The anesthesiologist personally provided monitored anesthesia care.

The anesthesiologist personally provided monitored anesthesia care. The patient is 68 years old and the physical status was -P5. LOCATION: Inpatient, Hospital PATIENT; Nicole Lynn PHYSICIAN; Mark Munkenson, M.D. ANESTHESIOLOGIST: Julie Moses M.D PREOPERATIVE DIAGNOSIS: 1. Acute aspiration pneumonitis 2. Acute hypoxemic respiratory failure POSTOPERATIVE DIAGNOSIS: Same PROCEDURES PERFORMED: 1. Direct laryngoscopy 2. Endotracheal intubation INDICATIONS: The patient was in severe respiratory distress secondary to acute aspiration pneumonitis maintaining her saturations on nonrebreather mask. The patient was still retching and having severe nausea so BiPAP was initially tried but she was not a good candidate for BiPAP due to persistent nausea. Family discussion was held and they wanted the patient to be intubated. PROCEDURE DESCRIPTION: The patient was laid supine on the bed and bag valve ventilation was performed and we were still not able to get saturations above 88% despite adding external PEEP. The patient was given 4mg of Versed IV and 10 mg of etomidate. MAC 3 blade was used for direct laryngoscopy. the patient did have thick secretions in the posterior oropharynx. Vocal cords were visualized grade 1 view. Subsequently size 8 endotracheal tube was passed under direct visualization and left at 22 cm at the tip and tube was secured in place. Tube position was confirmed by auscultation and end tidal CO2 monitoring. the patient’s expiration improved immediately to 94 to 95% after intubation. COMPLICATIONS: There were no immediate compilations. The patient tolerated the procedure well. The postprocedural chest x-ray was reviewed. Endotracheal tube was at the level of main carina. We pushed it back by at least 2 cm. The patient still has bilateral breath sounds present. and continues to maintain good saturation levels. IMPRESSION: Technically successful direct laryngoscopy and endotracheal intubation. CAN YOU IDENTIFY ANESTHESIA CPT CODES AND MODIFIERS?

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