG leads.

HEENT:

Showed normocephalic and atraumatic head. Her conjunctivae were nonicteric and sclerae were clear. Her eye movements were conjugate in nature. Her tongue and mucous membranes were moist.

Neck:

Chest:

Clear to auscultation bilaterally without crackles, wheezes or rhonchi.

Cardiovascular:

Showed a normal sinus rhythm without murmur.

Abdomen:

Showed soft, nontender, and nondistended, with good bowel sounds. There was no hepatomegaly or splenomegaly, or other masses noted on examination.

Extremities:

Showed IV placement in the right upper extremity with appropriate restraints from the IV. There was no evidence of clubbing, cyanosis or edema throughout. She had no functional deformities in any of her peripheral limbs.

Neurological:

From neurological standpoint, her cranial nerves were grossly intact throughout. Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation. Her overall resting tone was normal. Sensory examination was grossly intact to light touch throughout the upper and lower extremities. Reflexes were 1+ in bilateral patella. Toes were downgoing bilaterally. Coordination showed accurate striking ability and good rapid alternating movements. Gait examination was deferred at this time due to EEG lead placement.

ASSESSMENT:

A 2-1/2 year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.

RECOMMENDATIONS

  • For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.
  • As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day. If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.
  • I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings. EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results. The patient has been discharged and we will contact the family as an outpatient.
  • The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.
  • 780.32; R56.01
  • 780.39; R56.9
  • 780.31; R56.00
  • 780.33; R56.1

Answer

Essential tremor and torticollis

Description:

This 62 year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.

REASON FOR CONSULT:

Essential tremor and torticollis.

HISTORY OF PRESENT ILLNESS:

This is a 62 year-old right-handed now left-handed white female with tremor since 5th grade. She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam. She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better. She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity. Since around 6 to 7 years, she has had a head tremor, which is mainly "no- no" and occasional voice tremor also. Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart. She also has some stress incontinence. Last MRI brain was done in 2001 reportedly normal.

CURRENT MEDICATIONS:

  • Klonopin 0.5 mg twice a day.
  • Primidone 100 mg b.i.d.
  • Propranolol long-acting 80 mg once in the morning.

PAST MEDICAL HISTORY:

Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.

PAST SURGICAL HISTORY:

L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.

FAMILY HISTORY:

Both parents have ET and hypertension. Maternal cousin with lupus.

SOCIAL HISTORY:

Denies any smoking or alcohol. She is married since 44 years, has 3 children. She used to work as a labor and delivery nurse up until early 2001 when she retired.

REVIEW OF SYSTEMS:

No fever, chills, nausea or vomiting. No visual complaints. She complains of hearing decreased on the left. No chest pain or shortness of breath. No constipation. She does give a history of urge incontinence. No rashes. No depressive symptoms.

PHYSICAL EXAMINATION:

VITAL SIGNS:

Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg. HEENT: PERRLA. EOMI. CARDIOVASCULAR: S1 and S2 normal. Regular rate and rhythm. She does have a rash over the right ankle with a prior basal cell carcinoma was resected. NEUROLOGIC: Alert and oriented x4. Speech shows a voice tremor occasionally. Language is intact. Cranial nerves II through XII intact. Motor examination showed 5/5 power in all extremities with minimal increased tone. Sensory examination was intact to light touch. Reflexes were brisk bilaterally, but they were equal and both toes were downgoing. Her coordination showed minimal intentional component to bilateral finger-to-nose. Gait was intact. Lot of swing on Romberg's. The patient did have a tremor both upper extremities, right more than left. She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.

ASSESSMENT AND PLAN:

This 62 year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible. The patient did not wish to change any of her medication doses at this point. We will go ahead and check MRI brain, and we will get the films later. We will see her back in 3 months. Also, the patient declined any possible Botox for the mild torticollis she has at this point.

  • 781.0, 333.83; R25.9, G24.3
  • 781.0, 333.79; R25.1, G24.8
  • 333.4, 333.82; G10, G24.4
  • 333.1, 723.5; G25.0, M43.6

Answer

Intracranial aneurysm

Description:

Headache, improved. Intracranial aneurysm.

CHIEF COMPLAINT:

Headache.

HPI:

This is a 24 year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs.

PMH:

As above.

MEDS:

Vicodin.

ALLERGIES:

None.

PHYSICAL EXAM:

BP 180/110 Pulse 65 RR 18 Temp 97.5.

Mr. P is awake and alert, in no apparent distress.

HEENT:

Pupils equal, round, reactive to light, oropharynx moist, sclera clear.

Neck:

Supple, no meningismus.

Lungs:

Clear.

Heart:

Regular rate and rhythm, no murmur, gallop, or rub.

Abdomen:

Benign.

Neuro:

Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal.

COURSE IN THE ED:

Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice.

IMPRESSION:

Headache, improved. Intracranial aneurysm.

PLAN:

The patient will return tomorrow am for his angiogram.

  • 436; I67.89
  • 437.3; I67.1
  • 437.1; I67.89
  • 437.4; I67.7

Answer

Carpal tunnel syndrome - Release

Description:

Carpal tunnel release. Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.

PROCEDURE PERFORMED:

Carpal tunnel release.

INDICATIONS FOR SURGERY:

Nerve conduction study tests diagnostic of carpal tunnel syndrome. The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.

PROCEDURE:

The patient was brought to the operating room and, following a Bier block to the operative arm, the right arm was prepped and draped in the usual manner.

Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament. It was identified at its distal edge. Using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety. The canal was probed with a small finger to verify no evidence of any bone prominences. The nerve was examined for any irregularity. There was slight hyperemia of the nerve and a slight hourglass deformity. Following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture. A sterile dressing was applied.

The patient was taken to the recovery room in satisfactory condition.

The time of the Bier block was 30 minutes.

COMPLICATIONS:

None noted.

  • 354.4; G56.40; 64722-RT
  • 353.8; G54.8; 64704-RT
  • 354.0; G56.01; 64721-RT
  • 354.5; G58.7; 64782-RT

Answer

Creutzfeldt-Jakob disease

Description:

Heidenhain variant of Creutzfeldt-Jakob Disease (CJD)

CC:

Progressive memory and cognitive decline.

HX:

This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.

Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play "Murder She Wrote" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the "assassin." Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a "chuckle."

While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing "Murder She Wrote." She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.

She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.

Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was "Dementia of the Alzheimer's Type."

One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.

MEDS:

None.

PMH:

Unremarkable.

FHX:

Father and mother died in their 80's of "old age." There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.

SHX:

She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.

EXAM:

Vitals signs were within normal limits.

MS:

A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared "child-like" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page.

CN:

Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.

Motor:

5/5 strength throughout with normal muscle tone and bulk.

Sensory:

extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.

Coord:

unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.

Station:

No sign of Romberg or pronator drift. There was no truncal ataxia.

Gait:

decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.

Reflexes:

2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally.

COURSE:

CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD).

  • 046.11; A81.01
  • 290.0; F03.90
  • 046.19; A81.00
  • 780.93; R41.3

Answer

Hemangioma - CT brain

Description:

CT Brain: Midbrain hemangioma

CC:

Horizontal diplopia.

HX:

This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.

PMH:

  • 4Vessel CABG and pacemaker placement, 4/84.
  • Hypercholesterolemia.
  • Bipolar Affective D/O.

FHX:

HTN, Colon CA, and a daughter with unknown type of "dystonia."

SHX:

Denied Tobacco/ETOH/illicit drug use.

ROS:

No recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.

MEDS:

Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.

EXAM:

BP216/108 HR72 RR14 Wt81.6kg T36.6C

MS:

Unremarkable.

CN:

Horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.

Motor:

5/5 full strength throughout with normal muscle bulk and tone.

Sensory:

Unremarkable.

Coord:

Mild "ataxia" of RAM (left > right)

Station:

No pronator drift or Romberg sign

Gait:

Unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion)

STUDIES/COURSE: Gen Screen:

unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).

  • 228.09, V45.09, V45.82; D18.03, Z95.818, Z98.61; 70450
  • 431, V45.01, V45.02; I69.9, Z95.0, Z95.810; 70470
  • 432.0, V45.00, V45.09; I62.1, Z95.9, Z95.818; 70545
  • 228.02, V45.01, V45.81; D18.02, Z95.0, Z95.1; 70460

Answer