Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Vertigo Consult

Description: The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment.
(Medical Transcription Sample Report)

The patient's main complaint is vertigo. The patient is having recurrent attacks of vertigo and imbalance over the last few years with periods of free symptoms and no concurrent tinnitus or hearing impairment. She had previous normal MRI examination

Assessment for peripheral vestibular function follows:
OTOSCOPY: showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.
ROMBERG TEST: maintained postural stability.
FRENZEL GLASSES EXAMINATION: no spontaneous, end gaze nystagmus.
HEAD SHAKING: No provocation nystagmus.
DIX-HALLPIKE: showed no positional nystagmus excluding benign paroxysmal positional vertigo.
VESTIBULOCULAR REFLEX [HALMAGYI TEST]: showed corrective saccades giving the impression of decompensated vestibular hypofunction.

IMPRESSION: The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid.

PLAN: Planned for electronystagmography to document the degree of vestibular hypofunction.


Keywords: consult - history and phy., electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,
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