Cats3
Contributor
Would anyone be able to help me with the coding on this? I'm at a loss. Thank you in advance!
History: History of tracheostomy colostomy, revision, liver abscess status post drain placement and removal. Status post CT-guided drain placement into the liver abscess on 08/07/2024, CT-guided drain placement into the pelvic fluid collection on
08/14/2004. It was reported decreased output from the drainage tubes. Patient presented to IR for computed tomography (CT) and ultrasound guided placement of a percutaneous drain into the apparent liver abscess, repositioning drain tube, and the removal
of the pelvic drain tube with sedation.
Comparison: CT abdomen and pelvis with IV contrast on 08/18/2024
Medications:
1. Versed 1 mg IV
2. Fentanyl 50mcg IV
3. Lidocaine 2% for local anesthesia 10 ml
4. Patient already on antibiotics
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 45 minutes monitoring time.
Contrast Data:
Total Skin Dosage: mGy.cm
Complications: None
Specimens: Fluid sample sent to lab for analysis
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 a hyperechoic area in the posterior RIGHT hepatic lobe. Preliminary CT demonstrated a hypoattenuating area in the posterior RIGHT hepatic lobe. There was no residual fluid collection around the pelvic drainage
catheter.
Using the RIGHT lateral approach and ultrasound for guidance, a 5 French Yueh catheter was advanced through the liver parenchyma into the hyperechoic area in the posterior RIGHT hepatic lobe. CT abdomen was performed to confirm the location of catheter
tip in the hypoattenuation of the RIGHT hepatic lobe. However there was no fluid was aspirated through the catheter. The catheter was removed. Dermabond and a sterile dressing were applied.
The patient was placed on his the LEFT lateral decubitus. Maximum sterile barrier was used.
The suture of pre-existing catheter in the liver abscess was severed. In conjunction with the guidewire, the pre-existing catheter was advanced into the hypoattenuation of the RIGHT hepatic lobe under CT guidance. CT abdomen was performed to confirm the
pigtail loop in the liver abscess. 2 mL of cloudy yellow fluid was aspirated and sent to lab for culture. The catheter was secured to skin using 2-0 Ethilon and attached accordion drain. Sterile dressing was applied.
The suture over the pre-existing pelvic drainage catheter was severed. The catheter was removed in its entirety. Dermabond and sterile dressing was applied.
Results discussed in detail with the patient and family. Patient tolerated the procedure well and left procedure suite for return to inpatient room in good condition.
Multiple hardcopy computed tomography (CT) images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Ultrasound and CT-guided aspiration of the liver abscess. There was no fluid drained through catheter suggestive of organized infection or phlegmon.
2. Successful Ultrasound and CT-guided repositioning liver abscess drain tube. 2 mL of cloudy yellow fluid was aspirated and sent to lab for culture. The tube was connected with accordion bag.
3. Successful US and CT guided removal of pelvic drain tube.
History: History of tracheostomy colostomy, revision, liver abscess status post drain placement and removal. Status post CT-guided drain placement into the liver abscess on 08/07/2024, CT-guided drain placement into the pelvic fluid collection on
08/14/2004. It was reported decreased output from the drainage tubes. Patient presented to IR for computed tomography (CT) and ultrasound guided placement of a percutaneous drain into the apparent liver abscess, repositioning drain tube, and the removal
of the pelvic drain tube with sedation.
Comparison: CT abdomen and pelvis with IV contrast on 08/18/2024
Medications:
1. Versed 1 mg IV
2. Fentanyl 50mcg IV
3. Lidocaine 2% for local anesthesia 10 ml
4. Patient already on antibiotics
Upper extremity IV was used. Patient underwent continuous physiologic monitoring throughout the procedure. Conscious sedation was administered and monitored by me with total of 45 minutes monitoring time.
Contrast Data:
Total Skin Dosage: mGy.cm
Complications: None
Specimens: Fluid sample sent to lab for analysis
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 a hyperechoic area in the posterior RIGHT hepatic lobe. Preliminary CT demonstrated a hypoattenuating area in the posterior RIGHT hepatic lobe. There was no residual fluid collection around the pelvic drainage
catheter.
Using the RIGHT lateral approach and ultrasound for guidance, a 5 French Yueh catheter was advanced through the liver parenchyma into the hyperechoic area in the posterior RIGHT hepatic lobe. CT abdomen was performed to confirm the location of catheter
tip in the hypoattenuation of the RIGHT hepatic lobe. However there was no fluid was aspirated through the catheter. The catheter was removed. Dermabond and a sterile dressing were applied.
The patient was placed on his the LEFT lateral decubitus. Maximum sterile barrier was used.
The suture of pre-existing catheter in the liver abscess was severed. In conjunction with the guidewire, the pre-existing catheter was advanced into the hypoattenuation of the RIGHT hepatic lobe under CT guidance. CT abdomen was performed to confirm the
pigtail loop in the liver abscess. 2 mL of cloudy yellow fluid was aspirated and sent to lab for culture. The catheter was secured to skin using 2-0 Ethilon and attached accordion drain. Sterile dressing was applied.
The suture over the pre-existing pelvic drainage catheter was severed. The catheter was removed in its entirety. Dermabond and sterile dressing was applied.
Results discussed in detail with the patient and family. Patient tolerated the procedure well and left procedure suite for return to inpatient room in good condition.
Multiple hardcopy computed tomography (CT) images were obtained throughout the procedure and permanently stored in PACS system.
Impression:
1. Ultrasound and CT-guided aspiration of the liver abscess. There was no fluid drained through catheter suggestive of organized infection or phlegmon.
2. Successful Ultrasound and CT-guided repositioning liver abscess drain tube. 2 mL of cloudy yellow fluid was aspirated and sent to lab for culture. The tube was connected with accordion bag.
3. Successful US and CT guided removal of pelvic drain tube.