DATE: April 15, 2009
Patient: XXXXXXXX
DOB: XXXXXXXX
Physician/NP/PA: XXXXXXXX, M.D.
HISTORY: Please refer to recent
clinic visit and assessment note of 04/13/2009 leading up to today’s
intervention.
The following interventional procedure
was carried out at Pain Clinic fluoroscopy suite after discussing risks,
benefits, alternatives and complications to procedure.
PROCEDURE:
Bilateral L3/4, L4/5, and L5/S1
facet/zygapophysial joint injection/block with fluoroscopy.
PRE & POST PROCEDURE DIAGNOSIS:
Lumbar degenerative joint and disc
disease/lumbosacral spondylosis/low back pain.
Relevant
pre-procedure assessment carried out.
Integument corresponding to area examined negative for any active
infection. Vitals’ monitored and patient confirmed stable prior to proceeding
with procedure. Patient positioned prone, vertebrae squared, oblique or Scottie
dog view obtained, skin marked corresponding to lower pole of above facet
joints. Area swabbed with Betadine and
sterile draped. 25G Diamond point spinal
needles introduced and advanced to above facet joints down the barrel.
Intraarticular placement achieved with feel of needle entry. Small volume of Isoview-200, 0.25ml
injected to additionally confirm intraarticular-intracapsular localization of
contrast. Confirming negative aspiration
for heme 10 mg of Kenalog with 0.5 ml of 0.5% Marcaine injected into each facet
joint. Needle withdrawn, hemostasis
confirmed.
Patient
tolerated procedure well. No
complications encountered, no blood loss assessed. Stable clinical condition confirmed post
procedure. Safety with
ambulation/mobility assessed prior to discharge. Post-procedure care and discharge
instructions reviewed and a written copy given to patient.
Note: Additional
history intake, interval history updates, procedure specific informed consent,
pre and post-procedure assessment, post-procedure care and discharge
instructions documented in patient’s chart, please refer to.
“Procedure
Concordant Pain Relief Report Form” initiated and patient instructed to monitor
and mark degree of pain relief on a numeric pain scale ranging from 0 – 10 over
the next 24 hours.
Patient
instructed to call Pain Clinic or follow up as needed.
Sincerely,
___________________________
XXXXXXXX,
M.D.
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