Pain Medicine / Pain Management Medical Transcription Sample Reports


DATE OF SERVICE:  MM/DD/YYYY

The patient is here for a repeat lumbar sympathetic block.  The last one did give her excellent 100% temporary, but no long-term benefit.  She is here for her second diagnostic injection.

PROCEDURE:  The patient was prone.  The back was prepped and draped in sterile fashion.  After lidocaine local infiltration, under fluoroscopic guidance, a 22-gauge, 6-inch needle was advanced via the paramedian approach to the anterolateral border of the L3 vertebral body.  Isovue-M 300 dye was injected.  There was good cephalocaudal spread.  However, most of it spread from L3 up to L2 and there was very little spread down to L4.  I went ahead and injected 10 mL of 0.25% Marcaine there, and she had excellent temporary benefit from the injection.  I am not sure about the long-term benefit.  There were no complications.

IMPRESSION:  Complex regional pain syndrome versus neuropathy of the foot.

PLAN:  Return here in a few weeks for followup to assess the efficacy of this injection.
 

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DATE OF SERVICE:  MM/DD/YYYY

The patient is here for trigger point injections.  There was trigger point in the left and the right gluteus medius muscle.  After alcohol prep, a 25-guage, 3.5-inch needle was used and 10 mL of 0.25% Marcaine with 40 mg of Kenalog was injected.  There were no complications.

IMPRESSION:  Myofascial pain syndrome.

PLAN:  Return in five weeks for repeat injection.

 
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DATE OF SERVICE:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Intractable back pain which is due to diskogenic pain, L4-L5, L5-S1 as well as facet arthrosis and lumbar spondylosis, status post injury.
 
POSTOPERATIVE DIAGNOSIS:  Intractable back pain which is due to diskogenic pain, L4-L5, L5-S1 as well as facet arthrosis and lumbar spondylosis, status post injury.
 
PROCEDURE PERFORMED:  Bilateral L3-L4 medial branches, L5 distal primary ramus, and S1 accessory branch radiofrequency neurotomy.
 
FINDINGS AND PROCEDURE:  Following informed consent, the patient was taken to the operating room and placed prone on the fluoroscopy stretcher. The entire back was prepped and draped in sterile surgical fashion. Using a sterile technique, a fluoroscope was brought into view and the lumbar spine was examined. The superior medial aspect of the transverse processes of bilateral L4 and L5 at the junction of superior articular processes were denoted on the skin. The bilateral sciatic notch as well as the superior medial aspect of the posterior foramen of S1 was equally delineated. These areas were infiltrated with 1% lidocaine using 1-1/2-inch 27-gauge needle. Next, the radiofrequency pulse generator was primed ready and the safe test was completed. A Smith & Nephew device was utilized.
 
A 22-gauge, 10-mm tip radiofrequency cannula with a bent tip was gently advanced through the anesthetized skin and guided into the respective targets as noted above. Next, the radiofrequency sensory and motor stimulation parameters were then utilized to guide and locate the appropriate targets. The patient demonstrated paraesthesia on multifidus muscle stimulation at bilateral S1-L4 as well as L3. She had no significant stimulation or paraesthesia on the level of L5 dorsal primary ramus.
 
Radiofrequency lesion was then created at 80 degrees for 90 seconds at each of the above levels bilaterally. At the end of lesioning, an injection that contained 40 mg of Depo-Medrol and 0.5% bupivacaine was instilled, 1 mL into each level, to prevent post radiofrequency neuritis. The radiofrequency probe was removed and the cannula was dilated and removed. Pressure dressing was applied over all the injection sites. The patient was taken to the recovery area in stable condition.


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DATE OF PROCEDURE:  MM/DD/YYYY

PRE-PROCEDURE DIAGNOSIS:  Recurrent cervical radiculopathy.

POST-PROCEDURE DIAGNOSIS:  Recurrent cervical radiculopathy.

PROCEDURE PERFORMED:  Cervical epidural steroid injection under fluoroscopic guidance.

SURGEON:  John Doe, MD

ASSISTANT SURGEON:  Jane Doe, MD

ANESTHESIA:  Local.

ESTIMATED BLOOD LOSS:  Minimal.

INDICATIONS:  The patient presents for a cervical epidural steroid injection.  Her last injection was in January.  She had 99% relief of her symptomatology for about 6 months.  Her pain has subsequently recurred; although, she is still 30% improved.  It is in bilateral upper extremities, in the upper arm, forearm and fingers.  We will proceed with a repeat interlaminar injection today.  Risks and benefits were discussed.  She denies contraindications.

DESCRIPTION OF PROCEDURE:  After informed consent, she was brought to the procedure room, placed prone on a fluoroscopically compatible table.  Back of her neck was prepped and draped in sterile fashion.  Lidocaine 1% was used subcutaneously for local anesthesia.  Subsequently, an epidural was performed using a midline C7-T1 approach, an 18-gauge Tuohy needle and a loss-of-resistance technique.  No heme, CSF or paresthesias were encountered.  Placement was confirmed by injection of Isovue-M 300 under live fluoroscopy.  This led to an excellent bilateral epidurogram.  No vascular uptake was appreciated.  There was some provocation of sensation of warmth in her arms, where she normally gets her pain, which resolved when active injection ceased.  Subsequently, 12 mg of Celestone was injected.  The needle was then cleared with 1 mL of normal saline.  X-rays were checked, the needle was removed, and the patient was brought to the recovery room in stable condition to be discharged home the same day.


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DATE OF PROCEDURE:  MM/DD/YYYY

SURGEON:  John Doe, MD

PREOPERATIVE DIAGNOSES:  
1.  Cervical facet syndrome.
2.  Cervical stenosis.
3.  Cervical radiculopathy.

POSTOPERATIVE DIAGNOSES: 
1.  Cervical facet syndrome.
2.  Cervical stenosis.
3.  Cervical radiculopathy.

PROCEDURE PERFORMED:  Left cervical medial branch block, C3-4, C4-5, and C5-6 with fluoroscopic-guided needle placement.

PROCEDURE IN DETAIL:  After signing informed consent, the patient was brought to the fluoroscopy suite, placed in a prone position on the fluoroscopy table, and the left neck was prepped and draped in sterile fashion. A 3-1/2 inch Quincke spinal needle was used and directed toward the left C4-5 transverse process using live fluoroscopic AP and lateral views. Needle was advanced until bony contact was made at the lateral aspect of C4-5 at the facet line. Aspiration was negative for blood or CSF. A mixture of 0.25% bupivacaine with 2% lidocaine 1:1 and 6 mg of Celestone was injected at this site. Total volume was 0.5 mL. The needle was withdrawn slightly and redirected cephalad until it made bony contact at the transverse process of C3-4 at the facet line. Again, aspiration was negative prior to any injection. The same medication and volume was injected at this location. The needle was withdrawn slightly and redirected caudally until it made bony contact at the transverse process of the left C5-6 in the exact same technique, and medication was injected at this location as well. The needle was removed. Sterile bandage was placed. The patient reported relief a few minutes following the procedure. He was observed for several minutes and then discharged home without incident.

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DATE OF OPERATION:  MM/DD/YYYY

SURGEON:  John Doe, MD

PREOPERATIVE DIAGNOSIS:  Lumbar spinal stenosis, lumbar radiculopathy.

POSTOPERATIVE DIAGNOSIS: Lumbar spinal stenosis, lumbar radiculopathy.  

PROCEDURE PERFORMED:  Lumbar epidural steroid injection with fluoroscopic-guided needle placement.

PROCEDURE IN DETAIL:  After signing informed consent, the patient was brought to the fluoroscopy room, placed in the prone position on the fluoroscopy table. The lower back was prepped and draped in sterile fashion. Using AP fluoroscopic view, the L4-L5 interspace was identified slightly left to midline. The skin wheal was raised with a 25-gauge 1-inch needle with 1% lidocaine. Following this, a 20-gauge epidural Tuohy needle was inserted in gun-barrel fashion and directed downward until the interspinous ligament was contacted. Lateral view fluoroscopy was used to advance the needle until the tip was just within the epidural space. It was advanced until loss of resistance occurred with 3 mL preservative-free normal saline. Aspiration was negative for blood or CSF. A mixture of 80 mg of Depo-Medrol plus 8 mL of preservative-free normal saline was injected at this location. The needle was removed. Sterile bandage was placed. The patient was brought to the recovery area and discharged home without incident.

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DATE OF PROCEDURE:  MM/DD/YYYY

PRE-PROCEDURE DIAGNOSIS:  Postlaminectomy syndrome with radiculopathy and an old compression fracture.

POST-PROCEDURE DIAGNOSIS:  Postlaminectomy syndrome with radiculopathy and an old compression fracture.

PROCEDURES PERFORMED:
1.  Left T12 transforaminal epidural steroid injection.
2.  Left L5-S1 interlaminar epidural steroid injection.

SURGEON:  John Doe, MD

ASSISTANT SURGEON:  None.

ANESTHESIA:  Local.

ESTIMATED BLOOD LOSS:  Minimal.

DESCRIPTION OF PROCEDURE:  After informed consent, she was brought to the procedure room and placed prone on a fluoroscopically compatible table.  Her back was prepped and draped in sterile fashion.  Lidocaine 1% was used subcutaneously for local anesthesia.  Subsequently, an epidural was performed using a left interlaminar approach at the lowest lumbar level.  No heme, CSF or paresthesias were encountered.  Placement was confirmed by injection of Isovue-M 300.  This led to an excellent epidurogram.  There was good spread up to the level of her pedicle screws and down to the sacral segment.  There was provocation of her usual hip pain, which is where her symptoms usually start on active injection, which resolved when active injection ceased.  Depo-Medrol 80 mg was injected.  The needle was then cleared with 1 mL of 0.1% bupivacaine.  Subsequently, we did a transforaminal injection under the lowest full rib, on the left side.  Lidocaine 1% was used subcutaneously for local anesthesia.  Subsequently, a 22-gauge curved-tip spinal needle was directed into the anterior aspect of the foramen on the left side.  No heme, CSF or paresthesias were encountered.  Placement was confirmed by injection of Isovue-M 300 under live fluoroscopy.  This outlined the nerve root well, spread centrally and down across T12-L1.  There was provocation of her usual posterior leg pain on active injection, which resolved when active injection ceased.  Depo-Medrol 80 mg was injected.  The needle was then cleared with 0.5 mL of 0.1% bupivacaine.  No vascular uptake was appreciated even under injection under live fluoroscopy.  X-rays were checked.  The needle was removed and the patient was brought to the recovery room in stable condition for discharge home the same day.



DATE OF PROCEDURE:  MM/DD/YYYY

PRE-PROCEDURE DIAGNOSIS:  Spinal stenosis.

POST-PROCEDURE DIAGNOSIS:  Spinal stenosis.

PROCEDURE PERFORMED:  Epidural steroid injection under fluoroscopic guidance.

SURGEON:  John Doe, MD

ASSISTANT SURGEON:  None.

ANESTHESIA:  Local.

ESTIMATED BLOOD LOSS:  Minimal.

INDICATIONS:  The patient presents for an epidural steroid injection.  She has apparently been plagued by right-sided hip pain.  Her pain is in her back and goes into the groin.  It occurs primarily with standing and walking, relieved with lying flat on her back.  She denies any radiation to her legs.  She has been worked up for hip pathology, which was apparently negative.  She had an MRI of her lumbar spine, which did show multilevel facet arthropathy and spinal stenosis, most severe at L3-L4.  Elected to proceed with an interlaminar injection. Risks and benefits were discussed.

DESCRIPTION OF PROCEDURE:  After informed consent, the patient was brought to the procedure room, placed prone on a fluoroscopically compatible table.  Her back was prepped and draped in sterile fashion.  Lidocaine 1% was used subcutaneously for local anesthesia.  Subsequently, an epidural was performed using a right interlaminar L3-L4 approach, an 18-gauge Tuohy needle, and loss of resistance technique.  No heme, CSF or paresthesias were encountered.  Placement was confirmed by injection of Isovue-M 300.  This led to good multilevel epidurogram.  Most of the dye spreading cephalad, though there was some caudal spread at the end of injection.  Dye was actually seen extending up to T12 and down towards L4.  No provocation of symptomatology occurred.  Depo-Medrol 120 mg was injected.  The needle was cleared with 1 mL of 0.1% bupivacaine.  X-rays were checked.  The needle was removed.  I did examine her back under fluoroscopy.  She had some tenderness over her SI joint, on the right, as well as her L5 transverse process may be rubbing against the sacrum with weightbearing.  If she does not benefit from interlaminar transforaminal epidural steroid injections, we may want to consider an SI joint injection for both diagnostic and therapeutic purposes.  At the end of the procedure, the patient was brought to the recovery room in stable condition and discharged home the same day.

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DATE OF SERVICE:  MM/DD/YYYY

The patient is here for knee joint and trigger point injections.  The last time she had this was in September.

PROCEDURES:
1.  Bilateral knee joint injections.  After alcohol prep on each knee, taking lateral approach, posterior to the patella, a 25-gauge, 3.5-inch needle was advanced into the knee joint.  Five mL of 0.25% Marcaine with 20 mg of Kenalog was injected into each side for a total of two injections.
2.  Trigger points were identified bilaterally in the supraspinatus muscles.  A total of 10 mL of 0.25% Marcaine, 5 mL per side, with 40 mg of Kenalog total was used to inject the two trigger points.  There were no complications.

IMPRESSION:
1.  Osteoarthritis of the knees.
2.  Myofascial pain syndrome.

PLAN:  Return in about two months for repeat injections.       



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