Pain Medicine Procedure Sample Report #1
PREOPERATIVE DIAGNOSIS: Complex regional pain syndrome, left upper extremity.
POSTOPERATIVE DIAGNOSIS: Complex regional pain syndrome, left upper extremity.
PROCEDURE PERFORMED: Left stellate ganglion block.
SURGEON: John Doe MD
ASSISTANT: Jane Doe, MD
COMPLICATIONS: Nil.
DETAILS OF PROCEDURE: The patient was reevaluated at (XX). Details of the procedure including risks, benefits, and complications were discussed with the patient. The patient agreed to the procedure, was taken to the procedure room, and laid supine on the table. The transverse process of C6 was identified using palpation. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After identification of the transverse border of C6 vertebra, the confirmation was obtained by x-ray. A 25-gauge needle was gently introduced and touched to the bone. Intermittent aspiration to avoid other blood barrier coming into the needle. Then a 30 mL solution containing Marcaine 0.5% and Depo-Medrol 40 mg was gently injected while maintaining the needle in position and with intermittent aspiration. The patient tolerated the procedure well, and there were no complications. The patient was monitored in the postoperative area as per protocol and was discharged home the same day with advice to attend the clinic as scheduled earlier.
Pain Medicine Procedure Sample Report #2
PREOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.
POSTOPERATIVE DIAGNOSIS: Lumbar degenerative disk disease.
PROCEDURE PERFORMED: Lumbar epidural steroid injection.
SURGEON: John Doe MD
ASSISTANT: Jane Doe, MD
DETAILS OF PROCEDURE: The patient was evaluated in the preoperative area. The history and physical details of the procedure, including risks, benefits and complications were discussed with the patient. The patient agreed for the procedure. He was taken to the procedure room. The patient was laid prone on the procedure table and his skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 space was identified using the fluoroscopic guidance. The skin was anesthetized with 1% lidocaine, including the subcutaneous tissue.
The L4-L5 space was identified using intermittent fluoroscopic and loss-of-resistance technique after identification of the L4-L5 epidural space, which was confirmed by using 1.5% Isovue. After confirmation of this epidural space, an 8 mL solution containing 0.125% lidocaine and 120 mg of Depo-Medrol was gently introduced into the epidural space. The patient tolerated the procedure well. There were no immediate complications. The patient was taken to the postoperative area and was monitored as per the protocol. The patient was discharged home on the same day with advice to attend the pain clinic as arranged earlier.
Pain Medicine Procedure Sample Report #3
PREOPERATIVE DIAGNOSIS: Facet arthropathy.
POSTOPERATIVE DIAGNOSIS: Facet arthropathy.
PROCEDURE PERFORMED: Right L3, L4, L5, and S1 medial branch block.
SURGEON: John Doe MD
ASSISTANT: Jane Doe, MD
DETAILS OF PROCEDURE: The patient was evaluated again in the preop area. History and physical, details of the procedure including risks, benefits, and complications were discussed with the patient again. The patient agreed, was taken to the procedure room and was laid prone on the procedure table. The right L3-4, L4-5, L5-S1 and L2-L3 facet joints were identified. The skin was prepped with ChloraPrep x2 and draped in a sterile fashion.
In an oblique view, the skin was anesthetized with 1% lidocaine at each levels and a 22-gauge spinal needle, 3.5 inches long, was gently introduced towards the junction of the transverse process in the facet joint. After confirmation of this needle placement with fluoroscopic guidance, the same procedure was repeated at next 3 medial branches and a solution containing 30 mg of Depo-Medrol and about 1 mL of 0.25% bupivacaine was injected at each level.
After that, needle was withdrawn and flushed with 0.25% bupivacaine, Band-Aid was applied. The patient was taken to the postoperative area and was monitored as per the protocol. There were no immediate complications, and the patient was discharged home on the same day with the advice to attend the clinic in due course of time as arranged earlier.
Pain Medicine Procedure Sample Report #4
PREOPERATIVE DIAGNOSIS: Bilateral sacroiliac pain.
POSTOPERATIVE DIAGNOSIS: Bilateral sacroiliac pain.
PROCEDURE PERFORMED: Bilateral SI joint injection.
SURGEON: John Doe MD
ASSISTANT: Jane Doe, MD
DETAILS OF PROCEDURE: The patient was reevaluated. The risks, benefits, and details of the procedure including complications were discussed with the patient. The patient agreed to the procedure and was taken to the procedure room and laid prone on the procedure table. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After identification of the SI joint, a 22-gauge needle was gently introduced into the right SI joint followed by left SI joint after anesthetizing the skin and the subcutaneous tissue. After confirmation of the needle in the SI joint with fluoroscopic guidance, a 3 mL solution containing 120 mg of Depo-Medrol and 0.25% of bupivacaine was equally divided and slowly injected into the SI joint.
The patient tolerated the procedure well. The needles were then withdrawn and flushed with 0.25% Marcaine and a Band-Aid was applied.
The patient tolerated the procedure well and was taken to the postoperative area and was monitored as per protocol. There were no immediate complications, and the patient was discharged home after being monitored with the advice to attend the clinic in due course of time as arranged earlier.
Pain Medicine Procedure Sample Report #5
PREOPERATIVE DIAGNOSIS: Bilateral sacroiliac joint pain.
POSTOPERATIVE DIAGNOSIS: Bilateral sacroiliac joint pain.
PROCEDURE PERFORMED: Bilateral sacroiliac joint injections.
SURGEON: John Doe MD
ASSISTANT: Jane Doe, MD
COMPLICATIONS: Nil.
SPECIMENS REMOVED: Nil.
DETAILS OF PROCEDURE: The patient was reevaluated. Details of the procedure including risks, benefits, and possible complications were discussed with the patient. The patient agreed for the procedure and was taken to the procedure room. The skin was cleaned with ChloraPrep x2 and draped in a sterile fashion. After prepping the SI joint, right SI joint was identified using the fluoroscopic guidance and a 22-gauge 5-inch needle was gently introduced into the lower portion of the right SI joint. After confirmation of the needle placement in the right SI joint, the same procedure was repeated on the left side.
After confirmation of both needle placement, a 3 mL solution containing 120 mL of Depo-Medrol and 0.25% bupivacaine was equally divided and injected slowly on each side. The needle was then flushed with 0.25% bupivacaine and a Band-Aid was applied after removing the spinal needles.
The patient tolerated the procedure well. There were no immediate complications, and the patient was monitored as per the protocol in the postoperative area and discharged home with stable condition on the same day with advice to attend the clinic as arranged earlier.
Pain Medicine Procedure Sample Report #6
PREOPERATIVE DIAGNOSIS: Low back pain and lumbar degenerative disk disease.
POSTOPERATIVE DIAGNOSIS: Low back pain and lumbar degenerative disk disease.
PROCEDURE PERFORMED: LESI.
SURGEON: John Doe MD
ASSISTANT: Jane Doe, MD
DETAILS OF PROCEDURE: The patient was evaluated in the preop area. She is a referral from the Orthopedic Clinic. The H&P and consent was obtained and the medications were reviewed. The risks, benefits, and details of the procedure including possible complications were discussed with the patient. The patient understood and agreed to the procedure.
The patient was taken to the procedure room and put prone on the procedure table. The skin was prepped with ChloraPrep x2 and draped in a sterile fashion. The L4-L5 interlaminar space was identified using the fluoroscope, and the skin and the deeper tissues were anesthetized using 1% lidocaine. A 17-gauge 3.5-inch Tuohy needle was gently introduced into the interlaminar space using loss of resistance technique and intermittent fluoroscopy.
After identifying the epidural space, the confirmation was obtained by using 2 mL of Isovue dye. After confirmation of the correct placement of the Tuohy needle, an 8 mL solution containing 0.125% bupivacaine and 120 mg of Depo-Medrol was slowly injected 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 as per protocol. The patient was discharged home on the same day with advice to follow up in the orthopedic clinic and to call the pain clinic as per schedule for next LESI in 4 to 6 weeks.
