PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

COMPLICATIONS: Nil.

SPECIMENS REMOVED: Nil.

DETAILS OF PROCEDURE: The patient was evaluated in the preoperative holding area. The history and physical were reviewed again. The consent was checked. Details of the procedure, risks, benefits, and complications were discussed with the patient. The patient agreed for the procedure and was taken to the procedure room and laid prone on the procedure table.

The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-5 interlaminar space was identified using fluoroscopy. The skin was anesthetized with 1% lidocaine and 17 gauge 3.5 inch Tuohy needle was gently introduced into interlaminar space using intermittent fluoroscopy and loss of resistance technique.

After identification of the epidural space, the confirmation was obtained by using 1.5 to 2 mL of Isovue dye. After confirmation of the correct placement of the needle in the epidural space, an 8 mL solution containing 0.25% Marcaine and 120 mg Depo-Medrol was slowly injected into the epidural space.

The patient tolerated the procedure well. There were no immediate complications and was taken to the postop area and was monitored as per protocol. The patient was discharged home on the same day with advice to attend the Pain Clinic as arranged earlier.

Lumbar Epidural Steroid Injection Procedure Description Sample #2

PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

DETAILS OF PROCEDURE: The patient was evaluated in the preoperative area. The history and physical details of the procedure including risks, benefits and complications were discussed with the patient. The patient agreed for the procedure.

He was taken to the procedure room. The patient was laid prone on the procedure table, and his skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 space was identified using the fluoroscopic guidance. The skin was anesthetized with 1% lidocaine including the subcutaneous tissue.

The L4-L5 space was identified using the intermittent fluoroscopic and loss of resistance technique. After identification of the L4-L5 epidural space, which was confirmed by using 1.5% Isovue, an 8 mL solution containing 0.125% lidocaine and 120 mg of Depo-Medrol was gently introduced into the epidural space.

The patient tolerated the procedure well. There were no immediate complications. The patient was taken to the postoperative area and was monitored as per the protocol. The patient was discharged home on the same day with advice to attend the pain clinic as arranged earlier.

Lumbar Epidural Steroid Injection Procedure Description Sample #3

PROCEDURES PERFORMED: Lumbar epidural steroid injection, fluoroscopy, epidurography and IV sedation.

DETAILS OF PROCEDURE: A solution of Ringer’s lactate was commenced in the patient’s right hand. She was given a total of 4 mg of Versed intravenously and monitored with blood pressure and pulse oximetry.

The patient was placed prone on the x-ray table with pillows under her pelvis. Her lumbar area was painted with alcohol and Betadine. Sterile drape was applied to her lumbar area. Fluoroscopy was used to identify the L5-S1 disk space.

Then, 1.5% lidocaine with epinephrine was used to anesthetize the skin and visualized the L5-S1 interspace. Under fluoroscopic guidance, a 17 gauge Tuohy needle was advanced into the epidural space to the left of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage. Two milliliters of Isovue 300 was injected through the needle. This revealed flow of contrast in the epidural space to the left of the midline. This was confirmed under lateral fluoroscopy.

We then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken. The patient was returned to the recovery room where she was observed and monitored for approximately 1 hour before being discharged.

X-RAY REPORT: On the lateral view of the lumbar spine, contrast can be seen extending from L3 as far as the sacrum. On PA view, contrast can be seen extending from the L3 as far as the sacrum with bilateral infiltration of contrast slightly moved to the left than the right.

Lumbar Epidural Steroid Injection Procedure Description Sample #4

PROCEDURES PERFORMED: Lumbar epidural steroid injection, fluoroscopy, epidurography.

DETAILS OF PROCEDURE: The patient was placed prone on the x-ray table with pillows under her pelvis. The lumbar area was cleansed with alcohol and Betadine. Sterile drape was applied to his lumbar area. Fluoroscopy was used to identify the L5-S1 interspace. Lidocaine 1% with epinephrine was used to anesthetize the skin and attention was taken at the L5-S1 interspace.

Under fluoroscopic guidance, a 17 gauge Tuohy needle was advanced into her epidural space to the right of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage.

About 2 mL of Isovue M 300 was injected through the needle. This revealed good flow of contrast in the epidural space to the right of the midline. This was confirmed with lateral fluoroscopy. We then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken.

The patient was returned to the recovery room and she was observed and monitored for approximately 30 minutes before being discharged.

X-RAY REPORT: On the lateral view of the lumbar spine, contrast can be seen extending from L3-4 disk space as far as the sacrum. On PA view, it was somewhat difficult to make out the contrast, but we could see bilateral distribution of contrast extending from proximity of L4-5 as far as the sacrum.

The post Lumbar Epidural Steroid Injection Procedure Description appeared first on Medical Transcription Sample Reports.

PREOPERATIVE DIAGNOSIS: Complex regional pain syndrome, left upper extremity.

POSTOPERATIVE DIAGNOSIS: Complex regional pain syndrome, left upper extremity.

PROCEDURE PERFORMED: Left stellate ganglion block.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

COMPLICATIONS: Nil.

DETAILS OF PROCEDURE: The patient was reevaluated at (XX). Details of the procedure including risks, benefits, and complications were discussed with the patient. The patient agreed to the procedure, was taken to the procedure room, and laid supine on the table. The transverse process of C6 was identified using palpation. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After identification of the transverse border of C6 vertebra, the confirmation was obtained by x-ray. A 25-gauge needle was gently introduced and touched to the bone. Intermittent aspiration to avoid other blood barrier coming into the needle. Then a 30 mL solution containing Marcaine 0.5% and Depo-Medrol 40 mg was gently injected while maintaining the needle in position and with intermittent aspiration. The patient tolerated the procedure well, and there were no complications. The patient was monitored in the postoperative area as per protocol and was discharged home the same day with advice to attend the clinic as scheduled earlier.

Pain Medicine Procedure Sample Report #2

PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was evaluated in the preoperative area. The history and physical details of the procedure, including risks, benefits and complications were discussed with the patient. The patient agreed for the procedure. He was taken to the procedure room. The patient was laid prone on the procedure table and his skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 space was identified using the fluoroscopic guidance. The skin was anesthetized with 1% lidocaine, including the subcutaneous tissue.

The L4-L5 space was identified using intermittent fluoroscopic and loss-of-resistance technique after identification of the L4-L5 epidural space, which was confirmed by using 1.5% Isovue. After confirmation of this epidural space, an 8 mL solution containing 0.125% lidocaine and 120 mg of Depo-Medrol was gently introduced into the epidural space. The patient tolerated the procedure well. There were no immediate complications. The patient was taken to the postoperative area and was monitored as per the protocol. The patient was discharged home on the same day with advice to attend the pain clinic as arranged earlier.

Pain Medicine Procedure Sample Report #3

PREOPERATIVE DIAGNOSIS: Facet arthropathy.

POSTOPERATIVE DIAGNOSIS: Facet arthropathy.

PROCEDURE PERFORMED: Right L3, L4, L5, and S1 medial branch block.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was evaluated again in the preop area. History and physical, details of the procedure including risks, benefits, and complications were discussed with the patient again. The patient agreed, was taken to the procedure room and was laid prone on the procedure table. The right L3-4, L4-5, L5-S1 and L2-L3 facet joints were identified. The skin was prepped with ChloraPrep x2 and draped in a sterile fashion.

In an oblique view, the skin was anesthetized with 1% lidocaine at each levels and a 22-gauge spinal needle, 3.5 inches long, was gently introduced towards the junction of the transverse process in the facet joint. After confirmation of this needle placement with fluoroscopic guidance, the same procedure was repeated at next 3 medial branches and a solution containing 30 mg of Depo-Medrol and about 1 mL of 0.25% bupivacaine was injected at each level.

After that, needle was withdrawn and flushed with 0.25% bupivacaine, Band-Aid was applied. The patient was taken to the postoperative area and was monitored as per the protocol. There were no immediate complications, and the patient was discharged home on the same day with the advice to attend the clinic in due course of time as arranged earlier.

Pain Medicine Procedure Sample Report #4

PREOPERATIVE DIAGNOSIS: Bilateral sacroiliac pain.

POSTOPERATIVE DIAGNOSIS: Bilateral sacroiliac pain.

PROCEDURE PERFORMED: Bilateral SI joint injection.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was reevaluated. The risks, benefits, and details of the procedure including complications were discussed with the patient. The patient agreed to the procedure and was taken to the procedure room and laid prone on the procedure table. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After identification of the SI joint, a 22-gauge needle was gently introduced into the right SI joint followed by left SI joint after anesthetizing the skin and the subcutaneous tissue. After confirmation of the needle in the SI joint with fluoroscopic guidance, a 3 mL solution containing 120 mg of Depo-Medrol and 0.25% of bupivacaine was equally divided and slowly injected into the SI joint.

The patient tolerated the procedure well. The needles were then withdrawn and flushed with 0.25% Marcaine and a Band-Aid was applied.

The patient tolerated the procedure well and was taken to the postoperative area and was monitored as per protocol. There were no immediate complications, and the patient was discharged home after being monitored with the advice to attend the clinic in due course of time as arranged earlier.

Pain Medicine Procedure Sample Report #5

PREOPERATIVE DIAGNOSIS: Bilateral sacroiliac joint pain.

POSTOPERATIVE DIAGNOSIS: Bilateral sacroiliac joint pain.

PROCEDURE PERFORMED: Bilateral sacroiliac joint injections.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

COMPLICATIONS: Nil.

SPECIMENS REMOVED: Nil.

DETAILS OF PROCEDURE: The patient was reevaluated. Details of the procedure including risks, benefits, and possible complications were discussed with the patient. The patient agreed for the procedure and was taken to the procedure room. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After prepping the SI joint, right SI joint was identified using the fluoroscopic guidance and a 22-gauge 5-inch needle was gently introduced into the lower portion of the right SI joint. After confirmation of the needle placement in the right SI joint, the same procedure was repeated on the left side.

After confirmation of both needle placement, a 3 mL solution containing 120 mL of Depo-Medrol and 0.25% bupivacaine was equally divided and injected slowly on each side. The needle was then flushed with 0.25% bupivacaine and a Band-Aid was applied after removing the spinal needles.

The patient tolerated the procedure well. There were no immediate complications, and the patient was monitored as per the protocol in the postoperative area and discharged home with stable condition on the same day with advice to attend the clinic as arranged earlier.

Pain Medicine Procedure Sample Report #6

PREOPERATIVE DIAGNOSIS: Low back pain and lumbar degenerative disk disease.

POSTOPERATIVE DIAGNOSIS: Low back pain and lumbar degenerative disk disease.

PROCEDURE PERFORMED: LESI.

SURGEON: John Doe MD

ASSISTANT: Jane Doe, MD

DETAILS OF PROCEDURE: The patient was evaluated in the preop area. She is a referral from the Orthopedic Clinic. The H&P and consent was obtained and the medications were reviewed. The risks, benefits, and details of the procedure including possible complications were discussed with the patient. The patient understood and agreed to the procedure.

The patient was taken to the procedure room and put prone on the procedure table. The skin was prepped with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 interlaminar space was identified using the fluoroscope, and the skin and the deeper tissues were anesthetized using 1% lidocaine. A 17-gauge 3.5-inch Tuohy needle was gently introduced into the interlaminar space using loss of resistance technique and intermittent fluoroscopy.

After identifying the epidural space, the confirmation was obtained by using 2 mL of Isovue dye. After confirmation of the correct placement of the Tuohy needle, an 8 mL solution containing 0.125% bupivacaine and 120 mg of Depo-Medrol was slowly injected into the epidural space.

The patient tolerated the procedure well. There were no immediate complications, and the patient was taken to the postoperative area and was monitored as per protocol. The patient was discharged home on the same day with advice to follow up in the orthopedic clinic and to call the pain clinic as per schedule for next LESI in 4 to 6 weeks.

The post Pain Medicine Procedure Medical Sample Reports appeared first on Medical Transcription Sample Reports.

DATE OF PROCEDURE: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

PREOPERATIVE DIAGNOSIS:
Lumbar radiculopathy secondary to herniated disk at L5-S1.

POSTOPERATIVE DIAGNOSIS:
Lumbar radiculopathy secondary to herniated disk at L5-S1.

PROCEDURES PERFORMED:
1. Transforaminal epidural steroid injection, right L5.
2. Trigger point injection of the right lumbosacral area.

INDICATIONS FOR PROCEDURE: This (XX)-year-old Hispanic female presents with a six-month history of low back pain radiating to the right lower extremity and also has numbness of the toes. She received an epidural steroid injection recently, and she is about 50% improved and she is able to ambulate better. Her pain in the extremity has evidently decreased, and she is here for the second epidural steroid injection.

DESCRIPTION OF PROCEDURE: The patient was brought to the fluoroscopy imaging suite and was placed prone on the imaging table. The lumbosacral area was prepped with Betadine and was draped in the usual fashion. She was sedated using Versed and fentanyl and was monitored using noninvasive blood pressure and pulse oximetry throughout the procedure.

Once the patient was adequately sedated, the back was prepped with Betadine and was draped in sterile fashion. Using C-arm fluoroscopy, the lumbar vertebral bodies were identified, and the upper endplate of L5 vertebra was aligned with 20 degrees of lateral tilt. The right L5 pedicle was in view. At this time, the skin was anesthetized using 1% lidocaine, and a 22-gauge spinal needle was then advanced toward the 6 o’clock position on the right L5 pedicle under fluoroscopic guidance.

Once the needle tip was in position, the position was checked in lateral view, and the needle tip was found to be in the upper third of the foramen. After negative aspiration for any blood or CSF, 1 mL of Isovue-M 200 was injected, which showed the dye spreading along the nerve root and also in the epidural space. After negative aspiration for any blood or CSF, 120 mg of Depo-Medrol mixed with 2 mL of 0.5% Marcaine was injected. The patient tolerated the procedure well. She was monitored after the procedure in clinic for 1 hour and was discharged home in stable condition.

The patient was asked to follow up in the pain clinic in two to three weeks, if the patient has any significant improvement in her symptoms. If the patient did not receive any meaningful pain relief, we asked the patient to follow up directly with Dr. Jane Doe prior to the third epidural injection.

The post Transforaminal Epidural Steroid Injection Sample Report appeared first on Medical Transcription Sample Reports.

REFERRING PHYSICIAN: John Doe, MD

PREOPERATIVE DIAGNOSES:
1.  Chronic low back pain
2.  Lumbar radiculopathy secondary to failed back syndrome.
3.  Bilateral facet arthropathy and spinal stenosis.

POSTOPERATIVE DIAGNOSES:
1.  Chronic low back pain
2.  Lumbar radiculopathy secondary to failed back syndrome.
3.  Bilateral facet arthropathy and spinal stenosis.

OPERATION PERFORMED:
1.  Bilateral facet joint injections at L3-L4, L4-L5, And L5-S1.
2.  Epidural injection under fluoroscopy, L5-S1.

ANESTHESIA: Local and IV sedation.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old Asian female with a history of chronic low back pain for the past five years. She had a L4-L5 laminectomy and diskectomy four years ago secondary to a herniated disk; however, the patient continued to have low back pain and she has seen multiple physicians since. She was maintained on Vicodin on an as needed basis.

However, about three weeks ago, the patient had significant low back pain and she was admitted to the hospital, and during her admission, an MRI suggested multiple facet arthropathies and spinal stenosis. Dr. Jane Doe performed bilateral facet joint injections at multiple levels, which gave the patient some improvement and she was discharged and she was maintained on Vicodin and muscle relaxants and she is here for a second epidural steroidal injection.

She says her pain at this time is 10/10 because she has not taken any anti-inflammatories or her pain medications; therefore, an IV was started and she was already using Versed and fentanyl.

PROCEDURE #1:  The patient was brought to the fluoroscopy imaging suite. She was placed supine on the imaging table. The lumbosacral area was then prepped with Betadine and was draped sterilely. Using C-arm fluoroscopy in the AP view, lumbar vertebral bodies were identified and the interspace region, L5-S1, was selected for the epidural injection. After anesthetizing the skin with 1% lidocaine, 17-gauge Tuohy needle was introduced in the epidural space using fluoroscopic guidance and also loss-of-resistance technique. Once the needle tip was in the epidural space, 2 mL of Isovue-M 200 was injected which showed the dye spreading adequately in the epidural space. This was checked in lateral view also. After negative aspiration for any blood or CSF, 120 mg of Depo-Medrol mixed with 2 mL of 0.5% Marcaine was injected.

PROCEDURE #2:  Multiple facet injections. We started at the right L3-L4 after anesthetizing skin with 1% lidocaine, and 22-gauge Tuohy spinal needle was introduced into the facet joint under fluoroscopic guidance. Once the needle tip was in the joint, 0.5 mL of Isovue-M 200 was injected which showed the dye spreading adequately in the facet joint. This was followed by the injection of 40 mg of Depo-Medrol mixed with a 1 mL of 0.5% Marcaine. Similar procedures were carried out at left L3-L4, right L4-L5, left L4-L5, right paraspinal and left L5-S1. The patient tolerated the procedure well. She was monitored postoperatively for 1 hour and was discharged home in stable condition.

The post Facet Joint Injections Sample Report appeared first on Medical Transcription Sample Reports.

PREOPERATIVE DIAGNOSES:
1.  Lumbar facet syndrome.
2.  Lumbar degenerative disk disease.
3.  Lumbar radiculopathy.

POSTOPERATIVE DIAGNOSES:
1.  Lumbar facet syndrome.
2.  Lumbar degenerative disk disease.
3.  Lumbar radiculopathy.

PROCEDURE PERFORMED:  Lumbar epidural steroid injection of the right L3-4, L4-5, and L5-S1 medial branch nerves with fluoroscopic-guided needle placement.

SURGEON:  John Doe, MD

DESCRIPTION OF PROCEDURE:  After signing informed consent, the patient was brought to the operating room and placed in prone position on the operating room table. The lower back was prepped and draped in sterile fashion. The right sacral ala was identified with an AP fluoroscopic view. A 3-1/2-inch Quincke spinal needle was inserted until the tip made bony contact at the superior aspect of the sacral ala on the right. Aspiration was negative for blood or CSF. A mixture of 10 mg of Depo-Medrol was injected at this site with 1 mL of 0.5% bupivacaine and 1 mL of 2% lidocaine. This was a 1:1 mixture. With an oblique angulation of fluoroscopy, the L4-5 and L3-4 eye of the Scottie dogs were identified corresponding with the medial branch nerve location of L3-4 and L4-5. Following this, 3-1/2-inch Quincke spinal needle was inserted, gun barrel fashion, until it made bony contact at the eye of the Scottie dog. This was for the L4-5, and again a separate needle was placed at the L3-4 eye of the Scottie dog using the same technique and fluoroscopy. Aspiration was negative for blood or CSF. Same mixture of medication was injected at each site. Needles were removed. Sterile bandage was placed. The patient was brought to the recovery area and discharged home that day.

Sample #2

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Sciatica.

POSTOPERATIVE DIAGNOSIS:  Sciatica.

SURGEON:  John Doe, MD

ANESTHESIA:  Local anesthetic lidocaine 1% plain with 1 mL sodium bicarbonate, total volume 4 mL.

PROCEDURE PERFORMED:  Lumbar epidural steroid injection.

ESTIMATED BLOOD LOSS:  None.

INJECTABLES:  Preservative-free normal saline solution and Depo-Medrol 40 mg/mL single dose, total of 80 mg plus 0.0625% bupivacaine preservative-free.

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  Risks/benefits of the procedure were discussed with the patient and the patient understands. The risks include the possibility of infection, bleeding, nerve damage, failure of pain relief, transient increase in pain, inadvertent intravascular injection, spinal blockade, dural puncture, meningitis, or arachnoiditis. The n.p.o. status was confirmed and consent form was signed.

The patient was placed in a prone position on the procedure table, and a sterile lumbar prep and drape performed using sterile technique. A skin wheal was placed, and a 20-gauge Tuohy needle was atraumatically passed under direct fluoroscopic guidance in the L5-S1 interspace. Placement was confirmed with 3 mL Isovue-300 contrast and negative aspiration of CSF. A total volume of 6 mL of injectate was administered, and the needle removed. No paresthesias during the procedure were noted. The patient tolerated the procedure well and was transported to the postprocedure recovery area in stable condition. A postoperative assessment was performed. The patient showed no signs of any sensory or motor deficits that were not present before the procedure.

Postprocedure instructions were given to the patient. The patient will be seen in the office in two weeks.

The post Lumbar Epidural Steroid Injection Sample Report appeared first on Medical Transcription Sample Reports.

REFERRING PHYSICIAN:  John Doe, MD

PREOPERATIVE DIAGNOSES:
1.  Chronic low back pain with lumbar radiculopathy secondary to severe degenerative disk disease.
2.  Spondylosis of lumbar spine.
3.  Scoliosis.
4.  Myofascial pain to the left lower back.

POSTOPERATIVE DIAGNOSES:
1.  Chronic low back pain with lumbar radiculopathy secondary to severe degenerative disk disease.
2.  Spondylosis of lumbar spine.
3.  Scoliosis.
4.  Myofascial pain to the left lower back.

PROCEDURE PERFORMED:  Trigger point injection to the left gluteal muscle.

ANESTHESIA:  Local.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old very pleasant female who has been suffering from rheumatoid arthritis, sarcoidosis, and chronic pain secondary to severe degenerative disk disease with spinal stenosis, scoliosis of the lumbar spine. The patient also has a sacroiliitis on the left side, and she had multiple sacroiliac joint injections along with epidural steroid injection done. The last time, the patient was seen by Dr. Jane Doe and had a second series epidural steroid injection done by her.

The patient stated that this left hip pain has been better with the sacroiliac joint injection and trigger point injection, but her pain from the lower back to the legs bilaterally, bilateral posterior thigh has been worse since after the second injection. The patient feels sharp pain in her both gluteal area and thighs, goes down to the leg with any kind of movement. The patient was started on Lyrica by her rheumatologist, but the patient had severe dizziness and sedation effect with it, so she stopped taking it. The patient also has a history of severe nausea with any kind of narcotic. She cannot tolerate any Percocet, Darvocet, or any weak narcotic either.

We examined the patient, reviewed the patient’s chart. There are three or four trigger points identified in the left gluteal area, which was marked. Straight leg raise test negative bilaterally. Bilateral hip range of motion is normal. Motor and sensory exam was unremarkable. Plan is to do a trigger point injection to the left gluteal area, since the patient has no good response to epidural injection. We think, because of her severe stenosis, she is getting more irritation with epidural steroid injection, so we will try to avoid the last epidural steroid injection. After trigger point injection, we explained to the patient to consider medical management.

DESCRIPTION OF PROCEDURE:  The patient was explained about the procedure in detail, risks, benefits, and possible complications explained, and written consent was obtained. With the patient in the right lateral position, the gluteal area was prepped with alcohol and draped in a sterile fashion. Mild trigger point areas were injected with 0.5% Marcaine with Depo-Medrol.

Using 25 gauge 1-1/2 inch long needle, the trigger points were injected in fan-shaped manner, total 80 mg of Depo-Medrol with 15 mL of 0.5% Marcaine injected in the four different trigger point areas. The patient tolerated the procedure well without any complications. Sterile dressing was applied. The patient was able to walk without any problem.

The plan is to refer her for a TENS unit, will start Ultram. The patient was asked to start with the smaller dose and see whether she can tolerate it, then we will increase the dose according to her tolerance. We will start her on Cymbalta 20 mg at bedtime, and if she tolerates that, we might increase it. We also advised to continue Lidoderm patches. We will see her in four weeks for further medical management.

The post Gluteal Trigger Point Injection Sample Report appeared first on Medical Transcription Sample Reports.

PREOPERATIVE DIAGNOSES:
1.  Right lower lobe lung nodule.
2.  History of metastatic uterine sarcoma to the lung.

POSTOPERATIVE DIAGNOSES:
1.  Right lower lobe lung nodule.
2.  History of metastatic uterine sarcoma to the lung.
3.  Metastatic sarcoma, right lower lobe of the lung.

PROCEDURE PERFORMED:  Right fifth, sixth, seventh, and eighth intercostal space intercostal blocks with Marcaine 0.25% with epinephrine.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, PA

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  20 mL.

COMPLICATIONS:  None apparent.

INDICATIONS FOR PROCEDURE:  The patient is an (XX)-year-old woman with a history of metastatic uterine sarcoma to the left lung. Surveillance CT scan of the chest showed a new noncalcified right lower lobe lung nodule consistent with metastatic sarcoma. The patient was counseled on the risks, benefits, and alternatives to a right thoracoscopy with wedge resection, excisional biopsy. Informed consent was obtained.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in the supine position. Following smooth induction of general anesthesia, a left-sided double-lumen endotracheal tube was placed. Position was confirmed. A Foley catheter was placed. The patent was logrolled into the left lateral decubitus position. All pressure points were appropriately padded, and the right chest was prepared and draped in the usual sterile fashion. A time-out was held confirming correct patient, correct side, and correct procedure. Preoperative antibiotics and subcutaneous heparin have been administered. A warming blanket was on the lower body.

A 5 mm port was placed in the sixth intercostal space posteriorly. This was done after infiltration with Marcaine 0.25% with epinephrine. Under the guidance of a 5 mm 30 degree scope, a 12 mm port was placed in the sixth intercostal space anteriorly and a 11 mm port was in the eighth intercostal space in the posterior axillary line. Likewise, the two port sites were infiltrated with Marcaine 0.25% with epinephrine.

The inferior pulmonary ligament was freed up. The nodule was identified in the lateral basilar segment of the right lower lobe of the lung. It was wedged out with serial firings of a GIA stapler and placed into a specimen bag and brought out through the anterior port site. The specimen was sent to pathology. Frozen section revealed a metastatic sarcoma consistent with uterine primary.

Frozen section of bronchial margins was negative. The staple lines were inspected and were hemostatic. They were treated topically with 2 mL of Tisseel fibrin sealant. Under the guidance of 30 degree scope, intercostal blocks of the right fifth, sixth, seventh, and eighth intercostal spaces were performed with an initial 15 mL of Marcaine 0.25% with epinephrine.

A 10 French chest tube was placed through a separate small stab wound incision and the sixth intercostal space anteriorly and advanced to the posterior apex of the chest. This was secured to the skin with a #2 silk suture.

The right lung was ventilated and appropriately expanded to fill the right chest. The ports were removed, and the port sites were closed in layers with absorbable suture. The skin was approximated with a 4-0 Monocryl subcuticular skin stitch. The incisions were sealed with Dermabond.

The patient awoke from general anesthesia without difficulty. The patient was extubated and transported to the postanesthesia care unit in satisfactory condition. Sponge and needle counts were recorded as correct at the end of the procedure.

The post Intercostal Blocks Procedure Sample Report appeared first on Medical Transcription Sample Reports.

POSTOPERATIVE DIAGNOSIS: Cervicalgia.

PROCEDURE PERFORMED: Cervical epidural steroid injection.

DESCRIPTION OF PROCEDURE: The patient was brought to the Same Day Surgery Center. The history and physical and consent were reviewed. The details of the procedure including risks, benefits and alternatives were discussed with the patient. The patient agreed and was taken to the procedure room and was put prone on the procedure table. The cervical area was cleaned with ChloraPrep x 2 and draped in a sterile fashion. Interlaminar space of C6-C7 was identified with fluoroscopic guidance and a 17 gauge 3.5 inch Tuohy needle was gently introduced into the interlaminar space using loss of resistance technique. The confirmation of the needle placement was obtained by using loss of resistance and fluoroscopic guidance. Placement of the needle in the epidural space was confirmed with Isovue dye of 2 mL. Then, a 6 mL solution containing 120 mg Depo-Medrol and 0.125% bupivacaine was slowly injected into the epidural space. The patient tolerated the procedure well, and there were no immediate complications, and the patient was taken to the postoperative area and was monitored. The patient was discharged over the same day with advice to follow up in the clinic.

PREOPERATIVE DIAGNOSES:
1. Degenerative disk disease.
2. Lumbar radiculopathy.

POSTOPERATIVE DIAGNOSES:
1. Degenerative disk disease.
2. Lumbar radiculopathy.

PROCEDURE PERFORMED: Lumbar epidural steroid injection.

DESCRIPTION OF PROCEDURE: The patient was seen and reevaluated in the preoperative area and the history and physical and consent was reevaluated. The risks, benefits, and alternatives of the procedure were discussed with the patient. The patient agreed to the procedure and was taken to the procedure room. The patient was put prone on the procedure table, and the skin was prepped with ChloraPrep x 2 and draped in a sterile fashion. The interlaminar space, L5-S1, was identified using fluoroscopic guidance. The skin and subcutaneous tissues were anesthetized using 1% lidocaine. The epidural space was identified using a 17 gauge, 3.5 inch Tuohy needle under fluoroscopic guidance and with loss of resistance technique. After identification of the epidural space, it was confirmed with about 2 mL of Isovue dye. After confirmation of the correct needle placement, 10 mL solution containing 5 mL of 0.25% Marcaine, 120 mg of Depo-Medrol, and 3 mL of saline was gently introduced into the epidural space. The patient tolerated the procedure well. There were no immediate complications, and the patient was taken to the postoperative area and was monitored.

PREOPERATIVE DIAGNOSIS: Left sacroiliac joint pain.

POSTOPERATIVE DIAGNOSIS: Left sacroiliac joint pain.

PROCEDURE PERFORMED: Left SI joint injection.

DESCRIPTION OF PROCEDURE: The patient was reevaluated in the Same Day Surgery Center. History, physical, and the consent were reviewed with the patient again. The patient agreed with the procedure and was taken to the procedure room and put prone on the procedure table. The left SI joint was identified under the image intensifier. The skin was prepped with ChloraPrep x 2 and draped in a sterile fashion. After identification of the widest opening at the left SI joint, a 22 gauge 3.5 inch needle was introduced into the left SI joint. A 2 mL solution containing Depo-Medrol 80 mg and 2.5% Marcaine was gently introduced into the SI joint. The patient tolerated the procedure well and was taken to the postoperative area in stable condition. The patient was discharged home on the same day with advice to follow up in the clinic.

PREOPERATIVE DIAGNOSES:
1. Chronic low back pain.
2. Right L5 radiculopathy.

POSTOPERATIVE DIAGNOSES:
1. Chronic low back pain.
2. Right L5 radiculopathy.

PROCEDURE PERFORMED: Right L5 selective nerve root block.

DESCRIPTION OF PROCEDURE: The patient was seen and reevaluated in Same Day Surgery. History and physical and details of the procedure, including risks and benefits, were discussed with the patient again. The patient agreed to the procedure. He was taken to the procedure room and put prone on the procedure table. The skin was prepped with ChloraPrep and draped in sterile fashion. Right L5 foramen was identified with fluoroscopic imaging, and the skin and subcutaneous tissue were anesthetized with 1% lidocaine. A 5 inch 22 gauge needle was gently introduced with intermittent fluoroscopic guidance toward L5 foramen. After confirmation of the needle placement by fluoroscopic imaging, 2 mL Isovue was gently introduced into the area, which showed adequate spread of the dye along the nerve root and epidural space. Then, 5 mL of solution containing 120 mg of Depo-Medrol and 0.125% bupivacaine was gently introduced into the space. The patient tolerated the procedure well. He was taken to the postoperative area and was monitored. There were no immediate complications, and the patient was discharged home.

More Pain Clinic Sample Reports

PREOPERATIVE DIAGNOSIS: Intercostal neuralgia.

POSTOPERATIVE DIAGNOSIS: Intercostal neuralgia.

PROCEDURE PERFORMED: Thoracic epidural steroid injection.

DESCRIPTION OF PROCEDURE: The patient was seen in the preop area. The history, physical and consent was evaluated, reviewed again with the patient, and the patient agreed for the procedure and was taken to the procedure room. The patient was put prone on the procedure table. The skin was prepped with Chloraprep x 2 and draped in a sterile fashion. The skin and the subcutaneous tissues were anesthetized with 1% lidocaine and a 3.5 inch 17 gauge Tuohy needle was gently introduced into the interlaminar space between T8 and T9. The epidural space was identified using intermittent fluoro and loss of resistance technique. After identification, the confirmation was obtained by using Isovue dye. Then, 6 mL solution containing 120 mg of Depo-Medrol and 0.125% Marcaine was gently introduced into the epidural space. The patient tolerated the procedure well, and there were no immediate complications. The patient was transferred to postop area in stable condition and was monitored.

The post Pain Management MT Sample Reports appeared first on Medical Transcription Sample Reports.