Lung biopsy with CT guidance
Name:
Exam Date:
Indication:
CPT Code/s:
Procedure start time:
Procedure end time:
Attending radiologist:
Resident radiologist:
Anesthesia:
Moderate sedation analgesia was attained with __ mg of IV Versed and __ mcg of IV Fentanyl.
Anesthesia start time:
Anesthesia end time:
Consent:
After the explanation of the risks, benefits, alternatives and possible complications, written and verbal informed consent was obtained from the patient and placed in the chart.
Procedure:
The patient was identified in same day services and a brief history and physical was conducted and placed in the patients chart. The patient was then transfered to the computed tomography suite and placed in the ________ position. Contiguous 5 mm thick axial images through the chest were obtained without intravenous contrast. A ___ mm left/right upper/middle/lower lobe nodule/mass was again identified. An appropriate site was chosen for needle entry and this area was marked, prepped, and draped in the usual sterile fashion. Local infiltrative anesthesia was achieved with 1% Lidocaine without Epinephrine. Then, a ___ gauge, ___ centimeter Quick--Core biopsy needle was advanced to the pleural surface. Subsequent imaging revealed that the needle was angled correctly. The needle was then advanced to the lesion. Subsequent imaging revealed appropriate placement of the needle. At this time, the inner cannula was removed and the biopsy needle was placed. The throw was advanced into the lesion and confirmed with CT. ____ specimens were obtained and placed in formalin. The needle was then removed under continuous aspiration, hemostasis was achieved and a band-aid was placed.
Post procedural CT demonstrated no evidence for pneumothorax or hemorrhage. The patient was then transferred to same day services for continued monitoring by nursing staff. The specimens were hand delivered to pathology.
A 2 hour post procedural upright inspiratory and expiratory chest radiograph revealed no evidence of pneumothorax. The patient remained stable and had no complaints. They were given strict instructions to return to the nearest emergency department should they develop symptoms of chest pain or shortness of breath.
Impression:
Technically successful computed tomography guided lung biopsy.
Exam Date:
Indication:
CPT Code/s:
Procedure start time:
Procedure end time:
Attending radiologist:
Resident radiologist:
Anesthesia:
Moderate sedation analgesia was attained with __ mg of IV Versed and __ mcg of IV Fentanyl.
Anesthesia start time:
Anesthesia end time:
Consent:
After the explanation of the risks, benefits, alternatives and possible complications, written and verbal informed consent was obtained from the patient and placed in the chart.
Procedure:
The patient was identified in same day services and a brief history and physical was conducted and placed in the patients chart. The patient was then transfered to the computed tomography suite and placed in the ________ position. Contiguous 5 mm thick axial images through the chest were obtained without intravenous contrast. A ___ mm left/right upper/middle/lower lobe nodule/mass was again identified. An appropriate site was chosen for needle entry and this area was marked, prepped, and draped in the usual sterile fashion. Local infiltrative anesthesia was achieved with 1% Lidocaine without Epinephrine. Then, a ___ gauge, ___ centimeter Quick--Core biopsy needle was advanced to the pleural surface. Subsequent imaging revealed that the needle was angled correctly. The needle was then advanced to the lesion. Subsequent imaging revealed appropriate placement of the needle. At this time, the inner cannula was removed and the biopsy needle was placed. The throw was advanced into the lesion and confirmed with CT. ____ specimens were obtained and placed in formalin. The needle was then removed under continuous aspiration, hemostasis was achieved and a band-aid was placed.
Post procedural CT demonstrated no evidence for pneumothorax or hemorrhage. The patient was then transferred to same day services for continued monitoring by nursing staff. The specimens were hand delivered to pathology.
A 2 hour post procedural upright inspiratory and expiratory chest radiograph revealed no evidence of pneumothorax. The patient remained stable and had no complaints. They were given strict instructions to return to the nearest emergency department should they develop symptoms of chest pain or shortness of breath.
Impression:
Technically successful computed tomography guided lung biopsy.