Sample Report

NCS/EMG Report
John Smith, M.D. Patient Name: John Doe
Patient ID: 12345
100 Any Street Birth Date: 2/01/1976
Sampletown, MA 98765
Office use: ___________________
Test Performed: 1/30/2009 11:42:01 AM EST Treating Physician: _______________
Data Stored: 1/30/2009 12:07:13 PM EST
Study Technician: _______________
Report Generated: 1/30/2009 12:10:58 PM EST

History: □ See patient chart.

Patient is a woman 45 years of age, 5'6" and 170lbs. Nerve conduction study performed for evaluation of upper extremity
symptoms (possibly suggestive of cubital tunnel syndrome).
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Physical Examination: □ See patient chart.

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Electrodiagnostic Study Methodology:

Nerve conduction study performed using equipment with the following technical specifications. Constant current stimulator
(duration 100-500 usec, magnitude 0-100 mAmp, compliance >420 volt). Amplifier (two channels, common mode rejection >90
dB, noise < 2 uV rms, gain to X100,000, filter high pass 14/175 Hz for motor and sensory recordings respectively, filter low pass
7 kHz, sampling rate 20 kHz). Nerve conduction response waveforms and cursors displayed and edited, as required, in real-time.
Nerve conduction response parameters including latency, conduction velocity, amplitude, and waveform configuration displayed
on LCD in real-time.

Needle electromyography study performed using equipment with the following technical specifications. Amplifier (one channel,
common mode rejection >90 dB, noise < 2.5 uV rms, gain to X10,000, filter high pass 2/16 Hz selectable, filter low pass 5 kHz,
sampling rate 10 kHz). Loudspeaker (3.2 W, filter 4 pole low pass at 1.5 kHz). Electromyography traces displayed on LCD in
real-time.
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Page: 1 of 6
Tracking No.: 1283714 PN2202749 Rev. A
 NCS/EMG Report
John Smith, M.D. Patient Name: John Doe
Patient ID: 12345
Birth Date: 2/01/1976

Nerve Conduction Tests:

Left Right
Test Distance Temp Distance Temp
Median
Wrist►APB 29.0°C * 29.0°C *
Wrist►D3 29.0°C * 29.0°C *
Ulnar
Wrist►ADM 31.0°C * 32.0°C *
Wrist►D5 31.0°C * 32.0°C *
BE►ADM 30.0°C * 30.5°C *
AE►ADM to BE 105 mm 30.0°C * to BE 105 mm 30.5°C *
Footnote:
* Measurement results are in the table below.

Nerve Conduction Results:

Left Right
Outside Outside
Normal
Test Result Normal % Result Normal %
Limits Limits Limit♦
Median Wrist►APB
DML 3.70 56.60 3.33 87.96 ≤4.47
CMAP Amplitude 1.47 X 0.00 4.50 23.28 ≥2.97
CMAP Duration 5.39 5.26
MUD motor 1.17 0.88 ≤2.00
F-wave (mean) 27.66 32.27 27.56 34.76 ≤30.21
F-wave (maximum) 30.12 27.99 ≤36.45
F-wave Chronodispersion 3.79 35.71 0.51 99.70 ≤10.58
F-wave Persistence 0.78 0.71 ≥0.42
A-wave --- ---
Median Wrist►D3
DSL 2.91 2.81 ≤4.54
SNAP Amplitude (pk-pk) 50.49 67.88 35.94 36.33 ≥10.88
MUD sensory 0.27 90.86 0.27 90.86 ≤1.31
Ulnar Wrist►ADM
DML 2.58 26.21 2.64 19.67 ≤2.94
CMAP Amplitude 6.54 45.98 7.25 61.64 ≥3.65
CMAP Duration 3.69 3.79
F-wave (mean) 24.63 94.00 25.51 82.25 ≤29.95
F-wave (maximum) 25.60 91.85 26.62 80.08 ≤33.38
F-wave Chronodispersion 1.76 79.25 1.52 86.15 ≤7.79
F-wave Persistence 1.00 1.00 ≥0.43
A-wave --- ---
Ulnar Wrist►D5
DSL 2.98 40.00 3.03 33.77 ≤3.53
SNAP Amplitude (pk-pk) 42.72 48.55 26.26 12.82 ≥12.91
Ulnar BE►ADM
Motor Latency 6.49 36.83 6.30 53.67 ≤7.23
CMAP Amplitude 5.61 22.70 6.29 37.60 ≥3.72

Page: 2 of 6
Tracking No.: 1283714
 NCS/EMG Report
John Smith, M.D. Patient Name: John Doe
Patient ID: 12345
Birth Date: 2/01/1976

Left Right
Outside Outside
Normal
Test Result Normal % Result Normal %
Limits Limits Limit♦
Ulnar AE►ADM
Motor Latency 8.15 58.98 8.06 65.79 ≤9.34
CMAP Amplitude 5.67 25.89 6.35 40.87 ≥3.43
CV (onset) 63.25 91.42 59.73 80.13 ≥45.44
Footnotes:
♦ Reference data source: GormanRefRange_2 revision: 1.0

Nerve Conduction Findings:

• The left median (Wrist►APB) CMAP amplitude is outside normal limits.

Page: 3 of 6
Tracking No.: 1283714
 NCS/EMG Report
John Smith, M.D. Patient Name: John Doe
Patient ID: 12345
Birth Date: 2/01/1976

Needle Electromyography Results: □ Not medically necessary, see below. □ Contraindicated, see below.

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Clinical Notes: □ See patient chart.

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__________________________________________________ __________________________
Physician Signature Date

Page: 4 of 6
Tracking No.: 1283714
 NCS/EMG Report
John Smith,
Trinity HandM.D.
Specialists Patient Name: John
XXXXXXXXXX
Doe
Patient ID: 5350
12345
3/15/1963
Birth Date: 2/01/1976

Nerve Conduction Waveforms:

Left Right

Median
Motor

Median
F-waves

Median
Sensory

Page: 5 of 67
Tracking No.: 1283714
 NCS/EMG Report
John Smith,
Trinity HandM.D.
Specialists Patient Name: John
XXXXXXXXXX
Doe
Patient ID: 5350
12345
3/15/1963
Birth Date: 2/01/1976

Nerve Conduction Waveforms:

Left Right

Ulnar
Motor

Ulnar
F-waves

Ulnar
Sensory

Page: 6 of 67
Tracking No.: 1283714