Sample coded IVR Report Intervention Radiology

Report 1

Sample coded IVR Report Intervention Radiology
LUMBAR EPIDURAL STEROID INJECTION USING FLUOROSCOPIC GUIDANCE
STERILE SURGICAL TRAY UTILIZED

INDICATION/DIAGNOSIS: Suspected spinal fluid leak

TECHNIQUE: The risks and benefits of the procedure were discussed with the patient who verbalized understanding. The risks included, but were not limited to, bleeding, infection, and nerve injury. The patient gave both written and verbal informed consent to proceed. needle was advanced into the posterior epidural space under fluoroscopic guidance from a translaminar approach on the left side at L5-S1. Loss of resistance technique was utilized to enter the epidural space since there is a history of contrast allergy. After injection of 4 mL of a pelvic is blood the patient complained of increasing lower back and buttock pain and the injection was terminated. The pain returned to baseline quickly.

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FINDINGS: 8 seconds of fluoroscopy time was utilized for this procedure.

ESTIMATED BLOOD LOSS: Less than 10 mL

IMPRESSION:
1. Epidural blood patch. Very limited amount of blood was able to be injected before the procedure was terminated.

62311, 77003-26



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Report 2

ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION OF THE INCISIONAL FLUID:
COLLECTION WITH STERILE TRAY

INDICATION/DIAGNOSIS: Postop spine surgery. Fluid collection identified within the subcutaneous tissues at the laminotomy site as well as within the laminotomy defect. For aspiration today.

Sonographically, a superficial subcutaneous fluid collection is identified, and measures 2.7 x 1.2 x 0.9 cm. At the same level but deeper in location, a hypoechoic structure is present and measures 2.9
x 2.5 cm, likely corresponding to the fluid collection within the laminotomy defect on MRI. Pulsating color flow within the defect is noted, suspicious for a cerebral spinal fluid leak.

PROCEDURE: Informed written and verbal consent was obtained today, 19 November 2014. Potential complications discussed included pain, bleeding, and infection. The risks, benefits and alternatives to the procedure were discussed with the patient and she appeared to understand and did sign the consent.

The patient was positioned on the ultrasound table and the midline lower lumbar spine and back were prepped with chlorhexidine swabs and draped with sterile towels. Sterile ultrasound jelly was placed on the skin. Under continuous ultrasound guidance, approximately 4 mL of 1% lidocaine buffered with sodium bicarbonate was injected along the needle tract to the lymph node for local anesthesia. A surgical supply tray was used for the procedure. Under ultrasound guidance, a 16-gauge needle is placed into the superficial fluid collection and 3 cc of blood-tinged fluid is removed, without complication, (site 1).

Subsequently, a 20-gauge spinal needle is advanced into the dorsal aspect of the deeper 2.9 cm fluid collection. As the needle advanced into the dorsal most aspect of the fluid collection, the patient's leg pain was reproduced. The needle was repositioned elsewhere within the dorsal aspect of the fluid collection and 6 cc of clear fluid, much like CSF, was removed, (site 2). The patient did not experience any further pain.

Pressure was held over the biopsy site utilizing sterile 4 x 4 gauze and an ice pack until all bleeding subsided. A repeat ultrasound was performed and showed no active bleeding or hematoma formation. A bandage was placed across the skin at the biopsy site.

IMPRESSION: Ultrasound-guided fine needle aspiration of the
subcutaneous and paraspinal fluid collections.

10022 (site 1), 10022-59 (site 2),76942-26, 76942-26,59

Report 3

ULTRASOUND-GUIDED LEFT THORACENTESIS

INDICATION/DIAGNOSIS: Left pleural effusion

CONSENT: The procedure, risks, indications and alternatives were explained. All questions were answered and informed consent wasobtained, signed and witnessed from the patient.

TECHNIQUE: Ultrasound localization of the fluid was performed. The posterior chest was prepped and draped in the usual sterile fashion.

Local anesthesia was obtained with 1% lidocaine. The pleural fluid was accessed under direct ultrasound visualization with a 5F Yueh catheter. Using a closed system the pleural fluid was aspirated. 250
mL was obtained. The fluid was sent to the lab for analysis.

FINDINGS: Ultrasound appearance of the fluid was serosanguineous The fluid was thin yellow.

ESTIMATED BLOOD LOSS: Less than 10 mL.

SPECIMENS: 250 cc serosanguineous fluid from the left pleural space

COMPLICATIONS: None.

IMPRESSION:
1. Successful ultrasound-guided left sided thoracentesis.

32555-LT

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