Cardiology ICD-10 records with Dual Coding-ICD-10 Training

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Comprehensive ICD-10 Training by AHIMA ICD-10 approved trainer. Training

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Cardiology ICD-10 records with Dual Coding-ICD-10 Training

  1. 1. Medesun Healthcare Solutions---Updated-1st Dec, 2014 Comprehensive ICD-10 Training-Sample Medical records with dual coding. TrainingHyderabad, Delhi, Noida, Pune, Chennai, Bangalore.. Dr. Meriyala Santosh Kumar Guptha, CPC, CPC-H, CPC-P, CPMA, CEMC, CIMC, CFPC, CCS-P, CCS, RMC, RMA, CMBS, CMRS, CHA, CHL7, CSCS AHIMA Approved ICD-10CM/PCS Trainer Advisory Council Member (Lead), ICD-10 Coders Academy Dan Turner, CPC, CEMC, Certified ICD-10 Analyst® Report 1 of 10 Medical Specialty: Cardiovascular Hypertension Description: Problem of essential hypertension. Symptoms that suggested intracranial pathology. History of MI. SUBJECTIVE: The patient is a 78 year-old female with the problem of essential hypertension. She has symptoms that suggested intracranial pathology, but so far work-up has been negative. She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure. She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness. OBJECTIVE: Heart rate is 80 and blood pressure is 130/70. Head and neck are unremarkable. Heart sounds are normal. Abdomen is benign. Extremities are without edema. ASSESSMENT AND PLAN: The patient reports that she had an echocardiogram done in the office of Dr. X and was told that she had a massive heart attack in the past. I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc. So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. X. In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup. A. 402.90; I15.8 B. 401.9, 412; I10, I25.2 C. 402.10; I10, Z95.2
  2. 2. D. 401.9, V12.53; i10, Z86.74 Answer: B. Rationale: ICD-9-CM 401.9 Unspecified essential hypertension 412 Old myocardial infarction ICD-10-CM I10 Essential (primary) hypertension I25.2 Old myocardial infarction ....................... Report 2 of 10 Medical Specialty: Cardiovascular PAF - Cardioversion Description: Cardioversion. An 86 year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation HISTORY: The patient is an 86 year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress. Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation. I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure. After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday. The patient declined. I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate. PROCEDURE NOTE: The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff. The patient participated actively in this. She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect. She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm. This was confirmed on 12 lead EKG.
  3. 3. IMPRESSION/PLAN: Successful resumption of normal sinus rhythm from recurrent atrial fibrillation. The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress. She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted. She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend. This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside. A. 427.32, V43.3; I48.1, Z95.2; 92961 B. 427.2, V43.3; I47.9, Z95.2; 92960 C. 427.61, V43.4; I49.1, Z95.828; 92953 D. 427.31, V43.3; I48.0, Z95.2; 92960 Answer: D. Rationale: ICD-9-CM 427.31 Atrial fibrillation V43.3 Heart valve replaced by other means ICD-10-CM I48.0 Paroxysmal atrial fibrillation Z95.2 Presence of prosthetic heart valve CPT® 92960 Cardioversion, elective, electrical conversion of arrhythmia; external ......................... Report 3 of 10 Medical Specialty: Cardiovascular Empyema thoracis - Central line insertion Description: Central line insertion. Empyema thoracis and need for intravenous antibiotics. PREOPERATIVE DIAGNOSES 1. Empyema thoracis. 2. Need for intravenous antibiotics.
  4. 4. POSTOPERATIVE DIAGNOSES 1. Empyema thoracis. 2. Need for intravenous antibiotics. PROCEDURE: Central line insertion. DESCRIPTION OF PROCEDURE: The patient is a 66 year-old male. After obtaining informed consent, his left deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty. The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline. The catheter was fixed to the skin with sutures. The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter. A. 510.0; J86.0; 36556 B. 510.0; J86.9; 36571 C. 511.0; J90; 36568 D. 510.9; J86.9; 36556 Answer: D. Rationale: ICD-9-CM 510.9 Empyema without mention of fistula ICD-10-CM J86.9 Pyothorax without fistula CPT® 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older ........................... Report 4 of 10 Medical Specialty: Cardiovascular Ischemic cardiac disease Description: Patient with a history of ischemic cardiac disease and hypercholesterolemia. HISTORY OF PRESENT ILLNESS: The patient is a 68 year-old man who returns for recheck. He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test. He did walk for 8 minutes. The scan showed
  5. 5. some mild inferior wall scar and ejection fraction was well preserved. He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema. PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise. MEDICATIONS: Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily. ALLERGIES: None known. FAMILY HISTORY: Father died at the age of 84. He had a prior history of cancer of the lung and ischemic cardiac disease. Mother died in her 80s from congestive heart failure. He has two brothers and six sisters living who remain in good health. PERSONAL HISTORY: Quit smoking in 1996. He occasionally drinks alcoholic beverages. REVIEW OF SYSTEMS: Endocrine: He has hypercholesterolemia treated with diet and medication. He reports that he did lose 10 pounds this year. Neurologic: Denies any TIA symptoms. Genitourinary: He has occasional nocturia. Denies any difficulty emptying his bladder. Gastrointestinal: He has a history of asymptomatic cholelithiasis. PHYSICAL EXAMINATION: Vital Signs: Weight: 225 pounds. Blood pressure: 130/82. Pulse: 83. Temperature: 96.4 degrees. General Appearance: He is a middle-aged man who is not in any acute distress. HEENT: Mouth: The posterior pharynx is clear. Neck: Without adenopathy or thyromegaly. Chest: Lungs are resonant to percussion. Auscultation reveals normal breath sounds. Heart: Normal S1, S2, without gallops or rubs. Abdomen: Without tenderness or masses. Extremities: Without edema. IMPRESSION/PLAN: 1. Ischemic cardiac disease. This remains stable. He will continue on the same medication. He reports he has had some laboratory studies today. 2. Hypercholesterolemia. He will continue on the same medication. 3. Facial tic. We also discussed having difficulty with the facial tic at the left orbital region. This occurs mainly when he is under stress. He has apparently had numerous studies in the past and has seen several doctors in Wichita about this. At one time was
  6. 6. being considered for some type of operation. His description, however, suggests that they were considering an operation for tic douloureux. He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close. Repeat neurology evaluation was advised. He will be scheduled to see Dr. XYZ in Newton on 09/15/2004. 4. Immunization. Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment. We will have this discussed with him further when his laboratory results are back. A. 414.2, 272.4, 307.21; I26.09, E78.4, F95.9 B. 414.9, 272.0, 307.20, 412, V45.81; I25.9, E78.0, F95.9, I25.2, Z95.1 C. 414.3, 272.2, 307.22, V12.53, V45.81; I25.83, E78.2, F95.1, Z86.74, Z95.1 D. 414.8, 272.6, 307.3, V45.81; I25.9, E88.1, F98.4, Z95.1 Answer: B. Rationale ICD-9-CM 414.9 Chronic ischemic heart disease, unspecified 272.0 Pure hypercholesterolemia 307.20 Tic disorder, unspecified 412 Old myocardial infarction V45.81 Aortocoronary bypass status ICD-10-CM I25.9 Chronic ischemic heart disease, unspecified E78.0 Pure hypercholesterolemia F95.9 Tic disorder, unspecified I25.2 Old myocardial infarction Z95.1 Presence of aortocoronary bypass graft ................................ Report 5 of 10 Medical Specialty: Cardiovascular Dilated cardiomyopathy Description: A 63 year-old man with a dilated cardiomyopathy presents with a chief complaint of heart failure. He has noted shortness of breath with exertion and occasional shortness of breath at rest. REASON FOR VISIT: I have been asked to see this 63 year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.
  7. 7. HISTORY OF PRESENT ILLNESS: In retrospect, he has had symptoms for the past year of heart failure. He feels in general "OK," but is stressed and fatigued. He works hard running 3 companies. He has noted shortness of breath with exertion and occasional shortness of breath at rest. There has been some PND, but he sleeps on 1 pillow. He has no edema now, but has had some mild leg swelling in the past. There has never been any angina and he denies any palpitations, syncope or near syncope. When he takes his pulse, he notes some irregularity. He follows no special diet. He gets no regular exercise, although he has recently started walking for half an hour a day. Over the course of the past year, these symptoms have been slowly getting worse. He gained about 20 pounds over the past year. There is no prior history of either heart failure or other heart problems. His past medical history is remarkable for a right inguinal hernia repair done in 1982. He had trauma to his right thumb. There is no history of high blood pressure, diabetes mellitus or heart murmur. On social history, he lives in San Salvador with his wife. He has a lot of stress in his life. He does not smoke, but does drink. He has high school education. On family history, mother is alive at age 89. Father died at 72 of heart attack. He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. He has 3 healthy girls and 9 healthy grandchildren. A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness. MEDICATIONS: Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress. ALLERGIES: Denied. MAJOR FINDINGS: On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. His blood pressure is 120/70 in each arm seated. His pulse is 80 beats per minute and regular. He is breathing 1two times per minute and that is unlabored. Eyelids are normal. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. Neck is supple and symmetrical without adenopathy or thyromegaly. Jugular venous pressure is normal. Carotids are brisk without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is regular. The first and second heart sounds are normal. He does have a fourth heart sound and a soft systolic murmur. The precordial impulse is enlarged. Abdomen is soft without hepatosplenomegaly or masses. He has no clubbing, cyanosis or peripheral edema. Distal pulses are normal throughout both arms and both legs. On neurologic
  8. 8. examination, his mentation is normal. His mood and affect are normal. He is oriented to person, place, and time. DATA: His EKG shows sinus rhythm with left ventricular hypertrophy. A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease. Laboratory data shows his TSH to be 1.33. His glucose is 97 and creatinine 0.9. Potassium is 4.3. He is not anemic. Urinalysis was normal. I reviewed his echocardiogram personally. This shows a dilated cardiomyopathy with EF of 15%. The left ventricular diastolic dimension is 6.8 cm. There are no significant valvular abnormalities. He had a stress thallium. His heart rate response to stress was appropriate. The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged. The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity. ASSESSMENTS: This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain. PROBLEMS DIAGNOSES: 1. Dilated cardiomyopathy. 2. Dyslipidemia. PROCEDURES AND IMMUNIZATIONS: None today. PLANS: I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. In addition, he could benefit from a loop diuretic such as furosemide. I did not start this as he is planning to go back home to San Salvador tomorrow. I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide. In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. All of his siblings and his children should have an
  9. 9. EKG and an echocardiogram to make sure they have not developed the same thing. There is a strong genetic component of this. I will see him again in 3 to 6 months, whenever he can make it back here. He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD. A. 425.11, 272.6; I42.1, E88.1 B. 425.4, 272.4; I42.8, E78.4 C. 425.4, 272.4; I42.0, E78.5 D. 425.8, 271.9; I43, E74.9 Answer: C. Rationale: ICD-9-CM 425.4 Other primary cardiomyopathies 272.4 Other and unspecified hyperlipidemia ICD-10-CM I42.0 Dilated cardiomyopathy E78.5 Hyperlipidemia, unspecified ........................ Report 6 of 10 Medical Specialty: Cardiovascular Cardiac arrhythmia - Echocardiogram Description: Echocardiogram with color flow and conventional Doppler interrogation. REASON FOR EXAMINATION: Cardiac arrhythmia. INTERPRETATION: No significant pericardial effusion was identified. The aortic root dimensions are within normal limits. The four cardiac chambers dimensions are within normal limits. No discrete regional wall motion abnormalities are identified. The left ventricular systolic function is preserved with an estimated ejection fraction of 60%. The left ventricular wall thickness is within normal limits. The aortic valve is trileaflet with adequate excursion of the leaflets. The mitral valve and tricuspid valve motion is unremarkable. The pulmonic valve is not well visualized.
  10. 10. Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg. Doppler interrogation of the mitral in-flow pattern is within normal limits for age. IMPRESSION: 1. Preserved left ventricular systolic function. 2. Mild mitral regurgitation. 3. Mild tricuspid regurgitation. A. 427.9, 397.9; I49.9, I08.1; 93306 B. 427.9, 396.8; I49.9, I08.8; 93307 C. 428.0, 397.9; I50.9, I08.9; 93318, 93320 D. 427.31, 397.9; I50.31, I08.8; 93312 Answer: A. Rationale: ICD-9-CM 427.9 Cardiac dysrhythmia, unspecified 397.9 Rheumatic diseases of endocardium, valve unspecified ICD-10-CM I49.9 Cardiac arrhythmia, unspecified I08.1 Rheumatic disorders of both mitral and tricuspid valves CPT® 93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography ............................. Report 7 of 10 Medical Specialty: Cardiovascular Angina pectoris Description: H&P for a female with angina pectoris. CHIEF COMPLAINT (1/1): This 62 year old female presents today for evaluation of angina. Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw. Context: The patient has had no previous treatments for this condition. Duration: Condition has existed for 5 hours. Quality: Quality of the pain is described by the patient as crushing.
  11. 11. Severity: Severity of condition is severe and unchanged. Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53. ALLERGIES: No known medical allergies. MEDICATION HISTORY: Patient is currently taking Estraderm 0.05 mg/day transdermal patch. PMH: Past medical history unremarkable. PSH: No previous surgeries. SOCIAL HISTORY: Patient admits tobacco use. She relates a smoking history of 40 pack years. FAMILY HISTORY: Patient admits a family history of heart attack associated with father (deceased). ROS: Unremarkable with exception of chief complaint. PHYSICAL EXAMINATION: General: Patient is a 62 year old female who appears pleasant, her given age, well developed, oriented, well nourished, alert and moderately overweight. Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs. HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival hypertrophy, no pyorrhea and no abnormalities. Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable. Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.
  12. 12. Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted. Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted. Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus. Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar. Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6. Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit. Extremities: Right thumb and left thumb reveals clubbing. Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral. Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities. Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus. Lymphatics: No lymphadenopathy noted. IMPRESSION: Angina pectoris, other and unspecified. PLAN: DIAGNOSTIC & LAB ORDERS: Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation
  13. 13. and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl. PATIENT INSTRUCTIONS: Patient received literature on angina. PRESCRIPTIONS: Nitroglycerin; dosage: 0.1 mg/hr film, extended release Sig: as needed for chest pain, dispense: 20, refills: 0, allow generic: no. Digoxin; dosage: 0.125 mg tablet Sig: 1 qd, dispense: 30, refills: 0, allow generic: yes. A. 413.0, 272.0, 305.1, V17.49; I20.8, E78.0, F17.200, Z82.49 B. 413.1, 272.0, V15.82, V17.1; I20.1, E78.1, Z87.891, Z82.3 C. 413.9, 272.0, 305.1, V17.3; I20.9, F17.200, E78.0, Z82.49 D. 413.9, 272.2, V15.82, V17.49; I20.9, E78.2, Z87.891, Z82.49 Answer: C. Rationale: ICD-9-CM 413.9 Other and unspecified angina pectoris 272.0 Pure hypercholesterolemia 305.1 Tobacco use disorder V17.3 Family history of ischemic heart disease ICD-10-CM I20.9 Angina pectoris, unspecified E78.0 Pure hypercholesterolemia F17.200 Nicotine dependence, unspecified, uncomplicated Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system ............................. Report 8 of 10 Medical Specialty: Cardiovascular TIA and lumbar stenosis Description: Patient experienced a single episode of his vision decreasing. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale. CHIEF COMPLAINT: Transient visual loss lasting five minutes. HISTORY OF PRESENT ILLNESS: This is a very active and pleasant 82 year-old white male with a past medical history significant for first-degree AV block, status post pacemaker placement, hypothyroidism secondary to hyperthyroidism and irradiation,
  14. 14. possible lumbar stenosis. He reports he experienced a single episode of his vision decreasing "like it was compressed from the top down with a black sheet coming down". The episode lasted approximately five minutes and occurred three weeks ago while he was driving a car. He was able to pull the car over to the side of the road safely. During the episode, he felt nauseated and possibly lightheaded. His wife was present and noted that he looked extremely pale and ashen during the episode. He went to see the Clinic at that time and received a CT scan, carotid Dopplers, echocardiogram, and neurological evaluation, all of which were unremarkable. It was suggested at that time that he get a CT angiogram since he cannot have an MRI due to his pacemaker. He has had no further similar events. He denies any lesions or other visual change, focal weakness or sensory change, headaches, gait change or other neurological problem. He also reports that he has been diagnosed with lumbar stenosis based on some mild difficulty arising from a chair for which an outside physician ordered a CT of his L-spine that reportedly showed lumbar stenosis. The question has arisen as to whether he should have a CT myelogram to further evaluate this process. He has no back pain or pain of any type. He denies bowel or bladder incontinence or frank lower extremity weakness. He is extremely active and plays tennis at least three times a week. He denies recent episodes of unexpected falls. REVIEW OF SYSTEMS: He only endorses hypothyroidism, the episode of visual loss described above and joint pain. He also endorses having trouble getting out of a chair, but otherwise his review of systems is negative. A copy is in his clinic chart. PAST MEDICAL HISTORY: As above. He has had bilateral knee replacement three years ago and experiences some pain in his knees with this. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He is retired from the social security administration x 20 years. He travels a lot and is extremely active. He does not smoke. He consumes alcohol socially only. He does not use illicit drugs. He is married. MEDICATIONS: The patient has recently been started on Plavix by his primary care doctor, was briefly on baby aspirin 81 mg per day since the TIA-like event three weeks ago. He also takes Proscar 5 mg q.d and Synthroid 0.2 mg q.d. PHYSICAL EXAMINATION: Vital Signs: BP 134/80, heart rate 60, respiratory rate 16, and weight 244 pounds. He denies any pain. General: This is a pleasant white male in no acute distress. HEENT: He is normocephalic and atraumatic. Conjunctivae and sclerae are clear. There is no sinus tenderness.
  15. 15. Neck: Supple. Chest: Clear to auscultation. Heart: There are no bruits present. Extremities: Extremities are warm and dry. Distal pulses are full. There is no edema. NEUROLOGIC EXAMINATION: MENTAL STATUS: He is alert and oriented to person, place and time with good recent and long-term memory. His language is fluent. His attention and concentration are good. CRANIAL NERVES: Cranial nerves II through XII are intact. VFFTC, PERRL, EOMI, facial sensation and expression are symmetric, hearing is decreased on the right (hearing aid), palate rises symmetrically, shoulder shrug is strong, tongue protrudes in the midline. MOTOR: He has normal bulk and tone throughout. There is no cogwheeling. There is some minimal weakness at the iliopsoas bilaterally 4+/5 and possibly trace weakness at the quadriceps -5/5. Otherwise he is 5/5 throughout including hip adductors and abductors. SENSORY: He has decreased sensation to vibration and proprioception to the middle of his feet only, otherwise sensory is intact to light touch, and temperature, pinprick, proprioception and vibration. COORDINATION: There is no dysmetria or tremor noted. His Romberg is negative. Note that he cannot rise from the chair without using his arms. GAIT: Upon arising, he has a normal step, stride, and toe, heel. He has difficulty with tandem and tends to fall to the left. REFLEXES: 2 at biceps, triceps, patella and 1 at ankles. The patient provided a CT scan without contrast from his previous hospitalization three weeks ago, which is normal to my inspection. He has had full labs for cholesterol and stroke for risk factors although he does not have those available here. IMPRESSION: 1. TIA. The character of his brief episode of visual loss is concerning for compromise of the posterior circulation. Differential diagnoses include hypoperfusion, stenosis, and dissection. He is to get a CT angiogram to evaluate the integrity of the cerebrovascular system. He has recently been started on Paxil by his primary care physician and this should be continued. Other risk factors need to be evaluated; however, we will wait for the results to be sent from the outside hospital so that we do not have to repeat his prior workup. The patient and his wife assure me that the workup was complete and that nothing was found at that time. 2. Lumbar stenosis. His symptoms are very mild and consist mainly of some mild proximal upper extremity weakness and very mild gait instability. In the absence of motor stabilizing symptoms, the patient is not interested in surgical intervention at this
  16. 16. time. Therefore we would defer further evaluation with CT myelogram as he does not want surgery. PLAN: 1. We will get a CT angiogram of the cerebral vessels. 2. Continue Plavix. 3. Obtain copies of the workup done at the outside hospital. 4. We will follow the lumbar stenosis for the time being. No further workup is planned. A. 435.8, 426.10, 724.02, V45.00; G45.8, I44.1, M48.04, Z95.9 B. 435.9, 426.11, 724.02, V45.01; G45.9, I44.0, M48.06, Z95.0 C. 437.2, 426.10, 724.03, V45.09; I67.4, I44.30, M48.06, Z95.818 D. 437.0, 426.11, 724.2, V45.01; I67.4, I44.1, M54.5, Z95.0 Answer: B. Rationale: ICD-9-CM 435.9 Unspecified transient cerebral ischemia 426.11 First degree atrioventricular block 724.02 Spinal stenosis, lumbar region, without neurogenic claudication V45.01 Cardiac pacemaker in situ ICD-10-CM G45.9 Transient cerebral ischemic attack, unspecified I44.0 Atrioventricular block, first degree M48.06 Spinal stenosis, lumbar region Z95.0 Presence of cardiac pacemaker ............................ Report 9 of 10 Medical Specialty: Cardiovascular Palpitation, lightheaded, dizziness Description: Palpitation, lightheaded and dizziness. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. REASON FOR CONSULTATION: Palpitation, lightheaded and dizziness. HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded,
  17. 17. dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. The patient had some cardiac workup in the past, results are as mentioned below. Denies any specific chest pain. Activities fairly stable. She is actively employed. No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or overthe-counter medication usage. CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Nonsmoker. Cholesterol normal. No history of established coronary artery disease and family history noncontributory. FAMILY HISTORY: Nonsignificant. SURGICAL HISTORY: Tubal ligation. MEDICATIONS: On pain medications, ibuprofen. ALLERGIES: SULFA. PERSONAL HISTORY: She is a nonsmoker. Does not consume alcohol. No history of recreational drug use. PAST MEDICAL HISTORY: History of chest pain in the past. Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal. Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal. An echocardiogram at that time was also normal. At this time, presentation with lightheaded, dizziness, and palpitation. REVIEW OF SYSTEMS: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurry vision, or glaucoma. CARDIOVASCULAR: As above. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: Nonsignificant. NEUROLOGICAL: No TIA. No CVA. No seizure disorder. ENDOCRINE/HEMATOLOGIC: Nonsignificant. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.
  18. 18. HEENT: Atraumatic and normocephalic. NECK: Neck veins flat. No carotid bruits. No thyromegaly. No lympyhadenopathy. LUNGS: Air entry bilaterally fair. HEART: PMI normal. S1 and S2 regular. ABDOMEN: Soft and nontender. Bowel sounds present. EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis. CNS: Benign. PSYCHOLOGICAL: Normal. MUSCULOSKELETAL: Nonsignificant. EKG: Normal sinus rhythm, incomplete right bundle-branch block. LABORATORY DATA: H&H stable. BUN and creatinine within normal limits. Cardiac enzyme profile negative. Chest x-ray unremarkable. IMPRESSION: 1. No documented arrhythmia with the symptoms of palpitation. Lightheaded, dizziness in a 50 year-old female. 2. Normal cardiac structure by echocardiogram a year and half ago. 3. Normal cardiac catheterization in 11/07. 4. Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile. RECOMMENDATIONS: 1. From cardiac standpoint, observation, no other investigation at this juncture. 2. The patient was started on low dose of beta-blocker and see how she fares. Fortunately, no arrhythmia documented. If there is no documentation of arrhythmia, we will do observation. The patient was started empirically on beta-blocker and workup on outpatient basis explained to her. As mentioned above, she does not have any cardiac risk factors. A. 780.2; R55 B. 785.1, 780.4; R00.2, R42 C. 785.1; R00.2 D. 785.0, 780.4; R00.0, R40.1 Answer: B. Rationale: ICD-9-CM 785.1 Palpitations 780.4 Dizziness and giddiness ICD-10-CM
  19. 19. R00.2 Palpitations R42 Dizziness and giddiness ........................ Report 10 of 10 Medical Specialty: Cardiovascular Q-Fever Endocarditis Description: A 16 year-old male with Q-fever endocarditis. HISTORY OF PRESENT ILLNESS: This is a follow-up visit on this 16 year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis. He is also taking digoxin, aspirin, warfarin, and furosemide. Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well. This has not increased in frequency recently. Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute. He tolerated this procedure well. He has been doing well at home since that time. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm. GENERAL APPEARANCE: Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress. HEENT: Remarkable for the badly degenerated left lower molar. Funduscopic exam is unremarkable. NECK: Supple without adenopathy. CHEST: Clear including the sternal wound. CARDIOVASCULAR: A 3/6 systolic murmur heard best over the upper left sternal border. ABDOMEN: Soft. He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size. GU: Deferred. EXTREMITIES: Examination of extremities reveals no embolic phenomenon. SKIN: Free of lesions. NEUROLOGIC: Grossly within normal limits. LABORATORY DATA: Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. Hydroxychloroquine level obtained at that time was undetectable. Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL. Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6
  20. 20. and phase II antibodies at 1/128, which is an improvement over previous elevated titers. Studies on the pulmonary valve tissue removed at surgery are pending. IMPRESSION: Q-fever endocarditis. PLAN: 1. Continue doxycycline and hydroxychloroquine. I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. She assures me that he is compliant with his medications. We will however repeat his hydroxychloroquine and doxycycline levels. 2. Repeat Q-fever serology. 3. Comprehensive metabolic panel and CBC. 4. Return to clinic in 4 weeks. 5. Clotting times are being followed by Dr. X. A. 083.0, 421.1; A78, I39 B. 421.1, 083.0; I39, A78 C. 083.0; A78 D. 421.1; I39 Answer: A. Rationale: ICD-9-CM 083.0 Q fever 421.1 Acute and subacute endocarditis in diseases classified elsewhere ICD-10-CM A78 Q fever I39 Endocarditis and heart valve disorders in diseases classified elsewhere ……………………

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