solved: PLEASE HELP!!This is a case for an Outpatient Surgery  for D

  

PLEASE HELP!!This is a case for an Outpatient Surgery  for Digestive System.Please review the documentation of the patient encounter and code the case.There are 7 diagnoses codes (ICD-10-CM) and 4 procedure codes(CPT) CARDIAC CATHETERIZATION HISTORY AND PHYSICAL CHIEF COMPLAINT: S/p OHT for IDCM with mild transplant vasculopathy by angiography  HISTORY OF PRESENT ILLNESS: is a 9 year old who presents to the cardiac catheterization laboratory for full heart cath to evaluate hemodynamics, coronary arteries with IVUS, angiography and CFR and possible biopsy. Allergies•Measles, Mumps & Rubella Vac Contraindicated with heart transplant immunosuppression •Nsaids Contraindicated with heart transplant immunosuppression •Varicella Virus Vaccine Live Contraindicated with heart transplant immunosuppression MEDICATIONS: Prescriptions prior to admission Medication •NEORAL 25 MG Cap 75 mg (3 caps) by mouth every 12 hours 180 cap 6 •RAPAMUNE 0.5 MG Tab TAKE 1/2 TABLET BY MOUTH IN THE EVENING 15 tab 11 •azathioprine (IMURAN) 50 MG Tab TAKE 1 TABLET BY MOUTH EVERY DAY 30 tab 11 •atorvastatin (LIPITOR) 10 MG Tab TAKE 1/2 TABLET BY MOUTH EVERY DAY 15 tab 11 •Emollient (CETAPHIL) Cream as needed (after bath time). 454 g 0 •Pediatric Multivit-Minerals-C (MULTIVITAMIN/IRON) 60 MG Chew Tab 1 tab by mouth every day. 1 Bottle 3 •amoxicillin (AMOXIL) 500 MG Cap 3 caps by mouth. 30-60 minutes prior to dental appointments 3 cap 2 •aspirin 81 MG Tab 1 tab by mouth every day. 1 Bottle 6 History and Physical •Preterm infant about 32 weeks •Iron deficiency anemia •Dilated Cardiomyopathy •Feeding difficulties and mismanagement •Coronary artery disease of transplanted heart Past Surgical History Procedure •Patent ductus arteriosus closure Patent Ductus Arteriosus closure, device•Qpc=ins picc w/o subq <5 yrs •Qpc=ins picc w/o subq <5 yrs •Heart transplant REVIEW OF SYSTEMS: Constitutional: Negative for weight loss, fever, fatigue HEENT: Negative Eyes: Negative Respiratory: Negative for cough, SOB, pneumonia, asthma Cardiovascular: Negative for chest pain, SOB, exercise intolerance, orthopnea Gastrointestinal: Negative for abdominal pain, n/v/d Musculoskeletal: Negative for pain, difficulty with movement Hematology/Lymphatic: Negative Immune/Allergy/Rheumatologic: Negative Skin: Positive for eczema Central Nervous: Negative Pulses: +2 bilaterally throughout and capillary refill time: brisk ABDOMEN: soft, non-tender, non-distended, no organomegaly or masses EXTREMITIES: warm and well-perfused, without edema and moves extremities well SKIN: dry, scaly, erythematous skin neck, arms NEUROLOGIC: grossly intact, strength normal PHYSICAL EXAM: BP 121/80 | Pulse 116 | Temp 36.4 | Resp 22 | Ht 144 cm | Wt 35.1 kg | SpO2 97% Resp/Oxygen: RA GENERAL: alert, no acute distress, acyanotic, well developed, well nourished HEAD: normocephalic, atraumatic NOSE: septum midline, pink mucosa, no discharge MOUTH/THROAT: moist mucosa, no oral lesions TEETH: gingival hyperplasia NECK: supple, full range of motion, no JVD, no lymphadenopathy CHEST: Sternum: medial sternotomy, healed LUNGS: clear to auscultation bilaterally and normal work of breathing without intercostal retractions, or accessory muscle use CARDIOVASCULAR: Precordium: quiet Rhythm: RRR Sounds: negative for: rub, gallop, murmur or systolic click, normal S1 and split S2 DATA/DIAGNOSTIC STUDIES: Echo, ECG, labs ASSESSMENT:  a 9 year old with a history of Dilated Cardiomyopathy: Idiopathic. was transplanted on and is now 5 yrs 9 mths S/P cardiac transplant with mild transplant vasculopathy is doing well and entering 3rd grade. Father continues to have difficulty with language barrier and arranging appointments; attempted to help with arranging dental follow up. Also discussed with father changes to Neoral dosing based on slightly low levels. All discussions and consent were performed with Cyracom vietnamese interpreter via phone. Father did not have further questions or concerns. Father did not know how to use sunscreen and doesn't like playing outside unless she is in the shade. Encouraged light long sleeves, hat or sunscreen. Father verbalized understanding. PLAN: To cardiac catheterization laboratory for Right and left heart catheterization, Angiography, Endomyocardial biopsy, IVUS, Coronary Flow wire Time Spent/LOS Inpt: I personally spent a total of 45 minutes on the unit in direct management/discussion/coordination of care. Of that, 40 minutes was spent in counseling and/or coordination of care including: counseling patient/family regarding diagnosis, prognosis, and treatment plan (including risks and benefits)  Caroline H. Connell, CPNP-PC  I have reviewed this patient's history and performed a physical exam. The Transplant APN, Caroline H. Connell, discussed the case with me. I agree with the findings documented on the H&P. The cath plan was made by me. and implemented by me. CARDIAC CATHETERIZATION PRELIMINARY PROCEDURE NOTE Pre-Procedure Diagnosis: History of dilated cardiomyopathy (idiopathic), heart transplant, transplant coronary artery disease, history of left femoral vein occlusion. Post-Procedure Diagnosis: same Procedure: Biopsy, Coronaries, Coronary Flow Wire, Diagnostic R&L and IVUS Performed by: Bill Pietra Assistants: Eleanor Schuchardt Access: LFV: 6 Fr, LFA: 5 Fr Findings: Please see catheterization report for full details. In brief, RVEDP and LVEDP were normal. Coronary angiography appeared normal, IVUS showed thin intima. Angiograms: LV, left coronary artery, right coronary arteryEBL: minimal Specimens:endomyocardial biopsies Contrast: 44 ml Fluoroscopy: 23.3 minutes Complications: NoneDispo: Patient transferred to PACU in stable condition. Follow up: Follow up with primary cardiologist per previous plan (due for appointment in 1-2 weeks) Did you call the referring cardiologist: No Did you call the referring pediatrician/family physician: No Health Science Science Nursing HCMT 2025C Share QuestionEmailCopy link Comments (0)