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Cervical Epidural Steroid Injection Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

PREPROCEDURE DIAGNOSIS:  Cervical radiculopathy.

POSTPROCEDURE DIAGNOSIS:  Cervical radiculopathy.

PROCEDURE PERFORMED:  Cervical epidural steroid injection with fluoroscopy.

ANESTHESIA:  Local with IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was brought into the operating room and laid in a prone position. The patient's neck was prepped and draped in the usual sterile fashion. The skin and underlying subcutaneous tissues overlying the C7-T1 cervical epidural space was identified and infiltrated with 5 mL of 1% plain lidocaine. At this juncture, a 17 gauge Tuohy needle was advanced through the anesthetized area into the cervical epidural space. Loss of resistance was confirmed with air and saline. A nonstyletted epidural catheter was passed up to the level of C5-C6 on the left side and 2 mL of Isovue dye confirmed spread of the medication along the C6 nerve root. Four mL of preservative-free normal saline with 120 mg of Kenalog was administered and the needle was removed. A bandage was placed over the injection site and the patient was returned to the supine position and to the recovery room in stable condition. There were no complications as a result of the procedure.

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DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

PREPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Lumbar radiculopathy.

POSTPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Lumbar radiculopathy.

PROCEDURE PERFORMED:  Cervical epidural steroid injection under fluoroscopic guidance.

ANESTHESIA:  Local anesthetic with IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was brought to the procedure suite and positioned on the bed in the prone position. The area overlying the cervical and upper thoracic spine was prepped and draped in the usual sterile fashion. Using a 25 gauge needle, 1% lidocaine, roughly 5 mL was used to anesthetize the skin overlying C7-T1 epidural space. A 20 gauge epidural needle was used to find the epidural space using loss of resistance to both air and saline. Approximately 3 mL of Isovue-M 300 dye was injected showing bilateral spread to the level of bilateral C5 nerve root through T1. Negative for intravascular or intrathecal spread. Approximately 4 mL of 120 mg of Kenalog plus 2 mL of preservative-free normal saline was injected without complication. The needle was then removed. Sterile dressing was then placed. The patient was returned to supine position and brought to recovery room in stable condition.

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DATE OF PROCEDURE:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD 

PREPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Herniated disk at C5-C6.

POSTPROCEDURE DIAGNOSES:
1.  Cervical radiculopathy.
2.  Herniated disk at C5-C6.

PROCEDURE PERFORMED:  Cervical epidural steroid injection under fluoroscopy, injection #2.

ANESTHESIA:  Local with IV sedation.

DESCRIPTION OF PROCEDURE:  The patient was brought to the fluoroscopy imaging suite and positioned prone on the imaging table. The patient was sedated with Versed and fentanyl intravascularly. The neck area was prepped with Betadine and draped in a sterile fashion. With the C-arm in AP projection, cervical vertebral bodies were identified and C6-C7 interspace was selected for epidural injection. Lidocaine 1% was injected locally with a 25 gauge needle. With 18 gauge Tuohy, loss of resistance to air technique, epidural space was identified under fluoroscopic guidance. After reaching the epidural space, after negative aspiration for blood and CSF, 2 mL of Isovue-M 300 was injected and good epidural spread of the dye was confirmed with AP and lateral view on the C-arm. Again, after negative aspiration for blood and CSF, 120 mg of Kenalog with 2 mL of 0.25% Marcaine and 2 mL of preservative-free 0.9 normal saline was injected into the epidural space and the needle was removed. Sterile dressing was applied. The patient tolerated the procedure well without any complications. The patient was monitored in the clinic for an hour and discharged home in stable condition.