Shoulder Arthrogram for CT or MRI
Name:
Exam Date:
Indication:
CPT Code/s:
Procedure start time:
Procedure end time:
Attending radiologist: _______________ was present for and participated in the entirety of the procedure.
Resident radiologist:
Consent:
After the explanation of the risks, benefits, alternatives and possible complications, written and verbal informed consent was obtained from the patient and placed in the chart.
Procedure:
The patient was identified in the fluoroscopic suite. A brief history and physical was conducted. The patient was placed in the supine position with their R/L shoulder externally rotated. The anterior shoulder was prepped and draped in the usual sterile fashion. Local infiltrative anesthesia of the area overlying the superior humeral head was achieved utilizing 1% lidocaine without epinephrine through a 22 gauge 1.5 inch needle. Next, a 22 gauge spinal needle was inserted under real time fluoroscopic guidance until it reached the cortex of the superior medial humeral head just lateral to the coracoid. The correct placement was confirmed via fluoroscopic imaging.
The following was then injected into the shoulder capsule-
12 cc of a solution of 5 cc normal saline, 10 cc Omnipaque 300, and 5 cc 1% lidocaine for CT arthography.
-or-
12 cc of a solution of 5 cc normal saline, 5 cc Omnipaque 300, 10 cc 1% lidocaine, and 0.1 cc gadolinium for MR arthrography.
Again, correct placement within the joint was confirmed by the diffusion pattern of contrast as seen with real time fluoroscopic imaging. The needle was then removed and hemostasis was achieved. A band-aid was placed.
AP, Oblique, and Lateral spot images were then obtained which demonstrated contrast distention of the shoulder joint.
The patient reported no immediate complications and was sent to CT/MRI for further imaging.
Impression:
Technically successful R/L shoulder arthrogram
Exam Date:
Indication:
CPT Code/s:
Procedure start time:
Procedure end time:
Attending radiologist: _______________ was present for and participated in the entirety of the procedure.
Resident radiologist:
Consent:
After the explanation of the risks, benefits, alternatives and possible complications, written and verbal informed consent was obtained from the patient and placed in the chart.
Procedure:
The patient was identified in the fluoroscopic suite. A brief history and physical was conducted. The patient was placed in the supine position with their R/L shoulder externally rotated. The anterior shoulder was prepped and draped in the usual sterile fashion. Local infiltrative anesthesia of the area overlying the superior humeral head was achieved utilizing 1% lidocaine without epinephrine through a 22 gauge 1.5 inch needle. Next, a 22 gauge spinal needle was inserted under real time fluoroscopic guidance until it reached the cortex of the superior medial humeral head just lateral to the coracoid. The correct placement was confirmed via fluoroscopic imaging.
The following was then injected into the shoulder capsule-
12 cc of a solution of 5 cc normal saline, 10 cc Omnipaque 300, and 5 cc 1% lidocaine for CT arthography.
-or-
12 cc of a solution of 5 cc normal saline, 5 cc Omnipaque 300, 10 cc 1% lidocaine, and 0.1 cc gadolinium for MR arthrography.
Again, correct placement within the joint was confirmed by the diffusion pattern of contrast as seen with real time fluoroscopic imaging. The needle was then removed and hemostasis was achieved. A band-aid was placed.
AP, Oblique, and Lateral spot images were then obtained which demonstrated contrast distention of the shoulder joint.
The patient reported no immediate complications and was sent to CT/MRI for further imaging.
Impression:
Technically successful R/L shoulder arthrogram