Willie Gutierrez

Recv'd Date: 28650664 
 Bill DCN: 2019143GJ312119 
 05/05/2020 Fri 11:20 
 Lakefront Health 831-225-9933 
 ID: #11172 Page 1 of 2 
 Lakefront Health 
 OPERATIVE REPORT 
 PATIENT NAME: 
 Willie Gutierrez 
 birthdate: 
 24/03/1999 
 procedure date: 
 15/11/2020 
 PREOPERATIVE DIAGNOSIS: Congestive Heart Failure. 
 POSTOPERATIVE DIAGNOSIS: Congestive Heart Failure. 
 PROCEDURES: 
 1. Transforaminal lumbar epidural steroid injection via the right L5 neuroforamen. 
 SURGEON: Dr Joseph Lewis, M.D. 
 ANESTHESIA: Intravenous sedation and local anesthesia. 
 PATIENT IDENTIFICATION: This patient is a 30-year-old gentleman, who was injured at work by shuffling 
 concrete and he had an MRI scan that showed severe spinal stenosis at L3-L4, moderate bilateral lateral 
 recess narrowing and moderate bilateral foraminal narrowing at that level, at the level of L4-L5.
 DETAILS OF THE PROCEDURE: After informed consent, the patient was given intravenous access. He was 
 then taken to the operating room for the procedure.
 964 Sarah Stream
West Caroline, AZ 83982 
 Phone: (408) 988-0105 (406) 938-002 
 3672
