Epigastric abdominal pain - Differential diagnosis includes peptic ulcer disease[]. Risks/benefits of EGD discussed with patient including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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1. Pancreatitis - normal saline IVF at 200 cc/hr. Patient counseled on low-fat diet on discharge and avoiding alcohol as this can precipitate pancreatitis. Optimum diabetes management to avoid hypertriglyceridemia. ...Read more
Epigastric abdominal pain - Differential diagnosis includes peptic ulcer disease[]. Risks/benefits of upper endoscopy discussed with patient including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy. ...Read more
Medhost is an EMR. It has a tendency to lose consultation notes while you're typing the note. Write a paragraph for an assessment, hit preview, and the assessment is gone. -2019. ...Read more
Epigastric abdominal pain - Differential diagnosis includes peptic ulcer disease[]. Risks/benefits of EGD discussed with patient including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
This is an example of a Meditech template. Use F2 to move between text areas.
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Epigastric abdominal pain - Differential diagnosis includes peptic ulcer disease[]. Risks/benefits of upper endoscopy discussed with patient including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
...Read more
Epigastric abdominal pain - Differential diagnosis includes peptic ulcer disease with possible outlet obstruction and less likely stomach cancer[]. Risks/benefits of upper endoscopy discussed with patient including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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Epigastric abdominal pain - nausea/vomiting. Differential diagnosis includes peptic ulcer disease with possible outlet obstruction[]. Risks/benefits of upper endoscopy discussed with patient including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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Choledocholithiasis - elevated liver enzymes, elevated bilirubin, epigastric[] abdominal pain, probable ascending cholangitis[]. Risks and benefits of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) discussed with patient[] including bleeding, infection, perforation, pancreatitis, and death. Risk of pancreatitis stated as 15% for moderate pancreatitis and 1% for severe pancreatitis. Hand out describing procedure given to patient.
Patient agreeable to proceed with ERCP.[]
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Choledocholithiasis - elevated liver enzymes, elevated bilirubin, epigastric[] abdominal pain, probable ascending cholangitis[]. Risks and benefits of Endoscopic Retrograde Cholangio-Pancreatography (ERCP) discussed with patient[] including bleeding, infection, perforation, pancreatitis, and death. Risk of pancreatitis stated as 15% for moderate pancreatitis and 1% for severe pancreatitis. Hand out describing procedure given to patient.
Patient agreeable to proceed with ERCP.[] ERCP CPT codes. 43261 - ERCP. 43262 - ERCP with sphincterotomy. 43264 ERCP with stone removal
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[] year old male presented with epigastric abdominal pain for [] days, radiates [], []worse with eating. Associated nausea/vomiting.
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ICD 10 Diagnosis for Gastroenterology. Inpatient Gastroenterology. Hematemesis, hematochezia, melena, acute blood loss anemia, elevated liver enzymes, dysphagia esophagopharyngeal, epigastric abdominal pain, right upper quadrant abdominal pain, left upper quadrant abdominal pain, right lower quadrant abdominal pain, abnormal CT, ascites, hepatic encephalopathy, alcoholic cirrhosis, non-alcoholic cirrhosis, C. difficile diarrhea, acute pancreatitis, chronic pancreatitis, biliary pancreatitis, cannabis hyperemesis syndrome, cyclic vomiting syndrome, abnormal intraoperative cholangiogram.
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HPI: 57 year old female presented with epigastric abdominal pain, nausea and vomiting.
Past Medical History: Diabetes mellitus
Medications: Lantus
Allergies:
Family History: No history of colon cancer
Social History: 1 pack of cigarettes per day
Review of Systems: heartburn, constipation
Physical Exam: Epigastric tenderness
Labs/Radiology/Procedures: Normal abdominal x-ray
Assessment/Plan: EGD
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<p>HPI: 57 year old female presented with epigastric abdominal pain, nausea and vomiting. <p>Past Medical History: Diabetes mellitus<p>Medications: Lantus<p>Allergies: <p>Family History: No history of colon cancer<p>Social History: 1 pack of cigarettes per day<p>Review of Systems: heartburn, constipation<p>Physical Exam: Epigastric tenderness<p>Labs/Radiology/Procedures: Normal abdominal x-ray<p>Assessment/Plan: EGD to evaluate for gastric outlet obstruction. If no gastric outlet obstruction, then gastric emptying study to evaluate for diabetic gastroparesis.
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