I am new to gastro coding so I just want to make sure I am doing it right.
CLINICAL INDICATION: Cervical dysphagia, distal dysphagia, probable cervical web, possible distal stricture.
DESCRIPTION OF PROCEDURE:
Upon obtaining informed consent, the patient was given MAC anesthetic - see anesthesia report. The Fujinon endoscope was introduced into the small intestine. The patient had a gastrectomy and Bill Roth I anastomosis. The gastroenterostomy, remaining stomach, and enterostomy were all normal. Retroflexion revealed a hiatal hernia. There was a distal stricture. This was dilated with a 60 Fr balloon dilator 30 seconds x two. The esophagus was normal. There was no evidence of esophagitis. In the upper esophagus one could see a constriction consistent with a cervical web. This was dilated to a 54 Fr balloon dilator when one could see disruption of the stricture with some minimal bleeding, which is normal after post-stricture dilatation. The instrument was then withdrawn. The patient tolerated the procedure well.
Dysphagia primarily due to an upper cervical web - dilated to 54 French.
Hiatal hernia and distal stricture - dilated to 60 French.
We will review medications to make sure that she does not have any medication that is exacerbating her reflux and causing strictures.
Follow up with me in the office.
43235 787.29 553.3
43450 787.29 530.3
43450 59 553.3 530.3
some instruction would be appreciated
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