Hello List,
I need some clarification on conventional Arthrograms documentation. Will you look at this report and tell me if this documentation supports one please? Thanks in advance. Denise
Under fluoroscopic guidance the
access site was marked on the skin. The skin was prepped and draped
in the routine sterile fashion. After administering local anesthesia
a 22 gauge spinal needle was introduced into the shoulder joint using
an anterior approach. 12 cc of a combination of 5 cc of 1%
Xylocaine, 5 cc of Omnipaque 300, 10 cc of Bacteriostatic saline and
0.1 cc of Gadolinium was administered into the joint after confirming
the location. At the end of the procedure the needle was removed.
Patient tolerated the procedure without immediate complications.
Multiple spot views were obtained.
FINDINGS: The spot views of the left shoulder reveals a good
distention of the joint with contrast. No evidence for rotator cuff
tear. Glenohumeral joint and acromioclavicular joint are normal in
alignment.
IMPRESSION:
a. Successful fluoroscopic guided left shoulder
arthrogram. No evidence for rotator cuff tear.
b. Patient was shifted to the MR for an MR arthrogram
which will be interpreted separately.
I need some clarification on conventional Arthrograms documentation. Will you look at this report and tell me if this documentation supports one please? Thanks in advance. Denise
Under fluoroscopic guidance the
access site was marked on the skin. The skin was prepped and draped
in the routine sterile fashion. After administering local anesthesia
a 22 gauge spinal needle was introduced into the shoulder joint using
an anterior approach. 12 cc of a combination of 5 cc of 1%
Xylocaine, 5 cc of Omnipaque 300, 10 cc of Bacteriostatic saline and
0.1 cc of Gadolinium was administered into the joint after confirming
the location. At the end of the procedure the needle was removed.
Patient tolerated the procedure without immediate complications.
Multiple spot views were obtained.
FINDINGS: The spot views of the left shoulder reveals a good
distention of the joint with contrast. No evidence for rotator cuff
tear. Glenohumeral joint and acromioclavicular joint are normal in
alignment.
IMPRESSION:
a. Successful fluoroscopic guided left shoulder
arthrogram. No evidence for rotator cuff tear.
b. Patient was shifted to the MR for an MR arthrogram
which will be interpreted separately.