Homework Help Question & Answers

Health Record Face Sheet Record Number: 70-50-77 Age: 53 Gender: Male Length of Stay: 2 Days...

Health Record Face Sheet

Record Number: 70-50-77
Age: 53
Gender: Male
Length of Stay: 2 Days
Service Type: INPATIENT
Discharge Status: To Home
Diagnosis/Procedure: Idiopathic Dilated Cardiomyopathy


DISCHARGE SUMMARY

PATIENT NAME: HUGH ACUTE

ADMISSION DATE: 06-23-XX
DISCHARGE DATE: 06-25-XX

DISCHARGE DIAGNOSIS:
1. Idiopathic dilated cardiomyopathy, uncertain etiology.
2. Left bundle branch block.
3. Normal coronary arteries and normal hemodynamics.

PROCEDURES: Cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old male admitted for evaluation of grossly abnormal Thallium test.
LABORATORY DATA: Glucose 106, BUN 11, creatinine 1.1, liver function tests are all normal, albumin 4.2, sodium 141, potassium 4.8, cholesterol 166, triglycerides 122, iron 82. White count 6900, hemoglobin 17.2, MCV 95, platelets 136,000.
Resting MUGA ejection fraction is performed. This shows an ejection fraction of 47%.
HOSPITAL COURSE: The patient is admitted to the hospital and taken to the cardiac catheterization lab. The patient's hemodynamics showed right atrial pressure 4, pulmonary artery 32/14, pulmonary capillary wedge is 6, cardiac output is 6.5, pulmonary vascular resistance is 186, and oximetry is unremarkable. Coronary arteries are all perfectly normal. There is no mitral regurgitation. Left ventricle is quite dilated. Ejection fraction angiographically is 46%. All walls are hypokinetic except for the anterobasilar wall, which is normal.
This is felt to be due to an idiopathic cardiomyopathy with normal hemodynamics.
A resting MUGA scan was obtained as a baseline. The patient was discussed with Dr. XYZ. The patient was discharged on 12/19 to be admitted on 12/19/xx to USA Hospital for myocardial biopsy.
DISCHARGE MEDICATIONS: Enteric aspirin 5 grains once a day and Capoten 12.5 mg 1½ tablets q 12 hours.
He is to follow up with me in a couple of weeks.
_____________________________
DR HEART, M.D.


HISTORY AND PHYSICAL

PATIENT NAME: HUGH ACUTE
ADMISSION DATE: 06-23-XX
CHIEF COMPLAINT: Abnormal thallium treadmill. Admit for heart catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old white male receiving primary care with a grossly abnormal-thallium treadmill test. Admitted now for heart catheterization.
The patient really has minimal symptoms. He presented to the healthcare system recently for a complete physical just to make sure that everything was going fine. Dr. Know noted that the patient was having some fatigue and that he had a left bundle branch block. After discussing the case with Dr. Who, a thallium treadmill test was ordered which was quite abnormal as noted below.
ALLERGIES: None known.
MEDICATIONS: None.
SOCIAL HISTORY: The patient works in a potato cellar doing fairly manual labor. The patient smoked two packs of cigarettes daily for 30 years stopping 2 weeks ago. The patient is adopted and has no knowledge of his blood relatives.
MEDICAL HISTORY: He notes no exertional chest discomfort, neck discomfort, etc. of any type. He says that his exertional capacity and his exertional dyspnea is worse than it was 10 years ago, but feels that it is the same as it was 3 months ago and that it is the same as it was about a year ago. Apparently, he had an upper respiratory infection with productive cough, runny nose, sneezing, etc. this fall, but feels that he recovered satisfactorily from that. He does recall several episodes of epigastric discomfort manifest as a pressure sensation lasting perhaps a day at a time. He says he ignored it and it went away, and wondered whether he might have some gallbladder trouble. This never seemed to particularly get worse with exertion.
The patient has no orthopnea, PND, or edema. He has used two pillows on his bed at night under his head for a long time. He has occasional heart racing but no lightheaded spells, near syncope, or syncope. There is no history of hypertension, hyperlipidemia, diabetes, congenital heart disease, rheumatic fever, heart murmur, or MI.
REVIEW OF SYSTEMS:
His general review of systems in detail is unremarkable. His only surgery is minor surgery on his knee. He does not use alcohol at all and never has. He uses one caffeinated beverage a day. He has no GI distress. He denies history of drug abuse, eye problems, cancer liver disease, emphysema, thyroid problems, gout, asthma, hay fever, hives, migraine headaches, TIA's, stroke, deep venous thrombosis, pulmonary embolism, kidney stones, etc.
PHYSICAL EXAMINATION:
GENERAL: BP 128/94, pulse 96, respirations distension.
LUNGS: Clear.
HEART: S1, S2 within normal limits with no murmurs, gallops, or rubs.
ABDOMEN: Unremarkable.
SKIN: Is warm and dry. Temp 97.9.
NECK: No jugular venous distension.
EXTREMITIES: There is no peripheral edema.
ELECTROCARDIOGRAM: Complete left bundle branch block, with frequent PVC's. Axis is +90°. Borderline right atrial enlargement.
EXERCISE THALLIUM TEST 06-21-XX
The patient exercised 5 minutes 37 seconds on a Bruce Protocol elevating his heart rate to 178 (107% predicted maximum), and blood pressure to 174/84. He was stopped because of fatigue. The patient's heart rate increased rapidly with exercise and at the end of 3 minutes of exercise, his heart rate was already 165. At the end of 2 minutes off exercise, it was 157. He remained in left bundle branch block throughout and there- were no significant ST changes and no arrhythmias. He had no chest discomfort. The images showed a dilated left ventricle with hypoperfusion of the anterior wall, septal wall, and posterior wall. There was some redistribution of the anterior and anteraseptal aspects of the heart. There was no redistribution of the inferior aspect.
ECHOCARDIOGRAM:
06-21-XX is technically limited, but shows severely reduced left ventricular function with normal chamber dimensions. Left atrium is at 3.9cm E point to septal separation is 1.4.
ASSESSMENT:
1. High risk thallium scan with reduced IV function on echocardiogram inpatient with left bundle branch block and no symptoms.
2. Unknown family history.
3. Heavy smoking history.
PLAN: Admit for heart cath.
_________________________
DR. HEART, M.D.

CARDIAC CATHETERIZATION LABORATORY
PATIENT NAME: HUGH ACUTE
PROCEDURE REPORT:
PROCEDURE: Right and left heart catheterization, selective coronary angiography and left ventriculography.
PROCEDURE NOTE: The patient is brought to the cardiac catheterization lab, and the right inguinal area is prepped and draped in the usual manner. Using Seldinger technique, both the right femoral artery and right femoral vein are cannulated, and sheath introducers are placed in each vessel. All catheter manipulations are done using a guidewire and under fluoroscopic control. A fiberoptic Swan-Ganz catheter is positioned in the right heart. A pigtail catheter is positioned in the ascending aorta. Hemodynamic pressure measurements are-made. The aortic valve is crossed in a retrograde manner. Hemodynamic pressure measurements are made. Thermodilution cardiac output is measured. Oximetry is measured in the right and left heart. The Swan-Ganz catheter is removed.
Left ventriculography is performed in the RAO projection and is recorded on 35 mm cineangiographic film. The catheter is then pulled back across the aortic valve while pressure measurements are being made.
The catheter is then exchanged over a guidewire for a Judkin's left coronary catheter, and left coronary cineangiography is performed in multiple projections in the usual manner. The catheter is then exchanged over a guidewire for a Judkins right catheter, and right coronary cineangiography is performed in the usual manner.
At the conclusion of the case, hemostasis is obtained after catheters were pulled. There are no complications.
HEMODYNAMIC FINDINGS: Right atrial pressure mean is 4 mm. of mercury. X and Y descent appear to be normal. The right ventricular end diastolic pressure is equal to the left ventricular end diastolic pressure. These two pressure waveforms are superimposed throughout diastole. Pulmonary artery pressure is 32/14, mean 21. Pulmonary capillary wedge mean is 6, with a normal V wave. Left ventricular pressure is 125/, 8. Aortic pressure is 125/65, mean 86. There is no gradient across the mitral valve during diastole or across the aortic valve during systole. Thermodilution cardiac output is 6.46 liters per minute. Systemic vascular resistance is 1015. Pulmonary vascular resistance is 186. Oximetry on blood samples shows saturation as follows: pulmonary artery 65%, right ventricle 64%, right atrium 64.7%, vena cavae 65%. Room air blood gas in the left ventricle 7.45, P02 62, PCO2 37, Bicarb. 26, Saturation 89%.
LEFT VENTRICULOGRAM: There no mitral regurgitation. The anterobasilar wall moves normal. All other walls of the ventricle are hypokinetic. The left ventricle is moderately dilated, with an end diastolic volume of 321 cc's (upper limits of normal for his body surface area is 257 cc's). Ejection fraction is measured on several beats and ranges between 42 and 52%.
CORONARY ANGIOGRAPHY: The coronary arteries are perfectly smooth and within normal limits. The LAD gives rise to a moderate sized first diagonal branch and a moderately large second diagonal branch. There is a large bifurcated ramus intermedius branch. There are two moderately large posterolateral branches of the circumflex. The right coronary artery gives rise to the posterior descending artery and one posterolateral branch.
CONCLUSIONS:
1. Normal coronary arteries.
2. Dilated hypocontractile left ventricle with no mitral regurgitation.
3. Normal hemodynamics and cardiac output.
4. Normal oximetry.
5. Mild resting hypoxia.
This picture is consistent with an idiopathic dilated cardiomyopathy.

List ICD-10-Cm codes for:

Principal Diagnosis:

Secondary Diagnosis:

List ICD-10-PCS codes for:

Principal Procedure

Secondary Procedures

0 0
Add a comment
Answer #1

Sign Up to Unlock the answer FREE

Already have an account? Log in

Principal DIAGNOSIS is idiopathic dilated cardiomyopathy ICD 10 cm code is I42.9

Secondary DIAGNOSIS is left bundle branch block icd 10 cm code is I44.7.

Icd 10 pcs code for

Principal procedure

Cardiac catheterization

Icd 10 pcs code is B211YZZ

SECONDARY PROCEDURE

Left ventriculogram code is B211YZZ

Coronary angiogram code is 93455 - 93461

  

Add a comment
Know the answer?
Add Answer to:
Health Record Face Sheet Record Number: 70-50-77 Age: 53 Gender: Male Length of Stay: 2 Days...
Your Answer:

Post as a guest

Your Name:

What's your source?

Earn Coin

Coins can be redeemed for fabulous gifts.

Not the answer you're looking for? Ask your own homework help question. Our experts will answer your question WITHIN MINUTES for Free.
Similar Homework Help Questions
  • Record Number: 84-50-77 Age: 53 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge...

    Record Number: 84-50-77 Age: 53 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Atherosclerosis Coronary Arteries. Unstable Angina. Double Coronary Artery Bypass. DISCHARGE SUMMARY PATIENT: JED INPATIENT RECORD NUMBER: 84-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-20-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Atherosclerosis coronary arteries with chronic total occlusion. Unstable angina. Congestive heart failure, combined systolic and diastolic, chronic. PROCEDURE: Coronary artery bypass graft x 2. HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old...

  • Health Record Face Sheet Record Number: 77-50-77 Age: 76 Gender: Male Length of Stay: 6 Days...

    Health Record Face Sheet Record Number: 77-50-77 Age: 76 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Hemoptysis Fiberoptic bronchoscopy with biopsy DISCHARGE SUMMARY PATIENT: JARED INPATIENT RECORD NUMBER: 77-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-21-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Hemoptysis. Hypertension. Atelectasis. PROCEDURE: Fiberoptic bronchoscopy x 2 with biopsy. HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old white male admitted to the hospital with hemoptysis. The patient states that approximately three...

  • Health Record Face Sheet Record Number: 76-50-77 Age: 31 Gender: Male Length of Stay: 1 Day...

    Health Record Face Sheet Record Number: 76-50-77 Age: 31 Gender: Male Length of Stay: 1 Day Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Left Inguinal Hernia Herniorrhaphy DISCHARGE SUMMARY PATIENT: WALLACE INPATIENT Record Number: 76-50-77 ADMITTED: 06-03-XX DISCHARGED: 06-04-XX PHYSICIAN: DR. ALEX, M.D.DIAGNOSIS: Left inguinal hernia. PROCEDURE: Herniorrhaphy. HISTORY OF THE PRESENT ILLNESS: : The patient is a 31-year-old Caucasian male who was in his usual state of health until approximately 1-2 weeks prior to admission at which time...

  • Health Record Face Sheet Record Number: 79-50-77 Age: 36 Gender: Female Length of Stay: 5 Days...

    Health Record Face Sheet Record Number: 79-50-77 Age: 36 Gender: Female Length of Stay: 5 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Insulin reaction Renal failure Diabetes Mellitus, Type II, long term insulin dependence Permanent catheter right internal jugular Removal peritoneal dialysis catheter DISCHARGE SUMMARY PATIENT: RAINEY INPATIENT RECORD NUMBER: 79-50-77 ADMITTED: 12-19-XX DISCHARGED: 12-24-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSES: 1. Insulin reaction. 2. Renal failure. 3. Diabetes mellitus, Type II. OPERATIONS/ PROCEDURES: 1. Permanent catheter right...

  • Answer the questions based on the following Medical Record: History of present Illness: This 77 year...

    Answer the questions based on the following Medical Record: History of present Illness: This 77 year old gentleman was hospitalized with chest pain, and a diagnosis of myocardial infarction was made. The patient had CPK elevation to 800 with 10% MB fraction. He subsequently developed heart failure and cardiac arrhythmia. He underwent cardiac catheterization and coronary angiography. His ejection fraction was 30%. He has severe left main coronary artery stenosis and right coronary artery occlusion. The patient has had carcinoid...

  • Record Number: 81-50-77 Age: 32 Gender: Male Length of Stay: 2 Days Service Type: Inpatient Discharge...

    Record Number: 81-50-77 Age: 32 Gender: Male Length of Stay: 2 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Foreign Body Left Ankle DISCHARGE SUMMARY PATIENT: PATRICK INPATIENT RECORD NUMBER: 81-50-77 ADMITTED: 10-15-XX DISCHARGED: 10-17-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Healing fracture left ankle with retained foreign body implant. PROCEDURE(S): Removal of foreign body implant from left ankle (K-wire and screw). HISTORY OF THE PRESENT ILLNESS: This 32-year-old male patient is admitted for removal of hardware from his...

  • Record Number: 80-50-77 Age: 77 Gender: Female Length of Stay: 5 Days Service Type: Inpatient Discharge...

    Record Number: 80-50-77 Age: 77 Gender: Female Length of Stay: 5 Days Service Type: Inpatient Discharge Status: To Home Health Diagnosis/Procedure: Peritrochanteric Right Hip Fracture Mild Hypertension Total Right Hip Arthroplasty DISCHARGE SUMMARY PATIENT: JOY INPATIENT RECORD NUMBER: 80-50-77 ADMITTED: 09-15-XX DISCHARGED: 09-20-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Peritrochanteric right hip fracture. Mild hypertension. PROCEDURE(S): Total right hip arthroplasty. HISTORY OF THE PRESENT ILLNESS: This is a 77-year-old white female who presented to the emergency room with complaint of...

  • QUESTION 7 CASE STUDY 16: Determine which of the following CPT should be reported for the...

    QUESTION 7 CASE STUDY 16: Determine which of the following CPT should be reported for the OP services. A. 93452, 93454 B. 93459 C. 93458 D. 93461 10 points    QUESTION 8 CASE STUDY 16: Which statement from the procedural record indicates that a left heart catheterization was performed? (This question counts as 0 points, since it meant to demonstrate the differences between arteriography and a heart catheterization.) A. Approximate 60-70% stenosis in the midportion of the posterior descending coronary...

  • QUESTION 7 CASE STUDY 16: Determine which of the following CPT should be reported for the...

    QUESTION 7 CASE STUDY 16: Determine which of the following CPT should be reported for the OP services. A. 93452, 93454 B. 93459 C. 93458 D. 93461 10 points    QUESTION 8 CASE STUDY 16: Which statement from the procedural record indicates that a left heart catheterization was performed? (This question counts as 0 points, since it meant to demonstrate the differences between arteriography and a heart catheterization.) A. Approximate 60-70% stenosis in the midportion of the posterior descending coronary...

  • Record Number: 82-50-77 Age: 81 Gender: Female Length of Stay: 2 Days Service Type: Inpatient Discharge...

    Record Number: 82-50-77 Age: 81 Gender: Female Length of Stay: 2 Days Service Type: Inpatient Discharge Status: To Long-Term Care Diagnosis/Procedure: Severe Peripheral Venous Cellulitis Lower Extremities, Bilateral. DISCHARGE SUMMARY PATIENT: MYRA INPATIENT RECORD NUMBER: 82-50-77 ADMITTED: 03-15-XX DISCHARGED: 03-17-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Severe peripheral venous cellulitis with 4+ edema lower extremities (bilateral). HISTORY: This patient is an 81-year-old female admitted because of severe edema of her lower extremities and developing leg ulcers bilaterally. LABORATORY DATA: SMAC...

ADVERTISEMENT
Free Homework Help App
Download From Google Play
Scan Your Homework
to Get Instant Free Answers
Need Online Homework Help?
Ask a Question
Get Answers For Free
Most questions answered within 3 hours.
ADVERTISEMENT
ADVERTISEMENT