Transcribed Medical Transcription Sample Reports and Examples
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as on 3/19/2014

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Sample Type / Medical Specialty: Neurology

Diagnosis and medical treatment of diseases and abnormalities affecting the nervous system.

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Organic Brain Syndrome
Organic brain syndrome in the setting of multiple myeloma. The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.

Phenol Neurolysis & Botulinum Toxin Injection - 1
Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.

Phenol Neurolysis & Botulinum Toxin Injection - 2
Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.

Phenol Neurolysis & Botulinum Toxin Injection - 3
Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.

Physical Therapy - Brain Tumor Removal
Status post brain tumor removal. The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. She had a brain tumor removed and had left-sided weakness.

Pituitary Adenomectomy
Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma. Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.

Pseudotumor Cerebri
The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches.

Radiologic Exam - Spine
Cervical, lumbosacral, thoracic spine flexion and extension to evaluate back and neck pain.

Reflex Sympathetic Dystrophy - Letter
Reflex sympathetic dystrophy of both lower extremities.

Rolandic Epilepsy
Diagnosis of benign rolandic epilepsy.

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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