Heart catheterization.

E discuss. heart catheterization.pdf 1 / 1 100% + Chapter 7: Operative Reports MDC 5 OPERATIVE REPORT MDC 5-#5 Preoperative diagnosis: Chest pain with fixed anterior defect on nuclear study Postoperative diagnosis: Unstable angina Procedure performed: Selective coronary angiography, right and left coronary arteries; contrast left ventriculography with left heart catheterization; PICA with Resolute stent of the right coronary artery. Indications: The patient is a 53-year-old female with a markedly positive family history of coronary artery disease who presents with chest pain and a fixed anterior defect. Procedure description: The patient was brought to the catheterization suite where she was prepped and draped in the usual fashion and sedated using IV Versed and fentanyl. The skin and subcutaneous tissue overlying the right femoral artery was infiltrated with 1% lidocaine for local anesthesia. A 6-French sheath was placed in the right femoral artery. Diagnostic coronary angiography under fluoroscopy of the right and left coronary arteries using iso-osmolar contrast was performed with 6-French JL-4 and 6-French JR-4 diagnostic catheters, and a 6-French pigtail catheter was used to perform a left ventriculography, also under fluoroscopy with iso-osmolar contrast. It was determined that there was approximately 85-90% stenosis of the mid right coronary artery. A JR4 catheter was placed at the site of the stenosis, and the lesion was crossed with a guidewire. A 3.0 x 12 mm Resolute stent was deployed to a total of 14 atmospheres. Follow-up angiography demonstrated 0% residual stenosis. The catheter and sheath were removed and Angio-Seal plug was deployed. The patient was then transferred to the holding area in stable condition. Findings: There was 85-90% stenosis in the mid right coronary artery; percutaneous intervention was initiated. There is a 10% to 20% stenosis in the distal left main; this will be managed medically. There are no further significant obstructions in the coronary arteries. The left ventricular function is normal. There are no regional wall motion abnormalities. There is no mitral regurgitation. Code all relevant ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordance with official guidelines and coding conventions. Diagnosis Codes: Procedure Codes: MS-DRG: