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 Brain: Subdural hematoma

Description: CT of Brain - Subacute SDH.
(Medical Transcription Sample Report)

CC: Progressive unsteadiness following head trauma.

HX: A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.

PMH: 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.

SHX/FHX: Unremarkable. No h/o ETOH abuse.

MEDS: Meclizine, Procardia XL.

EXAM: Afebrile, BP132/74 HR72 RR16

MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.

CN: Left lower facial weakness only.

MOTOR: Left hemiparesis, 4+/5 throughout.

Sensory: intact PP/TEMP/LT/PROP/VIB

Coordination: ND

Station: left pronator drift.

Gait: left hemiparesis evident by decreased LUE swing and LLE drag.

Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.

Gen Exam: unremarkable.

COURSE: Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.

He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.

Keywords: neurology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis,
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