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.
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,