Case -AUDIT REPORT T6.1 CARDIAC CATHETERIZATION REPORT

Essay

Case
-AUDIT REPORT T6.1 CARDIAC CATHETERIZATION REPORT
LOCATION: Inpatient, Hospital
PATIENT: Matthew Logan
ATTENDING PHYSICIAN: Leslie Alanda, MD
SURGEON: James Noonar, MD
PROCEDURES PERFORMED: Right and left coronary angiogram, LV-gram left heart.
INDICATION: Unstable angina
HEMODYNAMICS:
1. Aortic pressure is 142/74.
2. LV pressure is 142/20 with no gradient on pullback.
VENTRICULOGRAM: Ventriculogram showed normal LV size. There is an inferior wall hypokinesis with an ejection fraction of 55%.
CORONARY ANGIOGRAM:
RIGHT CORONARY ARTERY: The right coronary artery is totally occluded in its proximal third. There is a large stent deployed from the proximal right coronary artery all the way close to the distal third that has in-stent restenosis with total occlusion and with TIMI-0 flow, and preobstructive collateral from the conus branch filling and the distal right coronary artery.
LEFT MAIN CORONARY ARTERY: The left main is normal.
LEFT ANTERIOR DESCENDING ARTERY: The left anterior descending artery has in its proximal third plaque that appears to be eccentric and severely obstructive. The left anterior descending artery thereafter has no significant disease. It gives rise in the midportion to a small diagonal that has no significant obstruction.
CIRCUMFLEX ARTERY: The circumflex artery as rises from the left main is trifurcate. The first marginal is diffusely diseased and in its midportion has a 50% to 70% stenosis. Thereafter, the circumflex bifurcates there to give two branches, the first of which is small in size and has a 50% stenosis in its proximal third, and the second marginal has a stent placed in it with severe in-stent restenosis.
IMPRESSION/CONCLUSION:
1. Preserved systolic function with inferior wall severe hypokinesis (decreased mobility).
2. Total closure of the right coronary artery with this in-stent restenosis of a very long stent placed in the proximal right coronary artery with very obstructive collateral filling from the conus branch to the distal right coronary artery that appears to be small.
3. Disease in the proximal left anterior descending artery.
4. In-stent restenosis of the second marginal and diffuse disease in the small marginal.
RECOMMENDATIONS: At this point, my recommendation is to percutaneously revascularize the left anterior descending artery as well as the in-stent restenosis of the circumflex.
The right coronary artery is currently totally occluded with preobstructive collateral filling the right coronary artery. (Restenosis of the stent is a complication of a cardiac implant NEC.)
T6.1:
SERVICE CODE(S): 93453____________________________________________
ICD-10-CM DX CODE(S): I25.110______________________________________
INCORRECT/MISSING CODE(S): _____________________________________