Cats3
Contributor
Would this be 47532 only? I cannot find anything about the aspiration of the fluid being included. The drainage cath was NOT left in so I can't use 47490, correct? Thank you in advance for your help!!
History: Abdominal pain, clinical suspicious for acute cholecystitis. CT scan ultrasound finding of pericholecystic fluid collection, gallbladder wall thickening, fat stranding. Patient presented IR for the ultrasound and fluoroscopy-guided percutaneous
cholecystostomy with conscious sedation.
Medications:
1. Versed 2 mg IV
2. Fentanyl 50mcg IV
3. Lidocaine 2% for local anesthesia 10 ml
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 60 minutes monitoring time.
Contrast Data: 20 mL Isovue-300 into the gallbladder
Fluoroscopy Time: 0.9 Minutes
Total Skin Dosage: 23 mGy
Complications: None
Specimens: None
Estimated blood loss: None
Description: Written informed consent was obtained from patient. Maximum sterile barrier was used. The patient was placed Supine.
Preliminary ultrasound demonstrated distended gallbladder with gallbladder wall thickening.
After local anesthesia, access was obtained into the gallbladder through the RIGHT transhepatic approach using a 5 French Yueh catheter under direct sonographic guidance. 20 mL of brown fluid was aspirated. The fluid was collected and sent to lab for
culture. Small amount of contrast was injected to confirm location, demonstrating contrast opacification of the gallbladder, cystic duct, hepatic ducts, common bile duct, and duodenum. The Yueh catheter was removed. Final fluoroscopy demonstrated no
complication. Sterile dressing was applied.
Results discussed with the patient . There was no family in our waiting room to talk to. The patient tolerated the procedure well and left procedure suite for return to recovery room in good condition.
Multiple hardcopy fluoroscopic images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Preliminary ultrasound demonstrated distended gallbladder with gallbladder wall thickening.
2. Cholecystogram demonstrating contrast flowing to the the gallbladder, cystic duct, hepatic ducts, common bile duct, and duodenum.
3. No drainage tube was placed.
4. 20 mL of brown-colored fluid was aspirated from the gallbladder and sent to lab for culture.
History: Abdominal pain, clinical suspicious for acute cholecystitis. CT scan ultrasound finding of pericholecystic fluid collection, gallbladder wall thickening, fat stranding. Patient presented IR for the ultrasound and fluoroscopy-guided percutaneous
cholecystostomy with conscious sedation.
Medications:
1. Versed 2 mg IV
2. Fentanyl 50mcg IV
3. Lidocaine 2% for local anesthesia 10 ml
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 60 minutes monitoring time.
Contrast Data: 20 mL Isovue-300 into the gallbladder
Fluoroscopy Time: 0.9 Minutes
Total Skin Dosage: 23 mGy
Complications: None
Specimens: None
Estimated blood loss: None
Description: Written informed consent was obtained from patient. Maximum sterile barrier was used. The patient was placed Supine.
Preliminary ultrasound demonstrated distended gallbladder with gallbladder wall thickening.
After local anesthesia, access was obtained into the gallbladder through the RIGHT transhepatic approach using a 5 French Yueh catheter under direct sonographic guidance. 20 mL of brown fluid was aspirated. The fluid was collected and sent to lab for
culture. Small amount of contrast was injected to confirm location, demonstrating contrast opacification of the gallbladder, cystic duct, hepatic ducts, common bile duct, and duodenum. The Yueh catheter was removed. Final fluoroscopy demonstrated no
complication. Sterile dressing was applied.
Results discussed with the patient . There was no family in our waiting room to talk to. The patient tolerated the procedure well and left procedure suite for return to recovery room in good condition.
Multiple hardcopy fluoroscopic images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Preliminary ultrasound demonstrated distended gallbladder with gallbladder wall thickening.
2. Cholecystogram demonstrating contrast flowing to the the gallbladder, cystic duct, hepatic ducts, common bile duct, and duodenum.
3. No drainage tube was placed.
4. 20 mL of brown-colored fluid was aspirated from the gallbladder and sent to lab for culture.