Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Pain Management
Sample Name: Epidural Steroid Injection - 1

Description: L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Herniated lumbar disk with intractable back pain.

POSTOPERATIVE DIAGNOSIS: Herniated lumbar disk with intractable back pain.

OPERATION PERFORMED: L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.

ANESTHESIA: Local/IV sedation.

COMPLICATIONS: None.

SUMMARY: The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin over sacral hiatus. A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood. A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level. After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected. The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected. Needle and catheter were removed intact. The patient was discharged in stable condition.

Keywords: pain management, epidural catheter, epidural steroid injection, lumbar disk, steroid injection, fluoroscopy, herniated, lumbar, needle, steroid, epidural, catheter, injection,
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