CT-guided abscess drainage sample dictation

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Procedure: CT-guided abscess drainage.


Radiologists: []


History: []


Technique:


After informed consent was obtained the patient was placed [supine] on the CT table. Initial images of the [lower abdomen] were obtained. The puncture site was marked on the patient's skin and 1% lidocaine was administered. Using a 19 gauge needle and under CT guidance the [right lower quadrant] collection was punctured via a [right posterior] approach. A J-wire was threaded through the needle into the collection.


After serial dilatations a [12] French APD was placed within the collection and sutured to the patient's skin with 2-0 silk.


Findings:


Initial CT images demonstrate [the patient status post right hemicolectomy with an ileocolonic anastomosis and an adjacent air-containing collection in the right lower quadrant].


Final images demonstrate the [12] French APD within this collection.


Approximately [200] cc of [purulent] fluid was aspirated and a sample was sent for culture and sensitivity.


The patient tolerated the procedure well without complications.


Dr. [], the attending interventional radiologist, was present for the critical portions of the procedure and reviewed all images obtained.


Medications: Versed [] mg IV, Fentanyl [] mcg IV


Impression:


Successful CT-guided drainage of the [right lower quadrant] collection. The catheter was left to gravity drainage. Cultures pending.