Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurosurgery

Surgery of the nervous system, including nerves, the brain or spinal cord.

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Lumbar Laminectomy & Discectomy
Injection for myelogram and microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.

Lumbar Laminotomy & Discectomy
Microscopic assisted lumbar laminotomy with discectomy at L5-S1 on the left. Herniated nucleus pulposus of L5-S1 on the left.

Lumbar Puncture
Possible CSF malignancy. This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak.

Lumbar Puncture - 1
Lumbar puncture with moderate sedation.

Lumbar Puncture - 2
Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.

Lumbar Re-exploration
Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.

Nerve & Tendon Repair - Finger
Repair of nerve and tendon, right ring finger and exploration of digital laceration. Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.

Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.

Ommaya reservoir
Leukemic meningitis. Right frontal side-inlet Ommaya reservoir. The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.

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.

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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