NESmith
Expert
I am very new to coding Cardio, Please help me with the coding of this op-report.
Indication: Angina, abnormal nuclear stress test.
Procedure: 1) Left heart catheterization
2) Selective coronary arteriography
3) Left Ventriculogram, right femoral approach
Left Ventriculogram: Dsiplays grossly normal LV systolic function, normal-appearing left
ventricular ejection fraction.
Coronary Arteriography: The left main trunk is patent.
The left anterior descending artery is patent. There is mild calcification, mild luminal irregularities.
There is a high intermediate branch with mild luminal irregularities.
The circumflex artery is patent with mild luminal irregularities small distal vessel. There is probably more significant disease in the distal circumflex distribution, small posterolateral branches nothing discrete.
The right coronary artery is patent, again with mild calcification, mild luminal irregularities.
Discussion: The patient has multiple risk factors for coronary artery disease, had developed recent symptoms and a nuclear stress test that showed attenuation defects with mild reversal bullding. he is obese and part of this must have been some degree of soft tissue attenuation. he does have some diffuse disease and small luminal diameter vessels distally. Risk factor modification and consideration for medical theray will be pursued.
Final Impressions:
1) Coronary artery disease, coronary artery calcification.
a) Patent left main trunk.
b) Patent left anterior descending artery luminal irregularites.
c) Patent circumflex artery, small distal vessel, probably diffusely diseased.
d) Patent dominant right coronary artery, mild luminal irregularities and calcification.
2) Normal left ventricular systolic function, normal appearing left ventricular ejection
fraction.
Thank You for anyone help. I am still learning.
Indication: Angina, abnormal nuclear stress test.
Procedure: 1) Left heart catheterization
2) Selective coronary arteriography
3) Left Ventriculogram, right femoral approach
Left Ventriculogram: Dsiplays grossly normal LV systolic function, normal-appearing left
ventricular ejection fraction.
Coronary Arteriography: The left main trunk is patent.
The left anterior descending artery is patent. There is mild calcification, mild luminal irregularities.
There is a high intermediate branch with mild luminal irregularities.
The circumflex artery is patent with mild luminal irregularities small distal vessel. There is probably more significant disease in the distal circumflex distribution, small posterolateral branches nothing discrete.
The right coronary artery is patent, again with mild calcification, mild luminal irregularities.
Discussion: The patient has multiple risk factors for coronary artery disease, had developed recent symptoms and a nuclear stress test that showed attenuation defects with mild reversal bullding. he is obese and part of this must have been some degree of soft tissue attenuation. he does have some diffuse disease and small luminal diameter vessels distally. Risk factor modification and consideration for medical theray will be pursued.
Final Impressions:
1) Coronary artery disease, coronary artery calcification.
a) Patent left main trunk.
b) Patent left anterior descending artery luminal irregularites.
c) Patent circumflex artery, small distal vessel, probably diffusely diseased.
d) Patent dominant right coronary artery, mild luminal irregularities and calcification.
2) Normal left ventricular systolic function, normal appearing left ventricular ejection
fraction.
Thank You for anyone help. I am still learning.
