Sample Name: Hip Injection
Description: Hip injection. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine.
(Medical Transcription Sample Report)
PROCEDURE: Hip injection.
INFORMED CONSENT: The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.
The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.
The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.
PROCEDURE: Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The X-ray technician was supervised and instructed to operate the fluoroscopy machine.
COMPLICATIONS: None. No complications. The patient tolerated the procedure well and was sent to the recovery room in good condition.
DISCUSSION: Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.
The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.
Follow up appointment was made in approximately 1 week.
Keywords: pain management, boney landmarks, fluoroscopy, femoral artery, planned needle approach, hip injection, injection, hip, needle,