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.
Methyl Prednisolone (DepoMedrol): 20 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,