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: Thoracic epidural steroid injection

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

PROCEDURE: Thoracic 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 and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 7 cc preservative free normal saline and 160 mg preservative free Depo-Medrol was injected. Neosporin and band-aid were applied over the puncture site. The patient was discharged to recovery room in stable condition.

Keywords: pain management, loss of resistance, cerebrospinal fluid, thoracic epidural steroid injection, fluoroscopy, thoracic, 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