Medical Reports

Included on this page will be transcriptions of my medical reports including the surgeon's report, the initial MRI report, the pathology report, and the report from my ER visit in January. Perhaps even the notes from my primary care doctor should they prove illuminating in my journey towards surgery and treatment. I have a hunch they will; she is an exceedingly sharp lady, incredibly thorough, and a dedicated and caring professional.

Not currently having all the various reports in hand, I have what I'm sure will be some interesting journeys into the bowels of Medical Records at several institutions. As I uncover the various reports, I will transcribe them when able

I thought of making .pdf's of the various documents so people could look at them on their own, but i don't think the size and quality would be adequate for squint-free reading. Besides, I want to be sure to redact the names of the various doctors and technicians who did the procedures and testing. No need to broadcast people's names all over the 'net. I want to be sure and protect them from potential hassles that can sometimes be associated with google searches. I will say as I've said before, the quality of care I've received has been nothing short of amazing. Every nurse, doctor, therapist, technician, and volunteer exhibited the highest standard of caring, compassion, and respect for what I would be going through that I've ever witnessed, and I thank them for it.

My Primary Care Doctor's Report after my "Sinus" symptoms had been going strong for a couple weeks:
Date: June 10, 2010
Reason for Consultation: 41 year-old male here to establish care.  He's been having problem with possible sinus infection now for the past couple weeks.  He did go to an immediate care clinic in Clackamas & was put on amoxicillin.  It made him more nauseous than he already was and he switched over to cephalexin.  He was still nauseous with that and stopped early approximately one week ago.  Seems like his headache symptoms did improve slightly.  He still however is having a lot of nausea and vomiting and a lot of stomach upset.  He feels that may be related to postnasal drip.  He has noted it is clear to yellow in color.  He also had some dizzy spells.  He denies any blurred vision or any numbness or tingling in the extremities or gait disturbances.  In January of this past year he was diagnosed with migraine auras.  He had gone up to OHSU because of a terrible left-sided headache and ear fullness.  He also had some numbness sensations over the side of his head.  A CT scan was done at the time and found to be normal.  He never really got the headache with that, and has still been having problems with auras, but not much headache.  His current symptoms do not seem to related to that.  The only other symptom he's noted is that his neck has felt tight and stiff.  He has lost weight and had no appetite.  He has not had a fever.

Medications: promethazine, excedrin migraine,
Allergies: no known drug allergies
Past History: migraine aura January, 2010
Surgical History: none
Family History: both parents with migraine headaches, paternal grandfather heart disease, paternal grandmother stroke
Social History: 41 year-old male has partnered with female ('bout time-TW), they have no children.  He works in manufacturing and engineering.  He is a non-smoker, no alcohol or caffeine.  He cycles to work daily (20 miles roundtrip-TW)

Review of Symptoms:
Constitutional: patient has lost about 10 pounds
HEENT: Ears he does admit to dizziness, but no ear pain; Eyes no blurred vision, no eye pain; Nose no epistaxis, no nasal congestion, no runny nose, no posterior nasal drainage; Throat no sore throat, no dysphagia, no hoarseness, no burning sensation in the back of the throat.
Cardiovascular: no angina, MI, syncopal episodes,  or acute CHF past 6 months
Respiratory: patient admits he has felt some shortness of breath with exertion
Gastrointestinal:  he has not noted any stool changes, but has had nausea and vomiting
Genitourinary: denies dysuria, polyuria, hematuria, incontinence, nocuteria
Musculoskeletal: denies joint swelling,restriction, myalgias, arthralgias
Integumentary (skin and/or breast): denies rashes, lesions, change in hair or nails
Neurological: denies seizures, sycope, paralysis, tremor, weakness
Psychiatric: denies depression, suicide attempts/plans, anxiety disorders
Endocrine: denies diabetes, thyroid disorders
Hematologic/Lymphatic: no history of anemia, abnormal bleeding, excessive bruising, lymphadenopathy, no history of past blood transfusions, no pitting edema. Neck, clavicular, axilllary, and inguinal nodes are not enlarged.

Physical Exam:  (All the basics were covered, and all were within acceptable ranges so I'll spare you looking through them)

Impression: 1. Probable ethmoid sinusitis 2. Nausea, vomiting 3. Dizziness 4. Shortness of breath with exertion.

Discussions/Recommendations: 1. We had a discussion about his symptoms, certainly there is some concern for the possibility of viral meningitis or something even more such as multiple sclerosis or a mass occupying lesion in his head.  We've decided to start conservatively because he does not currently have insurance and will get him going on a stronger antibiotic RX Avalox 400 mg once daily #10.  If the labs are normal and he responds to this I did not think further work will be necessary (*note: I did not respond to the treatment over the next few days, and I had a couple episodes where I lost my coordination as well as projectile vomiting and severe headaches so called her a few days later and she informed me she was going to  schedule an MRI for me with a Radiological service she and her clinic work with that work well with the uninsured.-TW)


MRI Report:
Date: June 16, 2010
Procedure: Scans are performed on the Siemens Symphony1.5T high-field, short-bore scanner.  Precontrast sagittal and axial T1, T2 axial single echo, axial T2 FLAIR, diffusion-weighted, axial T2* FLASH. Postcontrast sagittal and axial T1, coronal T1 fat-suppressed images.  20cc of Omniscan was administered intravenously.

Findings: There is a large mass involving the inferior aspect of the right temporal lobe and extending into the frontal lobe. The mass is heterogeneous with multiple cystic areas.  Following contrast administration, there is significant enhancement of solid portions as well as in the periphery of the the mass.  The mass measures approximately 4.0 x 5.1 x 5.2 cm.  there is pronounced edema in the adjacent white matter. and significant mass effect with effacement of the right lateral ventricle.  No other focal abnormalities are evident.  Infratentorial structures are normal in appearance.

Impression: Large intra-axial mass in the right frontal temporal region with both cystic and solid components and significant enhancement following contrast administration.  The appearance is most consistent with a primary brain malignancy and likely a high-grade glioma.

(I went in to my Primary Care Doctor's office the following day, June 17.  She gave me the news and told me she had already scheduled an appointment for me with an oncologist she regarded highly for June 18 and had forwarded him the reports.  I met with the oncologist who had already coordinated with a neurosurgeon, and through the neurosurgeon we scheduled surgery for June 20)


Surgeon's Report (A walking tour of my brain)
Preoperative Diagnosis: Brain Tumor
Postoperative Diagnosis: Brain Tumor, frozen section malignant tumor/glioma
Procedure Performed: Right-sided stereotactic frontal temporal craniotomy for tumor resection
Estimated Blood Loss: 300 ml
Implants: Synthes cranial fixation system
Drains: None

Indication: Mr. Whitecotten is a 41-year old right-handed white male with right temporal lobe tumor, manifesting itself as headaches, nausea, vomiting, malaise, with mild left pronator drift.  Full PARQ conference was held and we plan to proceed with the above stated procedure.

Narrative: Mr. Whitecotten was brought into the operating theater having been appropriately identified, site verification having occurred, and surgical safety checklist having been completed.  He underwent general endotracheal anesthesia and was placed supine on the operative table in the Mayfield skull clamp appropriately attached to the table.  The frameless stereotactic system was attached to the table and registered appropriately; and the area of the tumor was mapped out prior to him being shaved, prepped, and draped in standard sterile fashion.  A standard question mark incision being made after infiltration of local anesthetic and elevating the scalp flap and the muscle in 2 separate flaps with a cuff being left to be able to reconstruct the temporalis muscle at closure.  Making 3 small bur holes with a matchstick, I then elevated the frontal temporal flap, passed it off, opened the dura based on the sylvian fissure.  There was an area very anterior that appeared to be affected by tumor.  It was obvious the tumor was a bit deep to the cortex as well.  I then made a small cortical incision in the area that still showed that had the most superficial tumor, took some tumor and sent it off for frozen section.  It returned malignant neoplasm.

Then, choosing at this point to aggressively remove as much of the tumor up to the sylvian fissure as possible without trying to violate the sylvian fissure, I began a cortical incision roughly 5 cm posterior to the temporal tip, took it anteriorly and inferiorly to his collateral sulcus and got behind the tumor quite well, inferior to it as well, as well anterior.  Working to undercut the temporal lobe, removing it in roughly 3 pieces.  I initially took the lateral portion out, worked towards the temporal tip, bipolaring and cutting the veins and then working my way until I reached the incisura and the sphenoid wing and then resected the superior portion of the temporal lobe as well, without going into the sylvian fissure.  This was all sent off as additional specimen.  The area was copiously irrigated and I chose not to go up higher the frontal lobe.  I did remove some tumor and there was an amount of copious bleeding, both arterial and venous, as I got near the sylvian fissure.  Bipolaring this, I chose not to proceed any further.  The area was copiously irrigated.  Hemostasis was obtained.  Surgicel was placed.  The dura was closed with 4-0 Nurolon.  The tackup sutures had been previously placed in the dura and now a central one was placed as well.

Duragen was placed over this with the 2 central tackup sutures being brought through the skull.  The skull flap was replaced with Synthes cranial fixation system and the last tackup suture was tied.  We then reconstructed the temporalis muscle with 0 Vicryl, closed the scalp and galea with a combination of 0 and 3-0 Vicryl prior to closure of skin with staples.  Sterile dressing was placed, drapes were removed.  The patient was taken to the Intensive Care Unit.

...& happily enough, after all that, I'm not having any problems finding my keys, although I do seem to say "f*ck" a lot more...as far as the cranial fixation system goes, it's titanium, so I only have to wear half a bike helmet when I ride...

*Note: I've chosen not to transcribe the following pathology report verbatim with the main differences being that I will not reveal the names of various medical personnel cited in the original report for performing functions such as authenticating or offering concurring opinions or being the ordering doctor (which was the neurosurgeon who wrote the surgeon's report above, anyway).  I've also edited out items like the mechanics of how the report was dictated and where it was dictated in the interest of brevity.  Aside from that, the report is essentially as written

Pathology Report: Collected: 06/20/2010 12:01 AM  Accessioned: 06/21/2010 09:10 AM
Completed: 06/24/2010 02:50 PM

Clinical History: Right temporal lobe tumor

Diagnosis: A) and B) Brain Tumor and fluid, Right lateral temporal lobe:

1) Glioblastoma Multiforme

Comment: A concurring second opinion has been rendered.

Gross Description:

A) Brain Tumor and Fluid: Received fresh are four pieces of yellow-brown tissue aggregating 1 cm in greatest dimension.  Also received is an approximate 1 cc volume of fluid consistent with clotted blood.  The tissue is take for frozen section and some squash preps are made.

FROZEN SECTION DIAGNOSIS PERFORMED.  HIGH-GRADE MALIGNANT NEOPLASM, FAVOR GLIAL ORIGIN; DEFER TO PERMANENTS. (CBB)

Sections:

FSCA1) frozen section control;
A2) rest of tissue and some of the fluid

B) Right Lateral Temporal Lobe with Tumor: In formalin are five pieces of hemorrhagic and focally necrotic brain tissue aggregating 36 gm and 6.5 x 4.5 x 3.5 cm.  Necrotic tissue is grossly at the margins of resection which are marked with black ink.

It is difficult to determine the size of the tumor, but one of the pieces contains a bright yellow-orange area in B3 and B4.

Microscopic Description:

A) and B) Brain Tumor and Fluid, Right Lateral Temporal Lobe: Included on a set of six slides there are multiple fragments of a high-grade glial neoplasm.  the neoplasm is composed of malignant astrocytes characterized by ovoid, somewhat irregular, hyperchromatic nuclei.  These display finely stippled chromatin, inconspicuous nucleoli, and mitotic figures are readily recognized.  On slide FSCA1 there is a broad focus of necrosis.

The slides included as part B show brain tissue with some lower grade neoplasm, but on slide B4 there are fragments of very cellular neoplasm that show extensive vascular proliferation as well as mitotic activity and foci of necrosis.

Block B4 is evaluated  with a limited panel of  monoclonal antibodies.  A stain for GFAP is strongly positive but negatively stains the foci of capillary proliferation.  A stain for epithelial membrane antigen is negative, tending to exclude a metastatic carcinoma.  CD31, which is an endothelial marker, highlights the very extensive vascular proliferation and an M1 immunostain demonstrates variable but significant positivity.