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: Neurology - Discharge Summary

Description: Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.
(Medical Transcription Sample Report)

PRELIMINARY DIAGNOSES:
1. Contusion of the frontal lobe of the brain.
2. Closed head injury and history of fall.
3. Headache, probably secondary to contusion.

FINAL DIAGNOSES:
1. Contusion of the orbital surface of the frontal lobes bilaterally.
2. Closed head injury.
3. History of fall.

COURSE IN THE HOSPITAL: This is a 29-year-old male, who fell at home. He was seen in the emergency room due to headache. CT of the brain revealed contusion of the frontal lobe near the falx. The patient did not have any focal signs. He was admitted to ABCD. Neurology consultation was obtained. Neuro checks were done. The patient continued to remain stable, although he had some frontal headache. He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure. The patient remained clinically stable and his headache resolved. He was discharged home on 11/6/2008.

PLAN: Discharge the patient to home.

ACTIVITY: As tolerated.

The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache. The patient has been advised to follow up with me as well as the neurologist in about 1 week.

Keywords: neurology, interhemispheric, frontal lobe, head injury, brain, contusion,
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