Procedure Macros
Procedural Sedation
The patient’s evaluation is consistent with _ for which procedural sedation was recommended. The details of the procedure were discussed with the patient including use of cardiopulmonary monitoring equipment, IV placement, specific drugs, airway support, and post-sedation monitoring; alternatives and likely outcomes including no sedation were communicated with the patient. Risks of the procedure were discussed including pain, failure/awareness, vivid dreams/emergence reactions, difficulty breathing, respiratory depression, or apnea and the need for respiratory support; and benefits including analgesia, anxiolysis, and decreased discomfort. The patient stated understanding and verbally agreed to the procedure with written consent obtained as well.
The patient was placed on cardiac and respiratory monitoring including capnography, rescue airway adjuncts were made readily available, and the patient’s airway was assessed prior to sedation. The patient was sedated with _ for the procedure, and tolerated the procedure well without any immediate complications.
Electrical Cardioversion
The patient presents with evaluation consistent with the aforementioned arrhythmia, for which an electrical cardioversion was recommended. The details of the procedure were discussed with the patient, including need for possible procedural sedation, placement of pads, and electrical shock, and post-procedural monitoring; alternatives and likely outcomes including observation, chemical cardioversion/rate control were communicated with the patient. Risks of the procedure were discussed including failure, pain, worsening of their arrhythmia or decompensation to a more dangerous rhythm such as ventricular fibrillation, need for cardiopulmonary resuscitation and defibrillation, thromboembolism and benefits including termination of the arrhythmia. The patient verbally agreed to the procedure with written consent obtained as well.
The patient was placed on cardiac and respiratory monitoring, rescue airway adjuncts were made readily available, a pre-procedural EKG was obtained demonstrating the aforementioned arrhythmia. Pads were placed on the patient and the cardiac monitor/defibrillator was placed in synchronized mode. The patient was successfully cardioverted with _ J after _ attempts, with post-procedural EKG showing normal sinus rhythm. The patient tolerated the procedure well without any immediate complications.
Joint Reduction
The patient evaluation is consistent with a joint dislocation. The details of the reduction procedure were discussed with the patient including the need for pre and post procedure imaging, multiple providers in the room and usage of adjuncts to assist with joint manipulation, and possible use of procedural sedation; alternatives and likely outcomes including no reduction which may lead to permanent deformity, chronic pain, and decreased ability to use the affected joint, or need for open reduction in the OR were communicated with the patient. Risks of the procedure were discussed including pain, failure, and injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally agreed to the procedure with written consent obtained as well.
Pre-procedure imaging showed a _ dislocation. A _ technique was used to reduce the affected joint, and post-procedural imaging confirmed reduction. The patient tolerated the procedure well without any immediate complications, and the affected extremity is neurovascularly intact at this time.
Lumbar Puncture
The patient’s presentation is concerning for _, thus a lumbar puncture was recommended. The details of the reduction procedure were discussed with the patient including positioning, the use of local anesthetic and a needle to obtain fluid from the subarachnoid space below the conus medullaris, with possible use of ultrasound or procedural sedation; alternatives and likely outcomes including no LP were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, post-LP headache, cerebral herniation, and injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally agreed to the procedure with written consent obtained as well.
Pre-procedure imaging did not show any signs of cerebral mass/lesion, cerebral edema, or obstructive hydrocephalus. The patient’s bony anatomy was palpated/approximated, the area was prepped in the standard sterile fashion. CSF was successfully aspirated with _ appearance. The patient tolerated the procedure well without any immediate complications.
Incision and Drainage
The patient presents with a drainable fluid collection located _, thus incision and drainage was recommended. The details of the procedure were discussed with the patient including positioning, the use of local anesthetic and a needle or scalpel to express fluid from the lesion, and then need for possible packing or antibiotics; alternatives and likely outcomes including no drainage were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, continual drainage and injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally consented to the procedure.
_ mL of _ was used for local anesthetic, and fluid was expressed using _, with a total volume of approximately _ mL. The wound was probed and deloculated. The wound was irrigated and cleaned. _The wound was packed with iodoform gauze and covered. The patient tolerated the procedure well without any immediate complications.
Peritonsillar Abscess Needle Aspiration/Drainage
The patient presents with a drainable peritonsillar fluid collection, thus needle aspiration/drainage was recommended. The details of the procedure were discussed with the patient including positioning, suctioning, the use of local/topical anesthetic and a needle aspirate fluid from the lesion, and then need for possible antibiotics; alternatives and likely outcomes including no drainage were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, continual drainage/bleeding, injury to nearby neurovascular and musculoskeletal structures, and airway compromise. The patient stated understanding and verbally consented to the procedure with written consent obtained as well.
Rescue airway adjuncts were readily available. _ was used for topical anesthetic, _ mL of _ was used for local anesthetic, and fluid was aspirated using _, with a total volume of approximately _ mL. The patient tolerated the procedure well without any immediate complications. The patient will be monitored closely for airway compromise and ability to PO.
Arthrocentesis
The patient presents with a swollen/inflamed joint with concerning evaluation, thus arthrocentesis was recommended. The details of the procedure were discussed with the patient including positioning, the use of local/topical anesthetic and a needle aspirate fluid from the joint, and then need for possible antibiotics; alternatives and likely outcomes including no drainage were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, continual drainage/bleeding, injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally consented to the procedure with written consent obtained as well.
_ mL of _ was used for local anesthetic, and fluid was aspirated using _, with a total volume of approximately _ mL of _ appearing fluid. The patient tolerated the procedure well without any immediate complications.
The patient’s evaluation is consistent with _ for which procedural sedation was recommended. The details of the procedure were discussed with the patient including use of cardiopulmonary monitoring equipment, IV placement, specific drugs, airway support, and post-sedation monitoring; alternatives and likely outcomes including no sedation were communicated with the patient. Risks of the procedure were discussed including pain, failure/awareness, vivid dreams/emergence reactions, difficulty breathing, respiratory depression, or apnea and the need for respiratory support; and benefits including analgesia, anxiolysis, and decreased discomfort. The patient stated understanding and verbally agreed to the procedure with written consent obtained as well.
The patient was placed on cardiac and respiratory monitoring including capnography, rescue airway adjuncts were made readily available, and the patient’s airway was assessed prior to sedation. The patient was sedated with _ for the procedure, and tolerated the procedure well without any immediate complications.
Electrical Cardioversion
The patient presents with evaluation consistent with the aforementioned arrhythmia, for which an electrical cardioversion was recommended. The details of the procedure were discussed with the patient, including need for possible procedural sedation, placement of pads, and electrical shock, and post-procedural monitoring; alternatives and likely outcomes including observation, chemical cardioversion/rate control were communicated with the patient. Risks of the procedure were discussed including failure, pain, worsening of their arrhythmia or decompensation to a more dangerous rhythm such as ventricular fibrillation, need for cardiopulmonary resuscitation and defibrillation, thromboembolism and benefits including termination of the arrhythmia. The patient verbally agreed to the procedure with written consent obtained as well.
The patient was placed on cardiac and respiratory monitoring, rescue airway adjuncts were made readily available, a pre-procedural EKG was obtained demonstrating the aforementioned arrhythmia. Pads were placed on the patient and the cardiac monitor/defibrillator was placed in synchronized mode. The patient was successfully cardioverted with _ J after _ attempts, with post-procedural EKG showing normal sinus rhythm. The patient tolerated the procedure well without any immediate complications.
Joint Reduction
The patient evaluation is consistent with a joint dislocation. The details of the reduction procedure were discussed with the patient including the need for pre and post procedure imaging, multiple providers in the room and usage of adjuncts to assist with joint manipulation, and possible use of procedural sedation; alternatives and likely outcomes including no reduction which may lead to permanent deformity, chronic pain, and decreased ability to use the affected joint, or need for open reduction in the OR were communicated with the patient. Risks of the procedure were discussed including pain, failure, and injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally agreed to the procedure with written consent obtained as well.
Pre-procedure imaging showed a _ dislocation. A _ technique was used to reduce the affected joint, and post-procedural imaging confirmed reduction. The patient tolerated the procedure well without any immediate complications, and the affected extremity is neurovascularly intact at this time.
Lumbar Puncture
The patient’s presentation is concerning for _, thus a lumbar puncture was recommended. The details of the reduction procedure were discussed with the patient including positioning, the use of local anesthetic and a needle to obtain fluid from the subarachnoid space below the conus medullaris, with possible use of ultrasound or procedural sedation; alternatives and likely outcomes including no LP were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, post-LP headache, cerebral herniation, and injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally agreed to the procedure with written consent obtained as well.
Pre-procedure imaging did not show any signs of cerebral mass/lesion, cerebral edema, or obstructive hydrocephalus. The patient’s bony anatomy was palpated/approximated, the area was prepped in the standard sterile fashion. CSF was successfully aspirated with _ appearance. The patient tolerated the procedure well without any immediate complications.
Incision and Drainage
The patient presents with a drainable fluid collection located _, thus incision and drainage was recommended. The details of the procedure were discussed with the patient including positioning, the use of local anesthetic and a needle or scalpel to express fluid from the lesion, and then need for possible packing or antibiotics; alternatives and likely outcomes including no drainage were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, continual drainage and injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally consented to the procedure.
_ mL of _ was used for local anesthetic, and fluid was expressed using _, with a total volume of approximately _ mL. The wound was probed and deloculated. The wound was irrigated and cleaned. _The wound was packed with iodoform gauze and covered. The patient tolerated the procedure well without any immediate complications.
Peritonsillar Abscess Needle Aspiration/Drainage
The patient presents with a drainable peritonsillar fluid collection, thus needle aspiration/drainage was recommended. The details of the procedure were discussed with the patient including positioning, suctioning, the use of local/topical anesthetic and a needle aspirate fluid from the lesion, and then need for possible antibiotics; alternatives and likely outcomes including no drainage were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, continual drainage/bleeding, injury to nearby neurovascular and musculoskeletal structures, and airway compromise. The patient stated understanding and verbally consented to the procedure with written consent obtained as well.
Rescue airway adjuncts were readily available. _ was used for topical anesthetic, _ mL of _ was used for local anesthetic, and fluid was aspirated using _, with a total volume of approximately _ mL. The patient tolerated the procedure well without any immediate complications. The patient will be monitored closely for airway compromise and ability to PO.
Arthrocentesis
The patient presents with a swollen/inflamed joint with concerning evaluation, thus arthrocentesis was recommended. The details of the procedure were discussed with the patient including positioning, the use of local/topical anesthetic and a needle aspirate fluid from the joint, and then need for possible antibiotics; alternatives and likely outcomes including no drainage were communicated with the patient. Risks of the procedure were discussed including pain, bleeding, infection, continual drainage/bleeding, injury to nearby neurovascular and musculoskeletal structures. The patient stated understanding and verbally consented to the procedure with written consent obtained as well.
_ mL of _ was used for local anesthetic, and fluid was aspirated using _, with a total volume of approximately _ mL of _ appearing fluid. The patient tolerated the procedure well without any immediate complications.
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