Sample Type / Medical Specialty: Neurology
Sample Name: Arnold Chiari II with Syrinx
MRI for Arnold Chiari II with syrinx
(Medical Transcription Sample Report)
Right sided numbness.HX:
28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.PMH:
1) Born prematurely and weighed 3#2oz., 2) Multiple episodes of aspiration pneumonia as an infant and child, 3) ASD repair age 14, 4) Left ptosis repair age 11, 5) Scoliosis, 6) Gait abnormality, 7) Poor pharyngeal reflexes.SHX/FHX:
Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.EXAM:
Short stature. Head tilt to right.
CN: Left ptosis, decreased left nasolabial fold, decreased gag reflex bilaterally.
Motor: Full strength
Sensory: Marked hypesthesia on entire right side.
Coord: Slowed RAM on left.
Station: No drift
Reflexes: 3+ throughout; Babinski signs bilaterally. 8 beat ankle clonus on right and 3 beat ankle clonus on left.MRI:
Arnold Chiari II with syrinx: Severe basilar invagination, marked compression of ventral pontomedullary junction, downward descension of cerebellar tonsils and vermis.COURSE:
Patient underwent transpalatal/pharyngeal ventral decompression of pons/medulla with resection of clivus/odontoid and tracheostomy placement. on 9/29/92. Halo vest and ring were removed 6/18/93. 6 months later his Philadelphia collar was removed. He was last seen 4/8/94 and he had mildly spastic gait with good strength and hyperreflexia throughout. His gag response had returned and he was eating without difficulty. Sensation had returned to his extremities.
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