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Pain Management Procedure Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURES PERFORMED:
1.  Lumbar epidural steroid injection.
2.  Fluoroscopy.
3.  Epidurography.

DESCRIPTION OF PROCEDURE:  The patient was placed prone on the x-ray table with pillows under her pelvis. The lumbar area was cleansed with alcohol and Betadine. Sterile drape was applied to her lumbar area. Fluoroscopy was used to identify the L5-S1 interspace. Lidocaine 1% with epinephrine was used to anesthetize the skin and the interspinous ligament at L5-S1 interspace. Under fluoroscopic guidance, a 17-gauge Tuohy needle was advanced into the epidural space to the right of the midline. The epidural space was encountered using loss of resistance technique. This was achieved without any problems, complications or CSF drainage. Two mL of Isovue 300 was injected through the needle. This revealed good flow of contrast in the epidural space to the right of the midline. This was confirmed with lateral fluoroscopy. I then proceeded to inject a 4 mL solution containing 80 mg of Depo-Medrol and 1 mL of Isovue 300. The needle was cleared and removed. Permanent films were taken.

The patient was taken to the recovery room where she was observed for about 30 minutes before being discharged.

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DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURES PERFORMED:
1.  Caudal steroid injection.
2.  Fluoroscopy.
3.  Epidurography.
4.  IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was placed prone on the x-ray table with pillows under her pelvis. Her sacral area was cleansed with alcohol and Betadine, and sterile drape was applied to her sacral area. Lidocaine 1.5% with epinephrine was used to anesthetize the skin and subcutaneous tissue at the sacral hiatus. Under fluoroscopic guidance, a 17-gauge Tuohy needle was advanced into her caudal space with the point of the needle to the left of the midline. The caudal space was encountered without any problems, complications, CSF or heme drainage. Two mL of Isovue M 300 was injected through the needle. This revealed good flow of contrast as far as the L5-S1 interspace. I then threaded a catheter for a distance of 15 cm and injected 50 mL of Isovue M. This revealed flow of contrast into a left nerve root. The catheter was therefore withdrawn and repositioned and 50 mL of Isovue M was injected. This revealed good flow of contrast and to the left of midline. I then proceeded to inject a 5 mL solution containing 80 mg of Depo-Medrol and 1.5 mL of Isovue M 300. The catheter was cleared and removed and came out intact. The needle was cleared and removed. Permanent films were taken.

The patient was returned to the recovery room where she was observed and monitored for approximately 1 hour before being discharged.

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