What CPT for US procedure note? Thanks!

kviolet

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ED Procedure Note: General:
Procedure Information:
Performed on: 01-May-2016 05:29.

Procedural/Moderate Sedation Administered: No.

Additional Comments:
· Additional Comments: Rapid ultrasound for assessment of shock performed, including
LIMITED THORACIC, ABDOMEN, CARDIAC & IVC views. Findings described below:

Focused bedside thoracic ultrasound performed by dr x
Indication: to guide fluid resuscitation
Linear probe used to evaluate thoracic cavity bilaterally at lung bases anterolaterally.
Findings:No abnormal findings noted
Images were archived in digital format. Patient was informed of limited nature of this exam and need for appropriate follow-up. Confirmatory or more comprehensive ultrasound was ordered/performed by department of radiology.

transabdominal ultrasound performed
Findings: right upper quadrant, left upper quadrant, and pelvis views obtained, including evaluation of costophrenic angle/lungs. Free fluid absentn all locations
Impression: NEGATIVE free fluid visualized in abdomen, pelvis, pericardial, pleural spaces.
Images were archived in digital format. Patient was informed of limited nature of this exam and need for appropriate follow-up. Confirmatory or more comprehensive ultrasound was ordered/performed by department of radiology.

Focused bedside cardiac ultrasound performed
Indication: unexplained tachycardia
Findings: parasternal long,parasternal short views were obtained. Cardiac motion was present with contractility appearing grossly adequate. Pericardial fluid was absent. IVC visualized in long-axis at point of entry into heart, dynamic collapse with inspiration.
Impression: no pericardial effusion, adequate contractility
Images were archived in digital format. Patient was informed of limited nature of this exam and need for appropriate follow-up. Confirmatory or more comprehensive ultrasound was ordered/performed by department of radiology.
Overall impression: some hypovolemia & capillary leak physiology likely, lungs not wet, so can give more fluids along with early pressors for persistent tachycardia.
 
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