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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CT Lumbar Spine - 1
This is a middle-aged female with low back pain radiating down the left leg and foot for one and a half years.

CT Lumbar Spine - 2
This is a middle-aged female with two month history of low back pain and leg pain.

CT of Lumbar Spine w/o Contrast
CT of Lumbar Spine without Contrast. Patient with history of back pain after a fall.

CT Scan of Brain w/o Contrast
CT Scan of brain without contrast.

CT Scan of Brain with Contrast
Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.

CVA - Discharge Summary
Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect. 2. Old coronary infarct, anterior aspect of the right external capsule. Acute bronchitis with reactive airway disease.

CVA Consult - ER Visit
Cerebrovascular accident (CVA). The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.

Dandy-Walker Malformation
CT Brain - unshunted hydrocephalus, Dandy-Walker Malformation.

Diagnostic Cerebral Angiogram
Diagnostic cerebral angiogram and transcatheter infusion of papaverine

He awoke one morning and had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. The next day he woke up and he had double vision again.

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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