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: Cervical Epidural Steroid Injection

Description: Cervical epidural steroid injection without fluoroscopy. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.
(Medical Transcription Sample Report)

PROCEDURE: Cervical epidural steroid injection without fluoroscopy.

ANESTHESIA: Local sedation.

VITAL SIGNS: See nurse's notes.

COMPLICATIONS: None.

DETAILS OF PROCEDURE: INT was placed. The patient was in the sitting position. The posterior neck and upper back were prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between C7-T1 ________. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted. After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected. Neosporin and band-aid were applied over the site. The patient discharged to recovery room in stable condition.

Keywords: pain management, epidural space, loss of resistance, cervical epidural steroid injection, fluoroscopy, lidocaine, steroid, epidural, cervical, 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