jtuominen
Guru
Wondering how other may tackle the coding of this report:
HISTORY: 53-year-old female with left hydronephrosis secondary to
metastatic endometrial cancer.
FINDINGS: The procedure and risks were explained to the patient and
her family in detail. Under sterile technique, an antegrade pyelogram
was performed with a 22-gauge needle. Posterior mid calyx was selected
and an 18-gauge needle was inserted into the dilated collecting
system. A JBI catheter and wire were directed down the left ureter and
a distal left ureterogram was performed demonstrating high-grade
obstruction at the left ureterovesical junction secondary to malignant
obstruction. The wire was then exchanged for a Glidewire and the
catheter was advanced over the wire into the bladder. The wire was
then exchanged for an Amplatz superstiff wire. The tract was dilated
to 10 French and 8 French 22 cm double J ureteral stent was placed.
Following stent placement 8 French nephrostomy tube was placed in the
left intrarenal collecting system and left external drainage. After
initial external drainage, the nephrostomy tube will be capped for a
trial of internal drainage and if tolerated the nephrostomy tube can
be removed.
Fluorotime 6.2 minutes.
Contrast: 20 mL Hexabrix.
Local anesthetic 10 mL 1% lidocaine.
Conscious sedation: 3.5 mg IV Versed, 175 mcg IV fentanyl.
Sedation time: 20 minutes.
The patient was monitored by radiology nursing staff under my
supervision and remained stable throughout the study.
IMPRESSION:
1. Moderate left hydronephrosis and hydroureter secondary to
high-grade obstruction at the level of the left ureterovesical
junction.
2. Successful left ureteral stent placement and left nephrostomy
placement.
HISTORY: 53-year-old female with left hydronephrosis secondary to
metastatic endometrial cancer.
FINDINGS: The procedure and risks were explained to the patient and
her family in detail. Under sterile technique, an antegrade pyelogram
was performed with a 22-gauge needle. Posterior mid calyx was selected
and an 18-gauge needle was inserted into the dilated collecting
system. A JBI catheter and wire were directed down the left ureter and
a distal left ureterogram was performed demonstrating high-grade
obstruction at the left ureterovesical junction secondary to malignant
obstruction. The wire was then exchanged for a Glidewire and the
catheter was advanced over the wire into the bladder. The wire was
then exchanged for an Amplatz superstiff wire. The tract was dilated
to 10 French and 8 French 22 cm double J ureteral stent was placed.
Following stent placement 8 French nephrostomy tube was placed in the
left intrarenal collecting system and left external drainage. After
initial external drainage, the nephrostomy tube will be capped for a
trial of internal drainage and if tolerated the nephrostomy tube can
be removed.
Fluorotime 6.2 minutes.
Contrast: 20 mL Hexabrix.
Local anesthetic 10 mL 1% lidocaine.
Conscious sedation: 3.5 mg IV Versed, 175 mcg IV fentanyl.
Sedation time: 20 minutes.
The patient was monitored by radiology nursing staff under my
supervision and remained stable throughout the study.
IMPRESSION:
1. Moderate left hydronephrosis and hydroureter secondary to
high-grade obstruction at the level of the left ureterovesical
junction.
2. Successful left ureteral stent placement and left nephrostomy
placement.