Sample Name: Epidural Steroid Injection - 3
Description: Epidural steroid injection. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated.
(Medical Transcription Sample Report)
PROCEDURE NOTE: The patient was placed in a prone position. The neck was sterilely prepped using a cervical prep set. A lidocaine skin wheal was raised over the C5-6 interspace. A 20-gauge Tuohy needle was used. Loss of resistance was obtained using hanging drop technique. This was followed by 2 mL of radiograph contrast material which showed spread of the dye into the epidural space. A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were then infiltrated. Following the infiltration, the patient noted warming of his arms and dramatic improvement of his symptoms. He was observed for 30 minutes and discharged home in good condition. There were no apparent complications to the procedure.
Keywords: pain management, methylprednisolone acetate, steroid, bupivacaine, methylprednisolone, acetate, epidural, injection,