Doctor: Before we begin today, sir, I just need a few pieces of background information. I see here on my chart that you're thirty years old, is that correct? 
Patient: Yes doctor, that's correct. 
Doctor: Okay, and which hand is your dominant hand? 
Patient: I use my right hand for everything. 
Doctor: Now, take me through the timeline of your symptoms, please. When did everything start?
Patient: I was doing well until July of nineteen ninety three. 
Doctor: What were your initial symptoms? 
Patient: I began having weakness in my right arm, and there was some neck pain too. 
Doctor: Okay, when these symptoms began, how did you manage them?
Patient: At first, I went to a chiropractor, but after a while my arm started atrophying, and my right hand felt tight. I couldn't extend all my fingers out. 
Doctor: Once you noticed the atrophy and contractures, that's the tightness you were experiencing, how were you treated? 
Patient: After that, I went to a neurosurgeon close to my house, and he ordered an, um, C T scan of my neck. 
Doctor: Okay, do you have the report of that C T Scan with you today?
Patient: Yes, doctor, I have it right here. They were one on the twenty fifth of September in ninety two.
Doctor: Thank you, okay, this shows an intramedullary lesion at C two three, and an extramedullary lesion at C six seven.  
Patient: That means tumor, right?
Doctor: Yes sir. Did you have neck surgery?
Patient: Yeah, I have the op notes right here. 
Doctor: Okay, just so you know, you had a C six T one laminectomy, and they decompressed the spinal cord. How did you respond to this surgery?
Patient: Well, honestly, I improved for about three months following the operation, but after that I just got worse and worse. 
Doctor: Once your symptoms worsened, what happened? 
Patient: Um, I started having this burning sensation on my left side. 
Doctor: Did you have any weakness, sir?
Patient: Yeah, I had weakness in both my arms.
Doctor: Was one side worse than the other? 
Patient: Yes, my right side was worse than my left. 
Doctor: In addition to the burning and weakness, did you have any other symptoms? 
Patient: Um, I had really bad balance, I felt nauseous, like I was going to throw up at all times, which I did do some, and, um, my heart was beating really fast, and my blood pressure went up really high. 
Doctor: After all these symptoms began, how were you treated? 
Patient: On, um, August thirty first nineteen ninety three I had an M R I of my neck, and I have that report right here, too. 
Doctor: Thank you, this shows diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa.
Patient: Sorry to interrupt, what does all that mean?
Doctor: Well, that's more tumors in the spine. Did you have another surgery for this?
Patient: Yeah, I had brain surgery. I have those notes right here, too. 
Doctor: Okay, so you had a suboccipital craniotomy with tumor excision, decompression, and biopsy. The biopsy showed hemangioblastoma. 
Patient: That's cancer, right? This was all done on September first of nineteen ninety three. 
Doctor: Well no, not exactly, it's a benign tumor. After this surgery how were your symptoms? 
Patient: I felt good, the doctors said I stabilized out. I went through some radiation procedures from September of ninety three to January nineteenth of ninety four. 
Doctor: How have your symptoms progressed since?
Patient: I went to the NeuroOncology clinic on October twenty sixth nineteen ninety five because I was having weakness in both arms and both legs, as well as trouble swallowing food. 
Doctor: How much weakness was there?
Patient: It was so bad I couldn't even put on a shirt, or raise my arms, or even feed myself. 
Doctor: Can you go up and down stairs?
Patient: No, not really, but I can climb them. 
Doctor: How about going to the bathroom, is everything normal there?
Patient: Yeah, no problems there. 
Doctor: Good, and what did the doctor at that clinic recommend?
Patient: They were considering doing chemo.

Clinical note:
Symptoms: RUE weakness, neck pain, atrophy and contractures of right hand, left sided paresthesia, upper extremity weakness (right worse than left), ataxia, nausea, vomiting, hyperreflexia, progressive proximal weakness of all four extremities, dysphagia, difficulty with manual dexterity, difficulty going down stairs.
Diagnosis: intramedullary lesion at C2-3, extramedullary lesion at C6-7, hemangioblastoma.
History of Patient: Started experiencing RUE weakness and neck pain in 7/93, initially treated by a chiropractor, developed atrophy and contractures of right hand, underwent C6-T1 laminectomy with exploration and decompression of the spinal cord, Symptoms stabilized post-operatively for 3 months then progressively worsened, developed left sided paresthesia and upper extremity weakness, underwent suboccipital craniotomy with tumor excision, decompression, and biopsy on 9/1/93, underwent radiation procedures from 9/93 through 1/19/94, evaluated in NeuroOncology clinic on 10/26/95.
Plan Of Action: Consideration of chemotherapy.