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

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Sample Type / Medical Specialty: General Medicine
Sample Name: MRI Brain - CO poisoning

Description: MRI Brain, Carbon Monoxide poisoning.
(Medical Transcription Sample Report)

CC: Found down.

HX: 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.

MEDS: unknown anxiolytic, estrogen.

PMH: PUD, ?stroke and memory difficulty in the past 1-2 years.

FHX: unknown.

SHX: divorced. unknown history of tobacco/ETOH/illicit drug use.

EXAM: BP126/91, HR86, RR 30, 37.1C.
MS: Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.
CN: unremarkable.
MOTOR: full strength throughout with normal muscle tone and bulk.
SENSORY: unremarkable.
COORD/STATION: unremarkable.
GAIT: not tested on admission.
GEN EXAM: notable for erythema of the face and chest.

COURSE: She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual "anxiety" disorder.

MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.

Keywords: general medicine, carbon monoxide poisoning, carbon monoxide, co poisoning, carboxyhemoglobin, neuropsychologic assessment, mri brain, poisoning, mri, brain,
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