NeuroInterventional Radiology Clinic Note

Patient Name: Sarah Jenkins MRN: SJ789012 DOB: 15/03/1972 Date of Service: 1 November 2024 History of Present Illness: Ms. Sarah Jenkins, a 52-year-old female, was referred for evaluation of persistent headaches and left-sided numbness. She has experienced these symptoms for approximately six months, with a gradual worsening over the past two months. Her primary care physician initiated the referral due to concerns regarding potential neurological pathology after an initial MRI showed a suspicious lesion. The patient reports daily headaches, primarily located in the left temporal region, described as a dull ache with intermittent sharp, stabbing pains. The pain intensity is rated as 6/10 on a visual analogue scale, increasing to 8/10 during severe episodes. She also experiences intermittent numbness and tingling in her left arm and leg, particularly when fatigued or stressed. She denies any visual changes, speech difficulties, or gait instability. Her past medical history includes hypertension, well-controlled with medication, and a history of migraines in her younger years, which resolved in her 30s. She underwent an appendectomy in 1995 and a cholecystectomy in 2010, both without complications. She denies any prior head trauma or neurological surgeries. Ms. Jenkins is currently taking Amlodipine 5mg daily for hypertension and occasionally uses over-the-counter ibuprofen for headache relief, which provides minimal benefit. She reports no known herbal supplements. Her only known allergy is to penicillin, which causes a rash. She is a retired schoolteacher and lives with her husband. She denies current tobacco use but smoked for 10 years in her youth, quitting at age 35. She reports occasional social alcohol consumption and denies any illicit drug use. Her symptoms have significantly impacted her ability to engage in her usual hobbies, such as gardening and walking, due to fatigue and discomfort. Over the past two months, her headaches have become more frequent and severe, and the numbness in her left extremities has become more consistent. She notes that stress and prolonged computer use seem to exacerbate her symptoms. Lying down in a quiet, dark room provides some temporary relief, but the symptoms always return. Physical Examination: Vital signs: BP 130/85 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C, SpO2 98% on room air. Gen. Appearance: Alert and oriented female, appears her stated age, no acute distress. Body habitus: Normosthenic, well-nourished. Cardiovascular: RRR, no murmurs, rubs, or gallops. Pulmonary: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds. Extremities: No clubbing, cyanosis, or oedema. Full range of motion in all joints. Neurological: Mental status: Alert and fully oriented to person, place, and time. Speech is fluent and coherent. Cognition intact. Cranial nerves: II-XII intact. Pupils equal, round, and reactive to light. EOMs intact. Facial sensation and motor function symmetrical. Motor: 4+/5 strength in left upper and lower extremities, 5/5 in right upper and lower extremities. No pronator drift. No fasciculations or tremors. Sensation: Decreased sensation to light touch and pinprick in left upper and lower extremities in a stocking-glove distribution. Proprioception and vibratory sense intact bilaterally. Cerebellar: Finger-to-nose and heel-to-shin test performed smoothly with mild dysmetria on the left. Romberg negative. Gait: Antalgic gait, tends to favour the right side slightly. Walks with a steady base. Deep tendon reflexes: 2+ bilaterally in biceps, triceps, patellar, and Achilles reflexes, except 1+ on the left patellar and Achilles. Radiology Findings: An MRI brain performed on 15/10/2024 revealed a 2.5 cm enhancing lesion in the right frontal lobe, suspicious for a primary brain tumour. No evidence of hydrocephalus or significant mass effect at this time. A previous CT scan from 01/08/2024 showed a smaller, non-enhancing lesion in the same area. Assessment and Plan: Ms. Sarah Jenkins presents with a clinical picture concerning for an intracranial mass, specifically a suspected right frontal lobe tumour, given her persistent headaches, progressive left-sided neurological deficits, and the MRI findings. The differential diagnosis includes primary brain tumour (e.g., glioblastoma, meningioma), metastatic disease, or a less likely inflammatory or infectious process. Further investigations are imperative to establish a definitive diagnosis and guide management. 1. Suspected Right Frontal Lobe Tumour Assessment, including the likely diagnosis and rationale based on subjective and objective findings. The patient's age, insidious onset of symptoms, progressive neurological deficits (left-sided weakness and sensory changes), and the enhancing lesion on MRI strongly suggest an intracranial neoplasm. The chronicity and worsening nature of the headaches further support this. The differential diagnosis includes primary brain tumour, metastatic disease, or a high-grade glioma. Differential diagnosis, considering other potential surgical or medical conditions. Considerations include primary brain tumour (e.g., astrocytoma, glioblastoma, oligodendroglioma), metastatic lesion (lung, breast, melanoma being common primaries), cerebral abscess, demyelinating plaque, or a vascular malformation with associated oedema. Given the enhancing nature and size, a neoplastic process is highly suspected. Investigations planned, specifying any additional imaging or tests needed for a definitive diagnosis or pre-operative planning. The immediate plan involves a referral to neurosurgery for further evaluation and consideration of a stereotactic biopsy or surgical resection to obtain tissue for histopathological diagnosis. A comprehensive ophthalmological examination is also recommended. Pre-operative blood work, including a full blood count, electrolytes, renal and liver function tests, and coagulation studies, will be arranged. Surgical treatment planned, detailing the type of procedure, expected outcomes, and potential risks. Surgical planning will be discussed with the neurosurgeon. Options may include craniotomy with maximal safe resection of the lesion. Expected outcomes include symptom improvement and pathological diagnosis. Potential risks include haemorrhage, infection, neurological deficit exacerbation, seizure, and anaesthetic risks. Pre-operative preparation, including any necessary lifestyle modifications, pre-medication, and fasting instructions. The patient will be advised to maintain her current medications, but NSAIDs should be discontinued 7 days prior to any planned surgery. Fasting instructions will be provided by the surgical team closer to the date of any procedure. She is encouraged to maintain hydration and a balanced diet. Post-operative care plan, covering expected hospital stay, pain management, wound care, and follow-up appointments. Post-operatively, she can anticipate a hospital stay of 3-7 days, depending on the extent of surgery and recovery. Pain management will be administered as needed. Wound care instructions will be provided at discharge. Regular follow-up with neurosurgery, neurology, and potentially neuro-oncology will be arranged. Rehabilitation services will be considered based on post-operative neurological function. Relevant referrals, for multidisciplinary care or further evaluation if needed. Referral to neurosurgery has been made. Depending on biopsy results, further referrals to neuro-oncology for chemotherapy/radiotherapy, palliative care, and occupational/physical therapy will be considered. Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools