Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurology

Diagnosis and medical treatment of diseases and abnormalities affecting the nervous system.



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EMG/Nerve Conduction Study - 9
Nerve conduction screen demonstrates borderline median sensory and borderline distal median motor responses in both hands. The needle EMG examination is remarkable for rather diffuse active denervation changes in most muscles of the right upper and right lower extremity tested.

Encephalopathy - Rehab Consult
Encephalopathy related to normal-pressure hydrocephalus.

Epidural Fluid Collection
Fall/loss of consciousness.

Epidural Hematoma
Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.

Epidural Hematoma Evacuation
Evacuation of epidural hematoma and insertion of epidural drain. Epidural hematoma, cervical spine. Status post cervical laminectomy, C3 through C7 postop day #10. Central cord syndrome and acute quadriplegia.

Essential Tremor & Torticollis
This 62-year-old white female has essential tremor and mild torticollis. Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.

Falls - Discharge Summary
Falls at home. Anxiety and depression. The patient had been increasingly anxious and freely admitted that she was depressed at home.

Feet & Hand Cramping
Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night.

First Followup - Shunt Surgery
Patient returns for his first followup after shunt surgery.

Frameless Stereotactic Radiosurgery
CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples