drobinson1
Networker
I'm having a tough time with this report. I got 76942/32422 for the thoracentesis but I'm not sure what to use for the injection.
History: Patient is a 54 yr old female w/symptomatic bilateral pleural effusions. Patient has a right sided aspira catheter which is poorly draining. patient presents for ultrasoun guided thoracenesis.
Ultrasound evaluation of the left chest reveals a moderate left pleural effusion. An image is on file in radiology.
Using ultrasound guidance a 5-French multi-sidehole catheter was inserted into the pleural effusion from a inferolateral posterior approach. Approximately 500 ml of bloody fluid was obtained. The fluid was sent for appropriate lab studies.
Ultrasound evaluation of the right chest reveals a small right pleural effusion. An image is on file in radiology. I flush the right chest tube. I was unable to aspirate fluid. I then injected 10 mg of TPA in 25 ml of normal saline into the right chest tube. This will infuse for 30 minutes.
Impression: Ultrasound guided left thoracentesis.
Probable obstruction of the right chest tube. TPA was instilled to clear out the catheter.
History: Patient is a 54 yr old female w/symptomatic bilateral pleural effusions. Patient has a right sided aspira catheter which is poorly draining. patient presents for ultrasoun guided thoracenesis.
Ultrasound evaluation of the left chest reveals a moderate left pleural effusion. An image is on file in radiology.
Using ultrasound guidance a 5-French multi-sidehole catheter was inserted into the pleural effusion from a inferolateral posterior approach. Approximately 500 ml of bloody fluid was obtained. The fluid was sent for appropriate lab studies.
Ultrasound evaluation of the right chest reveals a small right pleural effusion. An image is on file in radiology. I flush the right chest tube. I was unable to aspirate fluid. I then injected 10 mg of TPA in 25 ml of normal saline into the right chest tube. This will infuse for 30 minutes.
Impression: Ultrasound guided left thoracentesis.
Probable obstruction of the right chest tube. TPA was instilled to clear out the catheter.