JOGelico
Guest
I am stumped on what I can report and what I can't report. I would appreciate coding the following portion of this note:
The patient was placed seated with Terason T3200 ultrasound system used. The patient was initially placed with the arm abducted and long head of the biceps was visualized within the intertubercular groove with no fluid seen. Images were obtained both axial and longitudinally at the proximal humeral head. The patient was also placed in an externally rotated position to visualize the subscapular tendon. No tears were visualized. Images were reviewed in longitudinal and axial position as well as patient was placed in crass position with the supraspinatus tendon visualized with a possible articular-sided partial-thickness rotator tear visualized, as well as a small 2-3 mm area of hyperechogenicity within the supraspinatus tendon consistent with calcific tendinosis. The subacromial space was also visualized with a very small linear area of fluid, consistent with swelling of the subacromial/subdeltoid bursa. The infraspinatus and teres minor tendons were also visualized with no signs of rotator cuff tear. Ultrasound-guided steroid injection was then attempted using the same Terason 3200 probe using 17 hertz linear probe. The patient was placed seated. The area was prepped and draped in sterile manner. The supraspinatus tendon and area of hyperechogenicity consistent with calcific tendinosis was visualized. Initially, the subacromial/subdeltoid bursa was approached in plane to the ultrasound beam with the needle with approximately 3-4 mL of lidocaine and steroid injected into the area. The needle was then repositioned to the supraspinatus tendon to the area of the hyperechogenicity consistent with calcific tendinosis where another 3 or 4 mL of lidocaine and steroid were injected. Additionally, the area was dry needled in order to break up the areas of calcific tendinosis and calcium deposits. The calcific tendinosis was broken up and on repeat ultrasound imaging, the ultrasound images showed less hyperechogenicity of the area of perceived calcific tendinosis consistent with possible breaking up of the calcium deposit. The injection that was utilized was lidocaine 1% without epinephrine, approximately 5 mL with Depo-Medrol 40 mg per mL with 1 mL included in the solution. The patient tolerated the procedure well and on post-examination was able to range his shoulder with less discomfort than prior to the injection. No sedation was used.
Thank you fellow coders
JO
The patient was placed seated with Terason T3200 ultrasound system used. The patient was initially placed with the arm abducted and long head of the biceps was visualized within the intertubercular groove with no fluid seen. Images were obtained both axial and longitudinally at the proximal humeral head. The patient was also placed in an externally rotated position to visualize the subscapular tendon. No tears were visualized. Images were reviewed in longitudinal and axial position as well as patient was placed in crass position with the supraspinatus tendon visualized with a possible articular-sided partial-thickness rotator tear visualized, as well as a small 2-3 mm area of hyperechogenicity within the supraspinatus tendon consistent with calcific tendinosis. The subacromial space was also visualized with a very small linear area of fluid, consistent with swelling of the subacromial/subdeltoid bursa. The infraspinatus and teres minor tendons were also visualized with no signs of rotator cuff tear. Ultrasound-guided steroid injection was then attempted using the same Terason 3200 probe using 17 hertz linear probe. The patient was placed seated. The area was prepped and draped in sterile manner. The supraspinatus tendon and area of hyperechogenicity consistent with calcific tendinosis was visualized. Initially, the subacromial/subdeltoid bursa was approached in plane to the ultrasound beam with the needle with approximately 3-4 mL of lidocaine and steroid injected into the area. The needle was then repositioned to the supraspinatus tendon to the area of the hyperechogenicity consistent with calcific tendinosis where another 3 or 4 mL of lidocaine and steroid were injected. Additionally, the area was dry needled in order to break up the areas of calcific tendinosis and calcium deposits. The calcific tendinosis was broken up and on repeat ultrasound imaging, the ultrasound images showed less hyperechogenicity of the area of perceived calcific tendinosis consistent with possible breaking up of the calcium deposit. The injection that was utilized was lidocaine 1% without epinephrine, approximately 5 mL with Depo-Medrol 40 mg per mL with 1 mL included in the solution. The patient tolerated the procedure well and on post-examination was able to range his shoulder with less discomfort than prior to the injection. No sedation was used.
Thank you fellow coders
JO
!