Sample 1

 

PROCEDURE: Ultrasound-guided paracentesis

CLINICAL INDICATION:    

OPERATOR(S):

MEDICATIONS:    

 

PROCEDURE: Transverse real time images were obtained through the abdomen.

The risks and benefits of this procedure were discussed and informed written consent was obtained prior to performing the procedure. 

Limited ultrasound of the abdomen was performed.  The abdomen was then prepped and draped in standard sterile fashion.  Under ultrasound guidance, a 5 French centesis needle was advanced into the peritoneal fluid collection, and an image was stored to PACS documenting needle tip position.  The catheter was advanced into the collection over the needle, and the needle was removed. The catheter was connected to     and     fluid was removed. There were no immediate complications of the procedure, and blood loss was minimal. The patient tolerated the procedure well.  

FINDINGS: Large volume free peritoneal fluid. 

IMPRESSION: Successful ultrasound guided paracentesis.

 

 

Sample 2

 

Procedure:  Large volume paracentesis with ultrasound guidance          

Indication:  Ascites.    

Date:    

Operators:  Drs.    

Catheter:    

Volume:      cc clear yellow fluid

Medications:    

Albumin:     

Access site:     quadrant with ultrasound

Complications:  None immediate.

 

Procedure:

The risks, benefits, and alternatives to the procedure and sedation were explained to the patient.   The specific risks of bleeding, infection, and damage to organ or bowel were detailed and accepted. Written informed consent was obtained. A timeout was performed. 

The anterior abdominal wall was prepped and draped in sterile fashion. Ultrasonographic evaluation of the abdomen was carried out and an appropriate entry site chosen. Images were stored to PACS.

Using local anesthetic, the peritoneal cavity was accessed with    . Needle entry was documented and an image stored.   

The catheter was attached to a Vacutainer bottle wall suction  and approximately     cc clear yellow fluid were drained.   Follow-up ultrasound was performed, demonstrating no significant residual fluid.

The catheter was removed, and a sterile dressing was applied.

The procedure was well tolerated without immediate complication.

 

Findings:

There is ___ peritoneal fluid. 

Aspirated fluid was clear.

___  cc were removed without incident.

 

Impression:  

Successful ultrasound guided large volume paracentesis.