Sample Type / Medical Specialty: Pain Management
Sample Name: Epidural Steroid Injection - 2
Caudal epidural steroid injection without fluoroscopy.
(Medical Transcription Sample Report)
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.
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