Nephrostomy tube placement sample dictation

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Procedure: Fluoroscopically guided placement of [left] nephrostomy tube.


Radiologist: []


History: []


Technique:


After informed consent was obtained, the patient was placed prone on the fluoroscopy table. The [left] flank was prepped and draped in a sterile fashion. After administration local anesthesia and under ultrasound guidance, a lower pole calix of the [left] kidney was punctured with a 21 gauge needle. After a series of exchanges a 6 French introducer catheter was placed in the [left] renal pelvis. A guidewire was then advanced into the [left] renal pelvis. The intoducer was exchanged over the wire. A [8] French APD was placed within the [left] renal pelvis. The cathter was sutured to the patient's skin and a sterile dressing was applied.


Findings:


Initial ultrasound images demonstrate [moderate left hydronephrosis ]. Pyelogram images confirm the hydronephrosis .


Final images demonstrate an [8] French APD within the left renal pelvis.


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


Medications: Versed [ ] mg IV, Fentanyl [ ] ug IV.


Impression:


Successful placement of [left] 8 French nephrostomy tube.