HPI:

@NAME@ is a @AGE@ @SEX@ with a history of *** who presents to Neurology clinic for BOTOX injections for muscle ***. Previously had tried several medications. @HE@ would like to proceed with injections as planned today. Please see detailed BOTOX procedure note below.

BOTOX PROCEDURE NOTE:

A concentration of BOTOX brand botulism toxin was mixed as 100 units per 1 ml sterile in preservative free saline. Isopropyl alcohol was used for skin preperation. Prior to the injection patient was warned of potential adverse effects including transient pain and weakness that can last up to 3 months or until it wears off. Patient ID confirmed.

Using a a guided 27 guage EMG needle the following muscles were injected: :

Upper extremity:

Biceps brachii *** units divided in *** sites

Brachioradialis *** units divided in *** sites

Flexor carpi radialis *** units divided in 2 sites

Flexor carpi ulnaris *** units divided in 2 sites

Flexor digitorum profundus *** units divied in 2 sites

Flexor digitorum superficialis *** units divided in 2 sites

Lower extremity:

Gastrocnemius (medial head) *** Units divided in *** sites

Gastrocnemius (lateral head) *** units divided in *** sites

Soleus *** units divided in *** sites

Tibialis posterior *** units divided in *** sites

Flexor hallicus longus *** units divided in *** sites

Total Units Injected: *** Units

Total Units Wasted: *** units

The patient tolerated with procedure well without complications and was discharged from the clinic