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: Lumbar Epidural Steroid Injection

Description: Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.
(Medical Transcription Sample Report)

PROCEDURE: Lumbar epidural steroid injection without fluoroscopy.

ANESTHESIA: Local sedation.

VITAL SIGNS: See nurse's records.

COMPLICATIONS: None.

DETAILS OF PROCEDURE: INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected. Neosporin and a band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to the recovery room in stable condition.

Keywords: pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, 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