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Hello! could I get some help with these cases please?   Scenario 1 Title of Procedure:  Upper Inte

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Asked by CaptainManateeMaster451

Hello!

could I get some help with these cases please?

 

Scenario 1

Title of Procedure: 

Upper Intestinal Endoscopy with Biopsy

 

Anesthesia: 

General LMA

 

Preoperative Diagnosis/ Indications: 

Eosinophilic esophagitis

 

Postoperative Diagnosis/Findings:

Remarkable for mild furrowing, slightly irregular surface pattern more prominent in distal esophagus, and overall esophagus seemed less pliable. Small patch of erythema in the duodenal bulb.

 

Description of Procedure:

The risks and benefits of the procedure were reviewed with mother and father and informed consent was obtained. A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. underwent satisfactory anesthesia as described above. The Olympus GIF Q180 endoscope was introduced under direct visualization and advanced into the esophagus. The esophageal mucosa was remarkable for mild furrowing, slightly irregular surface pattern more prominent in distal esophagus, and overall esophagus seemed less pliable. The lower esophageal sphincter was located 30 cm from the mouth. The stomach appeared normal. Retroflexion appeared normal. The duodenum was intubated, was remarkable for small patch of erythema in duodenal bulb but was otherwise normal appearing. Biopsies were taken from the duodenum, antrum, body, distal esophagus and proximal esophagus for histology. Urease testing was not performed. No additional diagnostic maneuvers were performed. The endoscope was readvanced to the stomach, which was suctioned of all contents, and then withdrawn. 

 

The patient was allowed to awaken from anesthesia.

 

Estimated Blood Loss: 

Less than 5 ml

 

Specimens: 

duodenum, antrum, body, distal esophagus and proximal esophagus

 

Complications: 

None known

 

 

 

Now that you have read Scenario 1, complete the following: 

 

Assign first listed ICD-10-CM Code   
Assign CPT Code   

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
MCCG 146

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