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 - 2

Description: Cervical epidural steroid injection, C5-6. The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level.
(Medical Transcription Sample Report)

PROCEDURE PERFORMED: Cervical epidural steroid injection, C5-6.

ASSISTANT: None.

ANESTHESIA: Local.

DETAILS OF PROCEDURE: The patient was brought to the operating theater and placed prone onto the radiolucent table. Subsequent monitored anesthesia care was administered. The C-arm was brought into the operative field and an AP view of the lumbar spine was obtained with particular attention to the C5-6 level. The neck area was then prepped with Betadine solution and draped sterile. A metallic marker was placed over the C5-6 lamina and a skin wheal was raised in the skin. A #20-gauge Tuohy needle was then advanced into the spinal canal using 1% Xylocaine anesthetic and the depth of penetration to the C5 lamina was determined. The needle was redirected into the interlaminar space and advanced to the previously determined level. A 10 cc syringe was then placed onto the end of the needle and, using an air-negative technique, the needle was advanced into the epidural space. When a free flow of air was produced, a solution of 80 mg Depo-Medrol, 2 cc of 1% Xylocaine injectable, and 5 cc of normal saline was then injected into the epidural space. The Tuohy needle was removed. Betadine was cleansed from the skin. A bandage was placed over the needle entrance point. The patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia. The patient was taken to the recovery room in stable condition.

Keywords: pain management, c-arm, cervical epidural steroid injection, ap view, lumbar spine, tuohy needle, epidural steroid, steroid 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