аЯрЁБс>ўџ 02ўџџџ/џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС'` №П:bjbj{P{P .&::П zџџџџџџЄšššššššЎ2 2 2 8j † ЎZ$Ў Ў Ў Ў Ў Ў Ў Ў §џџџџџџ~hцЄџšљ Ў Ў љ љ џššЎ Ў ===љ  šЎ šЎ §=љ §==šš=Ў Ђ D(ˆїЪ2 ™ ”=§*0Z=Š-ЌŠ=Šš=РЎ 0о "=  нЎ Ў Ў џџйdЎ Ў Ў Zљ љ љ љ ЎЎЎ„2 ЎЎЎ2 ЎЎЎššššššџџџџ  Information and consent form for soft tissue and joint injections Dr Harley has considered your case and decided that injection treatment would be likely to be helpful. The following information applies to steroid and anaesthetic injection treatments in general but the doctor will have informed you of any specific issues relating to your particular problem. Steroid (cortisone/hydrocortisone) injections are helpful in cases of soft tissue (muscle or ligament) and joint irritation/inflammation. The steroid solution administered locally has a very powerful anti-inflammatory effect and can help to reduce the pain from both local and generalised soft tissue, joint and nerve inflammation. There are many different types of steroid, both manufactured and natural. The drugs used for treatment of these conditions are made specifically for these purposes and are not the same as anabolic or other steroids. Dr Harley generally uses Triamcinolone which is a potent (but safe and well tried) long lasting steroid drug. You will receive an appropriate dose for your condition-normally between 5 and 40mg. Side effects of steroids are generally experienced only with higher doses used over several weeks so you are unlikely to experience any, but these do include hormone irregularities (menstrual disturbance in women), susceptibility to infection, blood pressure raise, bone, fat and muscle thinning, tendon rupture, allergic reactions, psychiatric and neurological effects, aggravation of diabetes, weight gain, ophthalmic and other rare side effects. A dimple or skin discoloration or depigmentation at the site of injection sometimes occurs. Local anaesthetic (lidocaine or bupivacaine) injection is normally given before or with the steroid injection. This is to reduce the discomfort you would tend to get with the injection, but does not abolish it entirely. The anaesthetic injection can have a beneficial diagnostic effect-i.e. if the pain goes for the duration of the effect of the anaesthetic (normally 2-3 hours) this tends to confirm the tissue injected is the source of the pain. Side effects of the local anaesthetic are rare but include allergy (sometimes severe with collapse), heart beat irregularity, dizziness, confusion, convulsions, drowsiness, depression of respiration (these latter effects are generally related to intravenous use which is not used in these conditions). General side effects of these injections not listed above are: small risk of joint and systemic infections, local pain and flare up (sometimes lasting several days), bruising, fainting. There is no guarantee of effectiveness! Please tell the doctor about any other medication you are taking (especially anticoagulants) as there may be a risk of interactions. Should you have any queries or problems before or after the injection please telephone the doctor to discuss them. Patient name………………………………………………. DOB……………………………….. Consent form: I have read and understood the information sheet above and give my consent for the injection/course of injections of………………………………………………………………………………………….. I confirm that the doctor has explained any concerns and the procedure to my satisfaction. Signed by patient………………………………………………………. Date……………………….. I confirm that I have explained the procedure of ………………………………………. to the patient. Signed by doctor……………………………………………………….Date………………………….. Procedure notes: Steroid used……………………………………………………………… Anaesthetic used………………………………………………………. Other notes re injection…………………………………………….     Dr Simon Harley MBBS MRCGP Dip MS Med 2, Deben Road, Ipswich, IP1 5EN Telephone 01473 741152 Fax 743237 BCD Ш т Q R & ' ` a b f ]nя./\]œЂ>?СУФХlёпаёУЖЉЖУЖœЖЖЖ‚ЖuЖuhu[u[Љu[h[h[hŸDmCJOJQJ\aJh‹o\CJOJQJ\aJhŠ4aCJOJQJ\aJho6ѕCJOJQJ\aJhjCJOJQJ\aJhUm–CJOJQJ\aJhЃCJOJQJ\aJhkФCJOJQJ\aJh\/жCJOJQJ\aJh4lћ5CJOJQJ\aJ"h\/жh\/ж5CJOJQJ\aJh\/ж5CJOJQJ\aJ#CDj k З R o/]?Х89klzьnoЇЈЉыћ23њњњњњњњѓѓѓѓѓѓѓѓѓѓѓѓѓѓѓѓѓѓѓѓѓЄ№gdkФgdэvЖП9§§lzЗыљњћ4DEFОПРТУХЦШЩЫёђѓ67юсдсЧсЧЙЎЙЧž–’–’–’–’ƒqme]UFh'ќhUm–CJOJQJaJh‹o\OJQJhjOJQJhUm–OJQJhj#h'ќhj5CJOJQJ^JaJhj5CJOJQJ^JaJhRnjhRnUh\/жhЃCJOJQJ\aJhЃ5OJQJ\hЃhЃ5OJQJ\hЃCJOJQJ\aJhєT,CJOJQJ\aJhŸDmCJOJQJ\aJ"hЃhŸDm5CJOJQJ\aJ34EFkl“”ПСТФХЧШЪЫёђѓјјјјјјјјііііііііФМі$a$gd'ќ2$$d!%d$&d/'d$-DMЦ џцццNЦџ!OЦџ$PЦџ/QЦџ$a$gd‹o\Є№gdkФѓ6789:ЭЭХУУМЄ№gdkФ$a$gdUm–2$$d!%d$&d!'d$-DMЦ џцццNЦџ!OЦџ$PЦџ!QЦџ$a$gd‹o\789:ќјшh\/жhЃCJOJQJ\aJhRnhj,1hА‚. 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