EMG Nerve Conduction Study Transcription Sample Reports For Medical Transcriptionists


DATE OF STUDY / DATE OF TEST / DATE OF EMG:  MM/DD/YYYY 

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:

This is an outpatient 56-year-old female with history of numbness in both lower extremities and both upper extremities, mostly tips of the fingers.  She also has history of LS spine disc surgery with continued low back pain.

She was referred for electrodiagnostic testing to rule out bilateral carpal tunnel syndrome and also bilateral lumbar radiculopathy.

In both upper extremities, median and ulnar nerves were tested for motor and sensory responses with F-wave latencies, and in both lower extremities, tibial and peroneal nerves were tested for motor responses with F-wave latencies.  Sural sensory nerves were also tested bilaterally.  Left H reflex latency was also obtained.

FINDINGS:

Left median nerve motor distal latency 4.42, borderline delayed.  Amplitude 15.5, normal.  Conduction velocity 47.2, normal.

Right median nerve motor distal latency 4.62, mildly delayed.  Amplitude 13.4, normal.  Conduction velocity 52.5, normal.

Ulnar nerve findings on both sides are normal.

Left tibial nerve motor distal latency 3.8, normal.  Amplitude 21.8, normal.  Conduction velocity 35.9, mildly slow.

Right tibial nerve motor distal latency 4.5 and amplitude 19.3, both normal.  Conduction velocity 40.2, mildly slow.

Both peroneal nerve findings were within normal limits.

Left median nerve sensory peak distal latency 4.52, mildly delayed.  Conduction velocity 31.0, mildly slow.  Right median nerve sensory peak distal latency 4.26, borderline delayed.  Conduction velocity 32.9, mildly slow.

Ulnar nerve sensory findings were within normal limits.

Sural sensory nerve findings on both sides were normal.

F-wave latencies for all the tested nerves were all within normal limits.

Left H reflex latency is 32, borderline delayed for her height.

IMPRESSION:

1.  Mild bilateral carpal tunnel syndrome, right more than the left.
2.  Possible early peripheral neuropathy in both lower extremities.

Clinical correlation is recommended.

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DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

INDICATION FOR STUDY:  The patient is a (XX)-year-old male who was referred for EMG nerve conduction study testing of bilateral upper extremities due to paresthesias. He reports just a few-week history of symptoms. Denies any neck injury. He does admit to muscle tightness. He denies any diabetes, thyroid disease, cancer or excess alcohol consumption.

SUMMARY:

1.  Nerve conduction studies were performed in bilateral upper extremities. 

2.  Bilateral median sensory nerve action potentials were within normal limits.

3.  Bilateral ulnar sensory nerve action potentials were within normal limits.

4.  Bilateral median motor complex muscle action potentials were within normal limits for latency, amplitude and conduction velocities.

5.  Bilateral ulnar motor complex muscle action potentials were within normal limits for latency, amplitude and conduction velocities.

6.  Needle examination was performed on the bilateral upper extremities and associated paraspinal muscles and showed no increased muscle membrane irritability or abnormal spontaneous activity. Of note, in terms of the volitional motor unit activity, there were increased amplitudes noted in the first dorsal interosseous bilaterally and also in the triceps muscle on the right side.

IMPRESSION:

1.  There is no electrodiagnostic evidence of an acute radiculopathy, plexopathy, myopathy or peripheral neuropathy of the bilateral upper extremities.

2.  Findings of increased amplitudes of volitional motor units noted in the C8 innervated muscles, more notable on the right than on the left is suggestive of reinnervation potentials and consistent with more of a chronic process. It is unlikely related to his current clinical findings.

3.  A new sterile disposable needle was used and discarded.

Thank you very much for this referral.

EMG Medical Transcription Sample Report

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DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURE PERFORMED:  Right upper extremity nerve conduction studies.

INDICATIONS:  Right upper extremity numbness.

HISTORY OF PRESENT ILLNESS:

The patient is a (XX)-year-old right-handed female who complains of right upper extremity numbness. She notes that it is especially worse with driving and while sleeping. She has no focal weakness. She notes it has been going on for 3-4 years. It does seem to be getting worse. The patient has had no trauma to her upper extremities. She does have some symptoms of numbness in the lateral aspect of the right upper forearm. She also notes that in the past her left hand used to have symptoms, which sound like Raynaud's syndrome. She has had none on the right side.

PAST MEDICAL HISTORY:

Negative for diabetes, thyroid disease, malignancies, cancers, alcohol abuse. She has never had any neck surgery, but she notes that she has some arthritis of the neck. She has not had any imaging of her neck. She does not take blood thinners.

PHYSICAL EXAMINATION:

On exam, the patient has good muscle bulk in her upper extremities. There is questionable atrophy in the hand intrinsic muscles.

NERVE CONDUCTION STUDIES:

The right median sensory nerve action potential (SNAP) is not recordable The right ulnar sensory nerve action potential demonstrates abnormal prolongation at 4.7 milliseconds, less than 3.8 milliseconds normal, with abnormal diminution in amplitude of 7.4 microvolts, greater than 10 microvolts is normal. The right median motor study shows very significant prolongation of the distal evoked response at 6.4 milliseconds, greater than 4.2 milliseconds normal. However, the right median compound muscle action potential demonstrates normal amplitude at 8.4 millivolts, greater than 4 millivolts normal. Additionally, nerve conduction velocity of the right median motor nerve across the forearm segment is normal at 49 meters per second. With proximal stimulation, there was no conduction block.

The right ulnar compound muscle action potential (CMAP) demonstrated a normal distal latency at 3.4 milliseconds. There was a decrement in amplitude of 4.7 millivolts, greater than 5 millivolts normal. With stimulation below the elbow, amplitude noted at 4.9 millivolts. With stimulation above right elbow, the ulnar CMAP was 3.4 millivolts, which is significant, which demonstrates significant conduction block. Nerve conduction velocity of the ulnar motor nerve across the right forearm was 47 meters per second. Nerve conduction velocity across the right forearm segment was 30 meters per second, 49-65 meters per second is considered normal; greater than 10 meters per second slowing across the elbow is considered significant electrodiagnostically. Repeat ulnar motor studies with different electrodes demonstrated virtually the exact same findings.

Needle EMG of the right upper extremity demonstrated an essentially normal study. There was no abnormal spontaneous activity including multiple proximal and distal median and ulnar innervated muscles. Motor unit analysis was essentially within normal limits with the possible exception of borderline large motor units in the first dorsal interosseous muscle, an ulnar innervated muscle distal to the wrist. Large motor units would be suggestive of a chronic process. However, there is no evident active denervation. Additionally, there was no active evident reinnervation electrodiagnostically. Right radial sensory nerve action potential at 10 cm demonstrated a distal latency of 2.7 milliseconds and amplitude of 25 microvolts, which is well within normal limits.

IMPRESSION:

1.  Abnormal study.

2.  There is electrodiagnostic evidence of median mononeuropathy at the right wrist, which is moderate in severity. This is based on the relative abnormal prolongation of the median versus ulnar.

3.  There is electrodiagnostic evidence of ulnar neuropathy at the elbow based upon evident conduction block and decrement slowing above 10 meters per second across the elbow segment only.

5. Cannot entirely rule out evident peripheral polyneuropathy based on this limited testing; however, the normal right radial sensory nerve action potential would strongly suggest there is no significant peripheral polyneuropathy. Believe the findings noted above can be explained by the carpal tunnel syndrome as well as mild ulnar neuropathy at the right elbow. Clinical correlation is necessary. If desired, a more formal testing could be performed if felt necessary.

6.  There is no electrodiagnostic evidence to suggest a right upper extremity radiculopathy.

7.  There is no electrodiagnostic evidence of a myopathic process.

8.  Although cannot be entirely excluded, the findings noted above are not suggestive of a brachial plexopathy.

Thank you very much for this referral.

More MT Sample Reports

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DATE OF STUDY:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

STUDY:  Left upper extremity EMG/nerve conduction studies. 

INDICATION:  Left upper extremity numbness and tingling. 

PHYSICAL EXAMINATION: 

EXTREMITIES:  The patient has good muscle bulk in his upper extremities. 

NERVE CONDUCTION STUDIES:  Standard nerve conduction studies were performed in the left upper extremity.  There is abnormal relative and absolute prolongation of the left median sensory nerve action potential (SNAP) with maintained amplitude.  The median motor studies are technically within normal limits though there is a relative prolongation of the median motor as compared to the ulnar motor study (the latency difference is 1.0 milliseconds with 1.5 milliseconds considered abnormal; therefore this does not quite reach significance).

Nerve conduction velocities of the left median motor and left ulnar motor nerves are well within normal limits.  A left ulnar F-wave was within normal limits.

Needle EMG was performed of the left upper extremity.  Mechanical insertional activity was within normal limits.  There was no abnormal spontaneous activity.  Motor unit analysis was within normal limits including multiple C5-C6 and median innervated muscles. 

IMPRESSION: 

1.  Abnormal study. 

2.  There is electrodiagnostic evidence of left upper extremity median mononeuropathy at the wrist (carpal tunnel syndrome).  This median mononeuropathy at the left wrist is considered mild in severity based upon the abnormal relative and absolute prolongation of the median sensory nerve action potential and maintained common normal median motor study. 

3.  There is no electrodiagnostic evidence of left upper extremity radiculopathy, plexopathy, peripheral polyneuropathy or myopathic process.


DATE OF STUDY: 

This is an outpatient 50-year-old male with history of pain and paresthesia in both upper extremities.  He was referred for electrodiagnostic testing to rule out bilateral carpal tunnel syndrome versus cervical radiculopathy.

Median and ulnar nerves were tested for motor and sensory responses with F-wave latencies both sides.

FINDINGS:

Right median nerve motor distal latency is 5.28, mildly delayed.  Amplitude 3.68, normal.  Conduction velocity 54.1, normal.

Left median nerve motor distal latency is 5.96, mild to moderately delayed.  Amplitude 3.97, within normal limits.  Conduction velocity 71.0, normal.

Ulnar nerve motor findings, both sides, were normal.  Left ulnar nerve sensory peak distal latency 4.1, mildly delayed.  Conduction velocity 34.1, mildly slow.  Right ulnar nerve sensory peak distal latency 4.98, mildly delayed.  Conduction velocity 28.1, mildly slow.

F-wave latencies for all the tested nerves were within normal limits.

IMPRESSION:

1.  Bilateral carpal tunnel syndrome, left more than the right.
2.  Possible early bilateral ulnar sensory neuropathy.

Clinical correlation is recommended.



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