SienTC1720
Networker
Could someone help me out with this one please? This is only a week or so after the procedure. I just don't know what kind of modifiers I should use?
S. Here today in follow-up of his colonoscopy. He had a colonoscopy done for screening purposes and had a large tubulovillous adenoma in his rectum and another large one in his right colon in addition to a tubular adenoma in the hepatic flexure and transverse colon.
PMH: Basically unremarkable.
Meds: He currently takes only saw palmetto for prostate.
Drug Allergies: None known.
PSH: Include appendectomy and bilateral inguinal hernia repairs.
PE: Reveals his lungs are clear. Cardiac exam is normal S1 and S2 no murmurs. Abdomen is scaphoid, bowel sounds are present. There is an appendectomy scar and bilateral hernia scars.
P. I have discussed the findings with him. He had two large tubulovillous adenomas each 3 cm or so. The rectal one was completely ablated on my colonoscopy. The right-sided colon one was only biopsied. I have advised him that I would allow six weeks for healing of the rectal lesion and I would repeat the colonoscopy. At that time I would check for recurrence of the rectal lesion and also to make a final decision whether the right-sided polyp will require an operative procedure or endoscopic removal.
S. Here today in follow-up of his colonoscopy. He had a colonoscopy done for screening purposes and had a large tubulovillous adenoma in his rectum and another large one in his right colon in addition to a tubular adenoma in the hepatic flexure and transverse colon.
PMH: Basically unremarkable.
Meds: He currently takes only saw palmetto for prostate.
Drug Allergies: None known.
PSH: Include appendectomy and bilateral inguinal hernia repairs.
PE: Reveals his lungs are clear. Cardiac exam is normal S1 and S2 no murmurs. Abdomen is scaphoid, bowel sounds are present. There is an appendectomy scar and bilateral hernia scars.
P. I have discussed the findings with him. He had two large tubulovillous adenomas each 3 cm or so. The rectal one was completely ablated on my colonoscopy. The right-sided colon one was only biopsied. I have advised him that I would allow six weeks for healing of the rectal lesion and I would repeat the colonoscopy. At that time I would check for recurrence of the rectal lesion and also to make a final decision whether the right-sided polyp will require an operative procedure or endoscopic removal.