PREOPERATIVE DIAGNOSIS: Cervicalgia.
POSTOPERATIVE DIAGNOSIS: Cervicalgia.
PROCEDURE PERFORMED: Cervical epidural steroid injection.
DESCRIPTION OF PROCEDURE: The patient was brought to the Same Day Surgery Center. The history and physical and consent were reviewed. The details of the procedure including risks, benefits and alternatives were discussed with the patient. The patient agreed and was taken to the procedure room and was put prone on the procedure table. The cervical area was cleaned with ChloraPrep x 2 and draped in a sterile fashion. Interlaminar space of C6-C7 was identified with fluoroscopic guidance and a 17 gauge 3.5 inch Tuohy needle was gently introduced into the interlaminar space using loss of resistance technique. The confirmation of the needle placement was obtained by using loss of resistance and fluoroscopic guidance. Placement of the needle in the epidural space was confirmed with Isovue dye of 2 mL. Then, a 6 mL solution containing 120 mg Depo-Medrol and 0.125% bupivacaine was slowly injected into the epidural space. The patient tolerated the procedure well, and there were no immediate complications, and the patient was taken to the postoperative area and was monitored. The patient was discharged over the same day with advice to follow up in the clinic.
PREOPERATIVE DIAGNOSES:
1. Degenerative disk disease.
2. Lumbar radiculopathy.
POSTOPERATIVE DIAGNOSES:
1. Degenerative disk disease.
2. Lumbar radiculopathy.
PROCEDURE PERFORMED: Lumbar epidural steroid injection.
DESCRIPTION OF PROCEDURE: The patient was seen and reevaluated in the preoperative area and the history and physical and consent was reevaluated. The risks, benefits, and alternatives of the procedure were discussed with the patient. The patient agreed to the procedure and was taken to the procedure room. The patient was put prone on the procedure table, and the skin was prepped with ChloraPrep x 2 and draped in a sterile fashion. The interlaminar space, L5-S1, was identified using fluoroscopic guidance. The skin and subcutaneous tissues were anesthetized using 1% lidocaine. The epidural space was identified using a 17 gauge, 3.5 inch Tuohy needle under fluoroscopic guidance and with loss of resistance technique. After identification of the epidural space, it was confirmed with about 2 mL of Isovue dye. After confirmation of the correct needle placement, 10 mL solution containing 5 mL of 0.25% Marcaine, 120 mg of Depo-Medrol, and 3 mL of saline was gently introduced into the epidural space. The patient tolerated the procedure well. There were no immediate complications, and the patient was taken to the postoperative area and was monitored.
PREOPERATIVE DIAGNOSIS: Left sacroiliac joint pain.
POSTOPERATIVE DIAGNOSIS: Left sacroiliac joint pain.
PROCEDURE PERFORMED: Left SI joint injection.
DESCRIPTION OF PROCEDURE: The patient was reevaluated in the Same Day Surgery Center. History, physical, and the consent were reviewed with the patient again. The patient agreed with the procedure and was taken to the procedure room and put prone on the procedure table. The left SI joint was identified under the image intensifier. The skin was prepped with ChloraPrep x 2 and draped in a sterile fashion. After identification of the widest opening at the left SI joint, a 22 gauge 3.5 inch needle was introduced into the left SI joint. A 2 mL solution containing Depo-Medrol 80 mg and 2.5% Marcaine was gently introduced into the SI joint. The patient tolerated the procedure well and was taken to the postoperative area in stable condition. The patient was discharged home on the same day with advice to follow up in the clinic.
PREOPERATIVE DIAGNOSES:
1. Chronic low back pain.
2. Right L5 radiculopathy.
POSTOPERATIVE DIAGNOSES:
1. Chronic low back pain.
2. Right L5 radiculopathy.
PROCEDURE PERFORMED: Right L5 selective nerve root block.
DESCRIPTION OF PROCEDURE: The patient was seen and reevaluated in Same Day Surgery. History and physical and details of the procedure, including risks and benefits, were discussed with the patient again. The patient agreed to the procedure. He was taken to the procedure room and put prone on the procedure table. The skin was prepped with ChloraPrep and draped in sterile fashion. Right L5 foramen was identified with fluoroscopic imaging, and the skin and subcutaneous tissue were anesthetized with 1% lidocaine. A 5 inch 22 gauge needle was gently introduced with intermittent fluoroscopic guidance toward L5 foramen. After confirmation of the needle placement by fluoroscopic imaging, 2 mL Isovue was gently introduced into the area, which showed adequate spread of the dye along the nerve root and epidural space. Then, 5 mL of solution containing 120 mg of Depo-Medrol and 0.125% bupivacaine was gently introduced into the space. The patient tolerated the procedure well. He was taken to the postoperative area and was monitored. There were no immediate complications, and the patient was discharged home.
More Pain Clinic Sample Reports
PREOPERATIVE DIAGNOSIS: Intercostal neuralgia.
POSTOPERATIVE DIAGNOSIS: Intercostal neuralgia.
PROCEDURE PERFORMED: Thoracic epidural steroid injection.
DESCRIPTION OF PROCEDURE: The patient was seen in the preop area. The history, physical and consent was evaluated, reviewed again with the patient, and the patient agreed for the procedure and was taken to the procedure room. The patient was put prone on the procedure table. The skin was prepped with Chloraprep x 2 and draped in a sterile fashion. The skin and the subcutaneous tissues were anesthetized with 1% lidocaine and a 3.5 inch 17 gauge Tuohy needle was gently introduced into the interlaminar space between T8 and T9. The epidural space was identified using intermittent fluoro and loss of resistance technique. After identification, the confirmation was obtained by using Isovue dye. Then, 6 mL solution containing 120 mg of Depo-Medrol and 0.125% Marcaine was gently introduced into the epidural space. The patient tolerated the procedure well, and there were no immediate complications. The patient was transferred to postop area in stable condition and was monitored.
