Sample Name: Epidural Steroid Injection
Description: Epidural steroid injection, epidurogram, fluroscopy - Low back pain, herniated disc, lumbosacral Facet, arthropathy.
(Medical Transcription Sample Report)
PRE-OP DIAGNOSES: Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.
POST-OP DIAGNOSES: Low back pain - 724.2, Herniated disc - 722.10, Lumbosacral Facet, arthropathy - 724.4.
INTERVAL HISTORY: Plans, risks and options were reviewed with the patient in detail. The patient understands and agrees to proceed.
ANESTHESIA: General Anesthesia
PROCEDURE PERFORMED: Epidural steroid injection, epidurogram, fluroscopy.
RADIOLOGY: Injection of 3 cc of OMNIPAQUE showed spread of the dye into the epidural space on AP and Lateral imaging. The Needle was injected with Depo-Medrol 80 mg with Bupivacaine 1/16th , 8 cc total vol. Patient tolerated procedure well and was transferred to recovery room. Patient was discharged home with escort. Discharge instructions were given.
POST-OP PLAN: I will see the patient back in my office in two weeks. Continue p.r.n. medications as needed.
Keywords: pain management, back pain, herniated disc, lumbosacral facet, epidural needle, lumbosacral facet arthropathy, epidural steroid injection, facet arthropathy, epidural space, injection, epidurogram, fluroscopy, herniated, lumbosacral, steroid, arthropathy, epidural,