Medical Specialty:
Pain Management
Sample Name: Lumbar Epidural Steroid Injection
Description: Lumbar epidural steroid injection without fluoroscopy. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.
(Medical Transcription Sample Report)
PROCEDURE: Lumbar epidural steroid injection without fluoroscopy.
ANESTHESIA: Local sedation.
VITAL SIGNS: See nurse's records.
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 __________. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected. Neosporin and a band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to the recovery room in stable condition.
Keywords: pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, injection,
