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 - 2

Description: Caudal epidural steroid injection without fluoroscopy.
(Medical Transcription Sample Report)

PROCEDURE: Caudal epidural steroid injection without fluoroscopy.

ANESTHESIA: Local sedation.

VITAL SIGNS: See nurse's records.

PROCEDURE DETAILS: INT was placed. The patient was in the prone position. The back was prepped with Betadine. Lidocaine 1.5% was used to make a skin wheal over the sacral hiatus. A 18-gauge Tuohy needle was then placed into the epidural space. There were no complications from this (no blood or CSF). After negative aspiration was performed, a mixture of 10 cc preservative free normal saline plus 160 mg preservative free Depo-Medrol was injected. Neosporin and band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to outpatient recovery in stable condition.

Keywords: pain management, epidural space, epidural steroid injection, caudal epidural, caudal, fluoroscopy, steroid, 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