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
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
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