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

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Sample Type / Medical Specialty: Orthopedic
Sample Name: MRI C-spine

Description: MRI C-spine: C4-5 Transverse Myelitis.
(Medical Transcription Sample Report)

CC: Left hemibody numbness.

HX: This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena.

MEDS: none.

PMH: 1)Bronchitis twice in past year (last 2 months ago).

FHX: Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.

SHX: Denies Tobacco/ETOH/illicit drug use.

EXAM: BP112/76 HR52 RR16 36.8C

MS: unremarkable.

CN: unremarkable.

Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.

Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.

Coord: positive rebound in RUE.

Station/Gait: unremarkable.

Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.

Rectal exam not done.

Gen exam reportedly "normal."

COURSE: GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.

The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine.

Keywords: orthopedic, mri c-spine, c-spine, lhermitte's, myelitis, transverse myelitis, uhthoff's, ataxia, clumsy, hemibody numbness, mental status, numbness, tingling, weakness, mri c spine, hemibody, mri, spine, csf,
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