Transcribed Medical Transcription Sample Reports and Examples
MT HelpLine 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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Rotator Cuff Tear
Followup left-sided rotator cuff tear and cervical spinal stenosis. Physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.

SAH, Contusion, Skull Fracture
HCT: SAH, Contusion, Skull fracture

Skull Base Reconstruction
Squamous cell carcinoma of right temporal bone/middle ear space. Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.

Sleep Study Interpretation
Sleep study - patient with symptoms of obstructive sleep apnea with snoring.

Sleepiness - Consult
Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.

SOAP - Numbness & Tingling
Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. Carpal tunnel syndrome suspected.

SOAP - Temporal Mass
MRI demonstrated right contrast-enhancing temporal mass.

Status Epilepticus
A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.

Suboccipital Craniectomy
Right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.

Suspected Seizure Activity
Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.

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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