Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples

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Sample Type / Medical Specialty: Pain Management
Sample Name: Bilateral Carpal Tunnels Injection

Description: Injection of bilateral carpal tunnels
(Medical Transcription Sample Report)

Informed consent was obtained from the patient. The volar aspect of the left wrist was prepared with Betadine and alcohol and rested at a 45 degree angle on a rolled-up towel. The palmaris longus tendon was identified and marked and so was the distal wrist crease. A 25 gauge needle was used to enter the carpal tunnel, approximately 1/2 inch proximal to the distal wrist crease and ulnar to the palmaris longus tendon. Paresthesias were elicited in the median nerve distribution. The needle was withdrawn and reinserted slightly laterally without elicitation of further paresthesias. The needle was advanced through the carpal tunnel without any difficulty. 1 mL of triamcinolone was injected after aspiration. The medications flowed freely without any difficulty. The same procedure was then done to the right wrist also using 1 mL of triamcinolone with no elucidation of paresthesias. After the procedure, the patient clenched and unclenched the fingers of both hands for a period of two minutes to distribute the medication. There were no complications throughout the procedure and good relief of symptoms following the procedure.

POST PROCEDURE INSTRUCTIONS: The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the * extremity for the next 24 hours.

Keywords: pain management, injection. carpal tunnel, bilateral carpal tunnels, inflammation, longus tendon, palmaris longus, palmaris longus tendon, redness, rolled-up towel, swelling, volar aspect, wrist, wrist crease, bilateral carpal, carpal tunnels, paresthesias, carpal, tunnels, towel,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples