Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
|

View this sample in Blog format on MedicalTranscriptionSamples.com

Sample Type / Medical Specialty: Radiology
Sample Name: MRI C3 - Cord Compression.

Description: Left third digit numbness and wrist pain.
(Medical Transcription Sample Report)

CC: Left third digit numbness and wrist pain.

HX: This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.

SHX/FHX: 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.

EXAM: Vital signs unremarkable.
MS: A & O to person, place, time. Fluent speech without dysarthria.
CN II-XII: Unremarkable
MOTOR: 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.
SENSORY: Decreased PP in third digit of left hand only (palmar and dorsal sides).
STATION/GAIT/COORD: Unremarkable.
REFLEXES: 1+ throughout, plantar responses were downgoing bilaterally.
GEN EXAM: Unremarkable.

Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.

CLINICAL IMPRESSION: Left Carpal Tunnel Syndrome

EMG/NCV: Unremarkable.

MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.

COURSE: The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.

Keywords: radiology, wrist pain, spondylosis, disc bulge, digit numbness, mri, atrophy, numbness, wrist,
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.
Home | MedicalTranscriptionSamples | MT911 | MTDictionary | MTSetup | MTHelpLine
Sitemap | Tell a Friend | Contact Us | Disclaimer

Transcribed Medical Transcription Sample Reports and Examples