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: Kenalog Injection

Description: Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance. The patient is a 78-year-old female with back pain referring into the left side.
(Medical Transcription Sample Report)

PROCEDURE: Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.

INDICATIONS: The patient is a 78-year-old female with back pain referring into the left side. She has had a couple of epidurals in the past, both of which led to only short-term improvement with intralaminar and caudal placements. Therefore, transforaminal approach was selected for today's procedure.

Risks and benefits were discussed with the patient. She agreed to accept the risks and signed informed consent to proceed.

PROCEDURE DETAILS: The patient was placed prone on the table. The skin was thoroughly cleansed with betadine swabs x3 and wiped off with a sterile gauze. The subcutaneous intramuscular and interligamentous region was anesthetized with buffered 1% lidocaine.

A 5-inch, 22-gauge spinal needle was directed under intermittent fluoroscopic guidance using an oblique approach at the opening of the L5 nerve root. Once bony contact was made, a lateral was obtained and showed the needle tip to be against the posterior spinal body in the anterior epidural space. Then an AP view was obtained which showed the needle tip to be below the 6 o'clock position of the pedicle.

EPIDUROGRAM: Omnipaque 300, 1 mL, was placed through the foraminal opening of the L5 nerve root on the left. This did show dye spread pattern which was narrowed consistent with foraminal stenosis. The dye did traverse the foraminal opening and was seen spreading around the pedicle into the anterior epidural space. It was also spreading peripherally along the L5 nerve root.

The patient tolerated the procedure well. She did feel that the needle tip was placed at the epicenter of her pain, and this was improved with the placement of the anesthetic.

I will see the patient back in the office in the next few weeks to monitor response of the injection.

Keywords: pain management, transforaminal approach, epidural steroid injection, nerve root, needle tip, kenalog, transforaminal, fluoroscopic, guidance, foraminal, 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