is this enough info to code MCS 99144?
PROCEDURE: Esophagogastroduodenoscopy
a 41 year old female presenting for esophagogastroduodenoscopy. Indication is for nausea, vomiting in a patient who has been admitted for treatment of PID by the gynecologic team. She mentions that she has a nausea with narcotics, however she takes vicodin at home chronically for neuropathic pain from diabetes. She is also on antibiotics which may be associated with her nausea. No alarm signs of dysphagia, odynophagia, unintentional weight loss, GI bleeding (melena, hematemesis), fevers, chills, or jaundice. No early family history of colorectal cancer. The nausea and vomiting has resolved today. She has mild pelvic pain and a pelvic ultrasound has been ordered and pending.
Pertinent labs and records were reviewed.
Patient examined.
Vital signs stable.
NAD. NCAT, obese
RRR. CTA B/L
Abdomen: soft / mild tenderness in bilateral lower quadrants (pelvis) / ND
PROCEDURE:
Indications/risks/benefits/alternatives to procedure were discussed and informed consent was obtained. An Olympus endoscope was inserted through the mouth and advanced through the esophagus, stomach and then to the second part of the duodenum. Careful inspection was performed during introduction and withdrawal of the scope. Retroflexion was performed in the stomach. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturation were monitored continuously. The patient tolerated the procedure well without complication.
# of pathology specimen(s) sent to lab: one (antrum)
SEDATION:
Demerol 25 mg IV
Versed 6 mg IV
FINDINGS:
1. Esophagus:
-no obstruction, dilation, strictures, webs, diverticula, or polyps noted
-GE Junction located at 40 cm from the incisors
-no esophagitis
-small hiatal hernia
2. Stomach: mild gastritis noted in antrum, no bleeding, no ulcers
3. Duodenum: no ulcers, normal duodenum to 2nd portion.
IMPRESSION: a 41 year old female with nausea that has resolved. It may be due to a combination of narcotics/antibiotics and does not appear to be related to structural abnormalities on endoscopy. EGD was normal except for gastritis. Biopsies taken to rule out helicobacter pylori.
RECOMMENDATION:
-PPI
-await bx, test and treat for helicobacter pylori
-caution with narcotic balance
-await gastric emptying test results (performed yesterday 3/17/08- results pending)
-strict glycemic control with improve gastric emptying. (current blood sugars 150s-240s/ A1c 7.6).
PROCEDURE: Esophagogastroduodenoscopy
a 41 year old female presenting for esophagogastroduodenoscopy. Indication is for nausea, vomiting in a patient who has been admitted for treatment of PID by the gynecologic team. She mentions that she has a nausea with narcotics, however she takes vicodin at home chronically for neuropathic pain from diabetes. She is also on antibiotics which may be associated with her nausea. No alarm signs of dysphagia, odynophagia, unintentional weight loss, GI bleeding (melena, hematemesis), fevers, chills, or jaundice. No early family history of colorectal cancer. The nausea and vomiting has resolved today. She has mild pelvic pain and a pelvic ultrasound has been ordered and pending.
Pertinent labs and records were reviewed.
Patient examined.
Vital signs stable.
NAD. NCAT, obese
RRR. CTA B/L
Abdomen: soft / mild tenderness in bilateral lower quadrants (pelvis) / ND
PROCEDURE:
Indications/risks/benefits/alternatives to procedure were discussed and informed consent was obtained. An Olympus endoscope was inserted through the mouth and advanced through the esophagus, stomach and then to the second part of the duodenum. Careful inspection was performed during introduction and withdrawal of the scope. Retroflexion was performed in the stomach. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturation were monitored continuously. The patient tolerated the procedure well without complication.
# of pathology specimen(s) sent to lab: one (antrum)
SEDATION:
Demerol 25 mg IV
Versed 6 mg IV
FINDINGS:
1. Esophagus:
-no obstruction, dilation, strictures, webs, diverticula, or polyps noted
-GE Junction located at 40 cm from the incisors
-no esophagitis
-small hiatal hernia
2. Stomach: mild gastritis noted in antrum, no bleeding, no ulcers
3. Duodenum: no ulcers, normal duodenum to 2nd portion.
IMPRESSION: a 41 year old female with nausea that has resolved. It may be due to a combination of narcotics/antibiotics and does not appear to be related to structural abnormalities on endoscopy. EGD was normal except for gastritis. Biopsies taken to rule out helicobacter pylori.
RECOMMENDATION:
-PPI
-await bx, test and treat for helicobacter pylori
-caution with narcotic balance
-await gastric emptying test results (performed yesterday 3/17/08- results pending)
-strict glycemic control with improve gastric emptying. (current blood sugars 150s-240s/ A1c 7.6).
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