I am unclear of the codes I used....someone pls clarify if I'm correct...thanx
Description of procedure:
Prior to the procedure, I discussed witht he patient regarding the risks, benefits, alternatives and complications of ERCP including the risk of pancreatitis, bleeding and perforation. After the informed consent was obtained, the patient was placed in the prone position and premedicated. After adequate sedation was achieved, a pentax video duodenoscope scope was easily introduced into the UGI tract and advanced all the way to the second portion of the duodenum. Ampulla with adherent black pigmented tiny stone was found. Using a sphincerotome, selective cannulation of the bile duct was performed and a cholangiogram was obtained. The bild duct was 12 mm in its maximal diameter with suspected CBD stone. Biliary sphincterotomy was created followed by balloon sweep of the bile duct. A large 10 mm yellow stone was retrieved along with biliary sludge and debris. The bile duct was swept completely clear.
Est. Blood loss: <1 cc
Specimen removed? No
# of spec. bottles: 0
Versed 7 mg
Demerol 150 mg
1. DIlated CBD with 10 mm CBD stone and sludge
2. S/p biliary sphincterotomy with complete removal of bile duct stone and sludge
1. Continue with Abx
2. Recommend surgery consultation for cholecystectomy
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