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: Superior Gluteal Nerve Block

Description: Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.
(Medical Transcription Sample Report)

PRE-OPERATIVE DIAGNOSIS: Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.

POST-OPERATIVE DIAGNOSIS: Same

PROCEDURE: Superior Gluteal Nerve Block, Left.

After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the arms flaccid by the side. Alcohol was used to prep the skin 3 times, and a 27-gauge needle was advanced deep to the attachment of the Gluteus Medius Muscle near its attachment on the PSIS. The needle entered the plane between the Gluteus Medius and Gluteus Maximus Muscle, in close proximity to the Superior Gluteal Nerve. Aspiration was negative, and the mixture was easily injected. Aseptic technique was observed at all times, and there were no complications noted.

INJECTATE INCLUDED:
Methyl Prednisolone (DepoMedrol): 20 mg
Ketorolac (Toradol): 6 mg
Sarapin: 1 cc
Bupivacaine (Marcaine): Q.S. 2 cc.

The procedures, above were performed for diagnostic, as well as therapeutic purposes. This treatment plan is medically necessary to decrease pain and suffering, increase activities of daily living and improve sleep.

ZUNG SELF-RATING DEPRESSION SCALE© (SDS) RESULTS: The patient scored as 'mildly depressed.

NOTE: The pain was gone post procedure, consistent with the diagnosis, as well as with adequacy of medication placement.

Keywords: pain management, neurapraxia, impingement syndrome, neuralgia, superior gluteal, superior gluteal nerve block, gluteus medius muscle, gluteus maximus muscle, gluteus medius, nerve block, gluteal nerve, block, gluteus, nerve, gluteal,
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