8TH February, 2023
MEDICAL
REPORT
Q.B, 75 YEARS, FEMALE
WCA/6016/2023
Diagnosis-
Intrinsic left insula mass lesion
Management plan
– Stealth guided biopsy
Adjuvant
oncology treatment
The above named patient is a 75yrs old
presenting with recurrent seizures last was Dec 2022. Seizures is generalized
tonic with impairment of consciousness that lasted up to 2-3 hours. No loss of
urinary or bowel functions, no headache, no weakness of upper and lower limbs.
She is quite ambulant.
She
is hypertensive controlled with medications. She also has bilateral
osteoarthritis. Following the last episode of seizure while she was in vacation
in UK had a brain can which reveals intrinsic tumor. Subsequently placed on
reducing dose of dexamethasone and keppra. She has been stable since then but
added some weight due to intake of dexamethasone.
In
the clinic today, she walked in by herself accompanied by her daughter.
Following
the above complains she had neurological assessment which confirmed normal
cranial nerves (1-12). Normal fundoscopy on the neuro mutualizing sense.
MSS-
confirmed crepitations feelings on bilateral knee joints suggesting OA.
We
had the opportunity of reviewing MRI today (07/02/2022)
recon ducted in our hospital because of inability to open the previous one.
Radiological Imaging:
MRI
Brain confirms as previous
report significant changes in the region of left insula and adjacent temporal
lobe (opercular region). It takes up contrast poorly and hypo intense on T1.
This feature suggest astrocytoma probably transiting from grade 2 – grade 3.
Diagnosis was explained to the patient basic
understanding and the need for minimally invasive neuro- navigational assisted
biopsy of lesion discussed with patient and we will be happy to proceed with the
procedure as soon as consent is obtained.
Management
Plan:
·
To continue tabs dexamethasone 2mg B.D
·
Counselled on stealth guided biopsy
·
For stealth biopsy
Kindly revert for further
clarifications if need be.
Sincerely yours,
Dr.
Halima Ibrahim
For
Team Wellington Clinics.