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 - 2

Description: Lumbar epidural steroid injection, L5-S1. Low back pain.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Low back pain.

POSTOPERATIVE DIAGNOSIS: Low back pain.

PROCEDURE: Lumbar epidural steroid injection, L5-S1.

ANESTHESIA: Local.

SPECIAL EQUIPMENT: Fluoroscopic unit.

DETAILS OF PROCEDURE: The patient was taken to the Radiology Suite and was placed in the prone position where the entire back region was scrubbed, prepped, and draped in a sterile fashion with Betadine solution. The lumbar area was then draped with sterile towels and sterile drapes. The surgeon was gloved with sterile gloves and mask in order to create a sterile environment for the epidural injection. The fluoroscopy x-ray unit was then brought into the sterile field for a PA x-ray visualization of the spine. A Steinmann pin was then placed across the spine to localize the level of the planned injection. Local infiltration using 0.5% preservative-free Xylocaine via a 25-gauge needle was then placed into the dermis and subcutaneous tissue. A Tuohy needle was then oriented perpendicular to the skin and was then advanced through the dermis and subcutaneous tissues. Continuous injection of 0.5% preservative-free Xylocaine was used during the advancement of the Tuohy needle into the deeper spinous tissues. A solution of 80 mg of Depo-Medrol with 2 cc of 1% Xylocaine injectable and 5 cc of normal saline were then injected into the epidural space.

Keywords: pain management, back pain, lumbar epidural steroid injection, tuohy needle, steroid injection, subcutaneous, epidural, steroid, lumbar, sterile, 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