Physical Therapy 3Rd Floor
Resume:
Michigan Orthopaedic Surgeons • ***** Lahser Road, SOUTHFIELD MI 48033-2606
TAYLOR, Mark (id #1114486, dob: 05/30/1952)
MICHIGAN ORTHOPAEDIC SURGEONS PLLC
SOUTHFIELD, MI 48033-2606
Phone: 248-***-****
Fax: 248-***-****
Encounter Summary - Progress Note
Date Printed: 04/01/2025
Patient Taylor, Mark (72yo, M) #1114486
DOB 05/30/1952
Patient Demographics:
Address 29129 Worrell Woods Dr Apt 102
Southfield, MI 48034
Home Phone 248-***-****
Work Phone
Encounter Notes:
Encounter
Reason/Date
PR - Lumbar Interlaminar ESI with Epidurogram L4-5 04/01/2025 - 09:15AM - MOS_Southfield Pain
History of Present
Illness
Mark Taylor is 72 year old Male presenting for care.
-Previous osteoporosis dx: no
-Occupation: now retired
Review of Systems None recorded
Vitals None recorded
Results/Interpretations None recorded
Physical Exam None recorded
Procedures MHM Fluoro Lumbar Interlaminar ESI:
PROCEDURE PERFORMED: Lumbar lnterlaminar Epidural Steroid Injection with Epidurogram, L4/5
ANESTHESIA: Local without sedation.
SPECIMEN: None.
ESTIMATED BLOOD LOSS: Negligible.
PROCEDURE INDICATION: The patient has chronic intractable pain which was not responding to oral pain medications, physical therapy, or other conservative treatments. Multiple attempts were made with conservative treatments and physical therapy. Lumbar epidural injection was indicated for pain.
PROCEDURE DESCRIPTION:The patient was seen and identified in the pre- procedure area. Risks, benefits, complications, and alternatives were discussed; the patient agreed to proceed with the procedure and signed the consent. Pre-procedure vital signs were stable and the assessment performed by the clinical staff was reviewed. The H&P was reviewed and no significant updates or changes were identified. The patient was brought into the procedure room awake, alert, and responding to verbal command. The patient was placed in the prone position on the procedure table. Lumbosacral area was prepped with Chlora-Prep and draped in the usual sterile fashion. Time out was taken.
Using anterior-posterior fluoroscopy, the interlaminar space of level L4/5 was identified, and skin and deeper tissues were anesthetized with 1% Lidocaine. A 20 gauge, 4.5 inch Tuohy needle was guided by AP fluoroscopy until the tip was in the interspinous ligament. Then, with lateral fluoroscopy, the needle was advanced until loss of resistance was obtained. After negative aspiration of CSF and blood with no paresthesias, Omnipaque contrast dye was injected and an and blood with no paresthesias, Omnipaque contrast dye was injected and an excellent epidurogram was seen. Again after negative aspiration of CSF and blood with no paresthesias, a block solution containing 2 ml of 0.9% saline and 10 mg of Dexamethasone was injected. The needle was removed intact and the skin was cleansed.
COMPLICATIONS: The patient tolerated the procedure well without complications, and was discharged from the recovery room after meeting discharge criteria.
Fluoro time (seconds): 6.6
MRAD: 524.71
Assessment and Plan 1. Lumbar radiculopathy
M54.16: Radiculopathy, lumbar region
M47.26: Other spondylosis with radiculopathy, lumbar region XR, GUIDANCE (C-ARM) - Note to Imaging Facility: C-Arm for Pain Management Procedure
dexamethasone sodium phosphate (PF) 10 mg/mL injection solution - Take 1 mL by injection route. Quantity: (1) mL Lot #: 6036482 Route: Injection Exp Date: 10/01/2026 Administered
sodium chloride 0.9 % injection solution - Take 1 mL by injection route. Quantity:
(1) mL Lot #: LC6880 Route: Injection Exp Date: 01/31/2026 Administered
lidocaine (PF) 10 mg/mL (1 %) injection solution - Take 1 mL by injection route. Quantity: (1) mL Lot #: 6131415 Route: Injection Exp Date: 09/01/2027 Administered
Omnipaque 240 mg iodine/mL intravenous solution - Inject 1 mL by intravenous route. Quantity: (1) mL Lot #: 16952211 Exp Date: 08/13/2027 Administered
Return to Office
MARK MOUNAYER, MD for Reck 10 at MOS_Southfield Pain on 06/03/2025 at 01:20 PM
Patient Medical History:
Allergies List Allergies not reviewed (last reviewed 03/06/2025) NKDA
HN - Unknown reaction to Penicillin
Medications Medications not reviewed (last reviewed 03/06/2025) atorvastatin 20 mg tablet
TAKE 1 TABLET BY MOUTH EVERY DAY
03/02/25 filled
dexAMETHasone sodium phosphate (PF) 10 mg/mL
injection solution
Take 1 mL by injection route.
04/01/25 administered
famotidine 40 mg tablet
TAKE 1 TABLET BY MOUTH AT BEDTIME
02/09/25 filled
finasteride 5 mg tablet
TAKE 1 TABLET BY MOUTH EVERY DAY
07/30/23 filled
gabapentin 400 mg capsule
TAKE 1 CAPSULE BY MOUTH 3 TIMES A DAY
12/10/24 filled
glimepiride 2 mg tablet
TAKE 2 TABLETS BY MOUTH EVERY DAY
03/15/25 filled
lidocaine (PF) 10 mg/mL (1 %) injection solution
Take 1 mL by injection route.
04/01/25 administered
metFORMIN 1,000 mg tablet
TAKE 1 TABLET BY MOUTH 2 TIMES A DAY
02/09/25 filled
metoclopramide 10 mg tablet
TAKE 1 TABLET BY MOUTH 2 TIMES A DAY BEFORE MEALS
03/05/25 filled
Omnipaque 240 mg iodine/mL intravenous solution
Inject 1 mL by intravenous route.
04/01/25 administered
pantoprazole 40 mg tablet,delayed release 01/07/25 filled pantoprazole 40 mg tablet,delayed release
TAKE 1 TABLET BY MOUTH EVERY DAY
01/07/25 filled
pioglitazone 15 mg tablet
TAKE 1 TABLET BY MOUTH EVERY DAY
03/02/25 filled
sodium chloride 0.9 % injection solution
Take 1 mL by injection route.
04/01/25 administered
sucralfate 1 gram tablet
TAKE 1 TABLET BY MOUTH 4 TIMES A DAY before meals and at bedtime
12/24/24 filled
tamsulosin 0.4 mg capsule
TAKE 2 CAPSULES BY MOUTH IN THE EVENING
03/15/25 filled
traMADoL 50 mg tablet
TAKE 1 TABLET BY MOUTH 2 TIMES A DAY AS DIRECTED
03/19/25 filled
Family History Family History not reviewed (last reviewed 03/06/2025) Father - Family history of malignant neoplasm
- Heart disease
- Diabetes mellitus
Mother - Diabetes mellitus
- Heart disease
- Family history of malignant neoplasm
Daughter - Congenital disease
- Birth Defects
Brother - Diabetes mellitus
- Heart disease
Unspecified Relation - Hypertensive disorder
Past Medical
History
Past Medical History not reviewed (last reviewed 03/06/2025) Cancer: Y
Hepatitis B: Y
Neuropathy: Y - HN - Patient indicated this is not accurate. Vaccine
History
Vaccines not reviewed (last reviewed 03/06/2025)
Vaccine Type Date Amt. Route Site NDC Lot # Mfr. Exp. Date
VIS VIS
Given
Vaccinator
COVID-19
COVID-19,
mRNA, LNP-S,
PF, 30
mcg/0.3 mL
dose (Pfizer-
BioNTech)
01/24/23
COVID-19,
mRNA, LNP-S,
PF, 30
mcg/0.3 mL
dose (Pfizer-
BioNTech)
04/02/21
COVID-19,
mRNA, LNP-S,
PF, 30
mcg/0.3 mL
dose (Pfizer-
BioNTech)
01/24/21
COVID-19,
mRNA, LNP-S,
PF, 30
mcg/0.3 mL
dose (Pfizer-
BioNTech)
01/01/01
Electronically Signed by: MARK MOUNAYER, MD
Electronically Signed by: MARK MOUNAYER, MD
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