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Paracentesis (updated 01/2019)

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Procedure Note

[FM SPECIAL PROCEDURES CLINIC: ]Paracentesis performed by ultrasound guided imagery

 

INDICATION: [XXXXX].

PRE-PROCEDURE DIAGNOSIS: [XXXXX].

POST-PROCEDURE DIAGNOSIS: [XXXXX].

PROCEDURE OPERATOR: [XXXXX].

ATTENDING PHYSICIAN: [XXXXX].

[ROOM CHARGE: 99215]

[CPT CODE: 49083]

 

CONSENT:

Consent was obtained prior to the procedure. Indications, risks (bleeding, damage to bowel, and infection), and benefits were explained at length.  All questions were answered.  Consent signed.

 

PRE-PROCEDURE SURVEY:

-Labs were reviewed prior to the procedure. The labs showed [XXXXX].

-Examination of the abdomen revealed [tense ascites, positive fluid wave, and dullness to percussion].

-The curvilinear transducer was used to scan the abdomen, and the deepest pocket of fluid was found at the [LLQ] with a depth of [XXXXX cm] before visualizing bowel loops.  This area was marked.

-The linear transducer determined the thickness of the abdominal wall to be [XXXXX cm], and color flow was used to ensure the inferior epigastric vessels were not at the marked site.  

 

PROCEDURE SUMMARY: 

A time-out was performed identifying the correct patient, procedure, site, positioning, and the equipment. My hands were washed immediately prior to the procedure.  I put on a gown and sterile gloves.  The [LLQ] was cleansed and draped in the usual sterile fashion using chlorhexidine scrub.  Anesthesia was achieved with 1% lidocaine with extra attention given to anesthetizing the peritoneum.  A small skin incision with an 11-blade was used to nick the skin.  The paracentesis catheter-over-needle was advanced at 0.25 cm increments with the non-dominant hand while the dominant hand maintained negative pressure on the syringe until [yellow and clear] fluid was aspirated.  The needle was held steady, and the catheter was then advanced toward the pocket of fluid.  The needle was removed.  The catheter was connected to the vacutainer, and [XXXXX liters] of ascitic fluid were drained.  [XXXXX grams of Albumin was given to the patient.]  [Approximately XXXXX mL was sent for laboratory analysis in a sterile urine container.]  [Cultures were inoculated at bedside]. The catheter was removed, and no leaking was noted. A bulky pressure dressing was placed over the puncture wound.  The patient tolerated the procedure well, and there were [no] immediate complications.

 

TOTAL FLUID COLLECTED AND COLOR: [XXXXX].

LABS ORDERED: [XXXXX].

EBL: [XXXXX].

COMPLICATIONS: [XXXXX].

COUNSELING: Throughout the procedure, we counseled the patient regarding adherence with medication and dietary changes. ED and return precautions given.

IUD Removal (updated 07/2018)

PROCEDURE: IUD Removal.
INDICATION: [Patient desires pregnancy].
PROCEDURE OPERATOR: [].
ATTENDING PHYSICIAN: []. [Present for the procedure].
PRE-PROCEDURE DIAGNOSIS: [].
POST-PROCEDURE DIAGNOSIS: [].
 
CONSENT:
Consent was obtained from the patient. Indications, risks, and benefits were explained at length. All questions were answered.

PROCEDURE SUMMARY:
The patient received [Ibuprofen 600 mg] while waiting to be seen.  

A time out was performed.  The patient was placed in dorsal lithotomy position.  The speculum was placed and the IUD string visualized.  Ringed forceps were used to grasp the IUD string.  The IUD was removed successfully.  Bleeding was minimal.  A pad was provided to the patient.

Complications:  The patient tolerated the procedure well without complications.

Follow-up: PRN.  Return precautions given.

Thoracentesis (updated 07/2018)

PROCEDURE: [Diagnostic and Therapeutic] Thoracentesis.
INDICATION: Large [XXXXX] pleural effusion with respiratory distress.
PROCEDURE OPERATOR: [XXXXX].
ATTENDING PHYSICIAN: [XXXXX]. [Present for the procedure].
PRE-PROCEDURE DIAGNOSIS: Large [XXXXX] pleural effusion with respiratory distress.
POST-PROCEDURE DIAGNOSIS: Large [XXXXX] pleural effusion status post drainage with improvement in respiratory distress.

CONSENT:
Consent was obtained from the patient. Indications, risks, and benefits were explained at length. All questions were answered.

PROCEDURE SUMMARY:

A time out was performed and the pre-procedure chest x-ray were reviewed in addition to our ultrasound findings. The [XXXXX] side was confirmed and marked.

[Patient sat upright in the bed and we used a posterior approach.]

The ultrasound was used at the bedside to verify there is a pleural effusion. 

The phased array probe was used to identify the deepest pocket, which was [7 cm] from the surface of the skin to the lung, at the level of approximately the [T5] interspace, and stayed away from the diaphragm after identifying the structure on ultrasound. We verified there were no obvious loculations with the phased array probe. [We were able to see consolidations in the lung.] 

The linear array probe was used to scan the subcutaneous fascia.  The subcutaneous fascia was found to be approximately [3 cm deep] and clearly marked the superior surface of the rib using ultrasound guidance for entry.  We did not note any vascular structures using the color doppler. 

My hands were washed immediately prior to the procedure. I wore a sterile gown and sterile gloves throughout the procedure. The patient was prepped and draped in a sterile manner using chlorhexidine scrub after the appropriate level was determined via ultrasound and marked (as seen above). 1% plain lidocaine was used to anesthetize the skin, subcutaneous tissue, superior aspect of the rib periosteum and parietal pleura; straw colored fluid was aspirated at a depth of approximately [3 cm] with the syringe used to anesthetize. A 11-blade scalpel was used to nick the skin at the insertion site. The thoracentesis needle was then introduced through the skin incision into the pleural space using negative aspiration pressure. The thoracentesis catheter was then threaded without difficulty. 1000 ml of straw colored fluid was removed without difficulty via manual syringe aspiration in a closed system. The catheter was then removed while the patient hummed. A pressure dressing was applied. 

No immediate complications were noted during the procedure. The patient tolerated the procedure well. 

A post-procedure chest x-ray is pending at the time of this note.

[The fluid will be sent for studies.]

Estimated blood loss: [2 mL]