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SAMPLE REPORT - LUMBAR EPIDURAL STEROID INJECTION - LESI
Note: In major hospitals, the pain clinic physicians are usually anesthethesiologists - this is what they do when they aren't putting you to sleep! :)
PREPROCEDURE DIAGNOSIS: Lumbar radiculopathy.
POSTPROCEDURE DIAGNOSIS: Lumbar radiculopathy.
PROCEDURE PERFORMED: Lumbar epidural steroid injection.
ANESTHESIOLGIST: George Washington, M.D.
REFERRING PHYSICIAN: Abraham Lincoln, M.D.
ANESTHESIA GIVEN: Local.
INDICATIONS FOR PROCEDURE: This 53-year-old female presents with symptoms consistent with a lumbar radiculopathy. Previous epidural steroid injections have resulted in significant improvement of her pain. This is the second in a series of three of those injections.
DESCRIPTION OF PROCEDURE: The patient was placed in the left lateral decubitus position. The L4-5 interspace was identified with deep palpation. Local infiltration was carried out with 3 cc of 1% lidocaine. The area was prepped and draped in the usual sterile fashion. An 18-gauge Tuohy needle was advanced to the epidural space with the loss-of-resistance technique. Then a mixture of Depo Medrol 80 mg, normal saline 10 cc and lidocaine 1% at 5 cc was injected. No complications were encountered and the patient was returned to the outpatient surgery department in stable condition.
PLAN: To repeat this procedure in two weeks.
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Copyright 2005-2008, Copied with Permission from the web site, "Patients and Medical Transcription" at http://www.mt-stuff.com
If you do use these sample reports for students or classes, please let me know. My goal for this web site is to mentor future MTs to carry on our professional craft and legacy; I would like to know I helped in some small way to achieve that goal. Thank you and May God Bless You, Rosemarie  
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