esophagram cpt

CPC sample question # 5

Operations Performed: Esophagogastroduodenscopy and Maloney dilation.

Indications for Procedures: This is a 36-year-old femal with rheumatoid arthritis who has been developing progressive dysphagia over the last week. The patient had an outpatient attempt at esophagram in the emergency room, which suggested she had a proximal esophageal stricture; therefore, this examination is being done to evaluate this abnormality.

Description of Procedures: Informed consent was obtained from the patient. Demerol 60 mg, Versed 3 mg were given intravenous slowly for sedation. The patient was placed in the left lateral position.

The GIF-100 EGD scope was passed into the esophagus via the no-touch technique. The esophagus did not demonstrate a definite stricture endoscopically. Whether I passed it on inserting the scope, I cannot be certain. Nevertheless, there was certainly no resistance to the passage of the 9 mm scope into the proximal esophagus. The esophagogastric junction was at 40 cm. Stomach was entered and found to be within normal li,its, without ulceration. The duodenal bulb and descending duodenum were both normal. The scope was then withdrawn and Maloney dilators 36, 42, 46, and 52 were passed sequentially without difficulty.

The patient tolerated both procedures well and returned to the recovery room in good condition.

Impression: 1. Possible proximal esophageal stricture. 2. Status post Maloney dilation.


Similar Posts

Leave a Reply

Your email address will not be published.