Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurology
Sample Name: CT Head - 4

Description: CT head without contrast. Assaulted, positive loss of consciousness, rule out bleed. CT examination of the head was performed without intravenous contrast administration.
(Medical Transcription Sample Report)

EXAM: CT head without contrast.

INDICATIONS: Assaulted, positive loss of consciousness, rule out bleed.

TECHNIQUE: CT examination of the head was performed without intravenous contrast administration. There are no comparison studies.

FINDINGS: There are no abnormal extraaxial fluid collections. There is no midline shift or mass effect. Ventricular system demonstrates no dilatation. There is no evidence of acute intracranial hemorrhage. The calvarium is intact. There is a laceration in the left parietal region of the scalp without underlying calvarial fractures. The mastoid air cells are clear.

IMPRESSION: No acute intracranial process.

Keywords: neurology, extraaxial fluid, intracranial hemorrhage, parietal region, scalp, loss of consciousness, ct examination, ct head, intracranial, intravenous, contrast,
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