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Procedure: Selective____arteriography, embolization with follow-up angiogram Indication: Date: Access site: Right common femoral artery with US Operators: Drs. Medications: mg IV Versed, mcg IV fentanyl Embolic agent: Contrast: mL…
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PROCEDURE: Tunneled Hickman catheter exchange with fluoroscopy DATE: CLINICAL INDICATION: __ year-old female with malnutrition requiring TPN. Recently placed Hickman catheter broken. Needs new Hickman placed. OPERATING PHYSICIANS: John Doe, MD (Attending)/Jane Doe, MD (Fellow)…
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PROCEDURE: Tunneled Hickman catheter placement DATE: CLINICAL INDICATION: OPERATING PHYSICIANS: John Doe, MD (Attending)/Jane Doe, MD (Fellow) MEDICATIONS: ACCESS: ____vein with ultrasound guidance CONTRAST: None FLUOROSCOPY TIME: minutes COMPLICATIONS: None…
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PROCEDURE: Percutaneous image guided antegrade gastrostomy tube placement INDICATION: DATE: OPERATORS: John Doe, MD (Attending)/Jane Doe, MD (Fellow) MEDICATIONS: Glucagon mg IV, Versed mg IV, and Fentanyl …
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PROCEDURE: CT-guided gastrostomy tube placement DATE: CLINICAL INDICATION: __-year-old male achalasia, small bowel obstruction, unable to place nasogastric tube. Venting gastrostomy tube OPERATING PHYSICIANS: John Doe, MD (Attending)/Jane Doe, MD (Fellow) MEDICATIONS: Versed…
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PROCEDURE: IMAGE GUIDED RETROGRADE GASTROSTOMY TUBE PLACEMENT INDICATION: Head and neck cancer with tracheostomy requiring G-tube placement. OPERATOR: John Doe, MD (Attending)/Jane Doe, MD (Fellow) MEDICATIONS: Fentanyl 150 mcg IV Glucagon …
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Procedure: Selective SMA angiogram in the AP and RAO projections. Selective celiac axis angiogram. Selective IMA angiogram in the AP and LAO projections. Limited right common femoral angiogram. Closure of arteriotomy with VasCade device. …
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Procedure: Gastrostomy tube contrast evaluation and replacement Indication: Worn/Leaking Date: Operators: Medications: Fluoroscopy time: minutes Catheter: French ballooned gastrostomy tube Complications: None immediate. Procedure: The risks, benefits, and alternatives to…
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Patient Name: , DOB: SEX: Ordering Physician: , PROCEDURE: Gastrostomy to gastrojejunostomy tube conversion with fluoroscopic guidance DATE: CLINICAL INDICATION: OPERATING PHYSICIANS: John Doe, MD (Attending)/Jane Doe, MD…
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Procedure: Endovenous laser ablation of Right GSV and SSV left great and left small saphenous veins Indication: Long-standing venous insufficiency with failed medical therapy Date: Operators: John Doe, MD (Attending)/Jane Doe, MD (Fellow) …
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