Jane5711
Networker
Hi,
My Doctor did a PTCA and LHC/RHC on a patient who developed complications after the surgery. Unfortunately these complications lead to his death. Here's his discharge summary on the same day of the surgery:
DEATH DISCHARGE SUMMARY
DISCHARGE DIAGNOSES: The patient expired with episodes of acute hypoxemia
associated with pulseless electrical activity as well as acute
hypertension with inability to resuscitate the patient despite extensive
ACLS protocol run over 2 hours.
ADMITTING DIAGNOSES:
1. Progressing unstable angina pectoris with history of ischemic heart
disease and anterior inferior wall ischemia and lateral wall ischemia
as an outpatient.
2. Multi-vessel coronary artery disease with 90 percent ostial stenosis
of the left circumflex artery, proximal left circumflex artery,
another 90 percent stenosis, and another 80 to 90 percent stenosis of
the mid left circumflex artery, and 80 percent stenosis of the ostial
proximal left anterior descending, 75 percent stenosis of the right
coronary artery.
3. Chronic obstructive pulmonary disease with respiratory failure. The
patient is on oxygen, 3 L, chronic.
4. Obesity.
5. Sleep apnea.
6. Diabetes mellitus.
7. Hypertension.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient was admitted
electively for further evaluation and treatment because of recurrent and
worsening symptoms of angina pectoris with history of lateral wall
ischemia as well as anterior inferior wall ischemia. He had known history
of coronary artery disease, which was moderate several years ago, but then
he underwent cardiac catheterization today and was found to have critical
lesion in the ostial proximal left circumflex artery with subtotal 90
percent stenosis, another 90 percent stenosis of the proximal and mid left
circumflex artery, and another 80 percent of the ostial LAD with 75
percent stenosis of the right coronary artery. He underwent successful
angioplasty and stent of the ostial proximal LAD and ostial proximal left
circumflex artery, proximal and mid left circumflex artery with 3
drug-eluting stents, which the report is done elsewhere. The procedure
was very successful without any complications. During the procedure,
there were no complications.
After the patient was transferred to the floor, the patient complained of
brief episode of chest discomfort, which was pleuritic chest pain and
became hypertensive briefly. He was given resucitation by the nurse. An
EKG was done, which showed subtle ST-segment elevation in lead V3 followed
by another EKG done immediately after my arrival. This showed another
subtle ST-segment elevation in lead V1. The patient has baseline
intraventricular conduction delay, so it was not clear whether he was
having stent thrombosis, so he was emergently taken back to the cardiac
catheterization lab. He underwent repeat cardiac catheterization, which
showed patent LAD, patent left circumflex artery and diagonal branch,
patent mid LAD. All the coronary vessels had TIMI 3 flow. At this point,
the patients symptoms have resolved. He feels quite comfortable. His
arterial venous sheaths were removed and he was transported to the floor.
Once he was transferred to the floor, then within an hour or so _____
hypoxemia. He became short of breath, he became wheezy, and was having
gurgling breath sounds. At that point, the nurse called me and told me
that the patient then had gone into pulseless electrical activity, so I
asked them to call code blue and I immediately arrived to the scene. After
I arrived there, the patient was noted to be in pulseless electrical
activity with no blood pressure. The patient was given extensive
resuscitation, which has been detailed in my Critical Care progress note
as well as in the ACLS protocol. After initial no blood pressure, the
patient, after resuscitation, got a blood pressure of 110, but then blood
pressure would not sustain itself and went down to 80. After multiple
resuscitory efforts, including the patient initially undergoing CPR and
Ambu bagging followed by intubation with ET tube and mechanic ventilator
and then central venous line insertion as well as emergency
transesophageal echocardiogram at the bedside. The patient was transferred
in critical condition to the ICU for further care; whereupon, the patient
continued to be remain hemodynamically unstable and then after brief
episodes of sustained blood pressure, he would have _____. Despite
multiple inotropic agents including norepinephrine drip, epinephrine drip,
multiple injections of sodium bicarbonate, intravenous calcium, and even 2
units of blood transfusion, the patient could not be successfully
resuscitated. A bedside abdominal ultrasound study did not show
retroperitoneal hematoma.
Transesophageal echocardiogram revealed a small right ventricle, question
thrombus versus artifact in the mid portion of the right ventricle. Left
ventricular systolic function was excellent. There was a small
pericardial effusion.
There was no severe mitral valve regurgitation noted. Aortic valve
function was normal with aortic valve sclerosis. Mitral valve function
appeared to be normal. _____ could not be well visualized.
Despite all the resuscitory efforts for more than 2 hours, the patient did
not sustain the persisting blood pressure. Hemoglobin was noted to drop
from 12.9 on admission to 7.9 during the code with at least 5 L or more of
IV fluids already given. Then, at that point, the patient was given blood
transfusion; hemoglobin had already dropped also _____. It was not
apparent where he was bleeding. He had a distended abdomen, which was not
able to be decompressed, which was attempted to be decompressed with NG
tube suction earlier. But, the abdominal distention for the most part was
chronic and on physical examination was not very tight abdomen.
While suspicion of bleeding was entertained and hence, blood transfusion
was given. There was no obvious indication that he was bleeding except
for significant hypotension. We continued all these efforts and yet, when
patient not maintained the blood pressure and hence would remain in sinus
rhythm but with pulseless electrical activity subsequently and then went
into ventricular fibrillation, which initially was resuscitated.
Subsequent to that, during resuscitation, he would not convert back to
sinus rhythm. At that point, after discussion with the family and after
long ACLS protocol, so decided to call the code off and the patient was
pronounced expired.
No other dictation than the Discharge Summary. Family was notified. Wife
was notified. The patients daughter, who is power of attorney, was
notified and according to her wish, we had stopped the ACLS protocol.
CAUSE OF DEATH:
1. Not clear. Initial symptoms were pleuritic chest pain, brief lasting
with hypertension followed by sustained episode of shortness of breath
and possibly hypoxemia and pulses electrical activity. Questions were
raised whether the patient had pulmonary embolism with echodensity
noted in the right ventricle could be thrombus versus artifact.
2. Other cause of death considered was hypertension could be secondary to
hypovolemia secondary to internal bleeding, though we could not find
any obvious bleeding in the right groin area or in the physical
examination. Thus, we find abdominal distention as well as we could
not find any obvious bleeding by the abdominal ultrasound, which was
limited quality but done at the bedside.
3. Profound acidosis due to hypoxemia, contributing to possibly
associated hypertension and thus unrelenting _____ also had to be
considered as potentially a contributing cause to death.
4. All the coronary arteries were already noted to be patent, and this
was concern with the second cardiac catheterization during the same
hospitalization course. Left ventricular systolic function was
excellent until _____ as noted by transesophageal echocardiogram
during the ACLS protocol.
THIS IS AN ADDENDUM TO THE DISCHARGE SUMMARY:
ER physicians were doing ACLS protocol. Apparently the patient was on the
floor and had acute hypoxemia and pulseless activity and code blue was
called. Dr. Kapadia was present, close to the room, and was very helpful
in managing the patient. He remained throughout the ACLS protocol, while
he was on the regular floor helping assisting the patient with ACLS
protocol. Initially, the ER physicians also assisted in the ACLS
protocol. This process lasted more than an hour on the floor and
subsequently another 30 to 45 minutes on the ICU floor.
Would you code for a discharge outpatient 99217 and critical care?
Appreciate any help?
Thanks.
My Doctor did a PTCA and LHC/RHC on a patient who developed complications after the surgery. Unfortunately these complications lead to his death. Here's his discharge summary on the same day of the surgery:
DEATH DISCHARGE SUMMARY
DISCHARGE DIAGNOSES: The patient expired with episodes of acute hypoxemia
associated with pulseless electrical activity as well as acute
hypertension with inability to resuscitate the patient despite extensive
ACLS protocol run over 2 hours.
ADMITTING DIAGNOSES:
1. Progressing unstable angina pectoris with history of ischemic heart
disease and anterior inferior wall ischemia and lateral wall ischemia
as an outpatient.
2. Multi-vessel coronary artery disease with 90 percent ostial stenosis
of the left circumflex artery, proximal left circumflex artery,
another 90 percent stenosis, and another 80 to 90 percent stenosis of
the mid left circumflex artery, and 80 percent stenosis of the ostial
proximal left anterior descending, 75 percent stenosis of the right
coronary artery.
3. Chronic obstructive pulmonary disease with respiratory failure. The
patient is on oxygen, 3 L, chronic.
4. Obesity.
5. Sleep apnea.
6. Diabetes mellitus.
7. Hypertension.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient was admitted
electively for further evaluation and treatment because of recurrent and
worsening symptoms of angina pectoris with history of lateral wall
ischemia as well as anterior inferior wall ischemia. He had known history
of coronary artery disease, which was moderate several years ago, but then
he underwent cardiac catheterization today and was found to have critical
lesion in the ostial proximal left circumflex artery with subtotal 90
percent stenosis, another 90 percent stenosis of the proximal and mid left
circumflex artery, and another 80 percent of the ostial LAD with 75
percent stenosis of the right coronary artery. He underwent successful
angioplasty and stent of the ostial proximal LAD and ostial proximal left
circumflex artery, proximal and mid left circumflex artery with 3
drug-eluting stents, which the report is done elsewhere. The procedure
was very successful without any complications. During the procedure,
there were no complications.
After the patient was transferred to the floor, the patient complained of
brief episode of chest discomfort, which was pleuritic chest pain and
became hypertensive briefly. He was given resucitation by the nurse. An
EKG was done, which showed subtle ST-segment elevation in lead V3 followed
by another EKG done immediately after my arrival. This showed another
subtle ST-segment elevation in lead V1. The patient has baseline
intraventricular conduction delay, so it was not clear whether he was
having stent thrombosis, so he was emergently taken back to the cardiac
catheterization lab. He underwent repeat cardiac catheterization, which
showed patent LAD, patent left circumflex artery and diagonal branch,
patent mid LAD. All the coronary vessels had TIMI 3 flow. At this point,
the patients symptoms have resolved. He feels quite comfortable. His
arterial venous sheaths were removed and he was transported to the floor.
Once he was transferred to the floor, then within an hour or so _____
hypoxemia. He became short of breath, he became wheezy, and was having
gurgling breath sounds. At that point, the nurse called me and told me
that the patient then had gone into pulseless electrical activity, so I
asked them to call code blue and I immediately arrived to the scene. After
I arrived there, the patient was noted to be in pulseless electrical
activity with no blood pressure. The patient was given extensive
resuscitation, which has been detailed in my Critical Care progress note
as well as in the ACLS protocol. After initial no blood pressure, the
patient, after resuscitation, got a blood pressure of 110, but then blood
pressure would not sustain itself and went down to 80. After multiple
resuscitory efforts, including the patient initially undergoing CPR and
Ambu bagging followed by intubation with ET tube and mechanic ventilator
and then central venous line insertion as well as emergency
transesophageal echocardiogram at the bedside. The patient was transferred
in critical condition to the ICU for further care; whereupon, the patient
continued to be remain hemodynamically unstable and then after brief
episodes of sustained blood pressure, he would have _____. Despite
multiple inotropic agents including norepinephrine drip, epinephrine drip,
multiple injections of sodium bicarbonate, intravenous calcium, and even 2
units of blood transfusion, the patient could not be successfully
resuscitated. A bedside abdominal ultrasound study did not show
retroperitoneal hematoma.
Transesophageal echocardiogram revealed a small right ventricle, question
thrombus versus artifact in the mid portion of the right ventricle. Left
ventricular systolic function was excellent. There was a small
pericardial effusion.
There was no severe mitral valve regurgitation noted. Aortic valve
function was normal with aortic valve sclerosis. Mitral valve function
appeared to be normal. _____ could not be well visualized.
Despite all the resuscitory efforts for more than 2 hours, the patient did
not sustain the persisting blood pressure. Hemoglobin was noted to drop
from 12.9 on admission to 7.9 during the code with at least 5 L or more of
IV fluids already given. Then, at that point, the patient was given blood
transfusion; hemoglobin had already dropped also _____. It was not
apparent where he was bleeding. He had a distended abdomen, which was not
able to be decompressed, which was attempted to be decompressed with NG
tube suction earlier. But, the abdominal distention for the most part was
chronic and on physical examination was not very tight abdomen.
While suspicion of bleeding was entertained and hence, blood transfusion
was given. There was no obvious indication that he was bleeding except
for significant hypotension. We continued all these efforts and yet, when
patient not maintained the blood pressure and hence would remain in sinus
rhythm but with pulseless electrical activity subsequently and then went
into ventricular fibrillation, which initially was resuscitated.
Subsequent to that, during resuscitation, he would not convert back to
sinus rhythm. At that point, after discussion with the family and after
long ACLS protocol, so decided to call the code off and the patient was
pronounced expired.
No other dictation than the Discharge Summary. Family was notified. Wife
was notified. The patients daughter, who is power of attorney, was
notified and according to her wish, we had stopped the ACLS protocol.
CAUSE OF DEATH:
1. Not clear. Initial symptoms were pleuritic chest pain, brief lasting
with hypertension followed by sustained episode of shortness of breath
and possibly hypoxemia and pulses electrical activity. Questions were
raised whether the patient had pulmonary embolism with echodensity
noted in the right ventricle could be thrombus versus artifact.
2. Other cause of death considered was hypertension could be secondary to
hypovolemia secondary to internal bleeding, though we could not find
any obvious bleeding in the right groin area or in the physical
examination. Thus, we find abdominal distention as well as we could
not find any obvious bleeding by the abdominal ultrasound, which was
limited quality but done at the bedside.
3. Profound acidosis due to hypoxemia, contributing to possibly
associated hypertension and thus unrelenting _____ also had to be
considered as potentially a contributing cause to death.
4. All the coronary arteries were already noted to be patent, and this
was concern with the second cardiac catheterization during the same
hospitalization course. Left ventricular systolic function was
excellent until _____ as noted by transesophageal echocardiogram
during the ACLS protocol.
THIS IS AN ADDENDUM TO THE DISCHARGE SUMMARY:
ER physicians were doing ACLS protocol. Apparently the patient was on the
floor and had acute hypoxemia and pulseless activity and code blue was
called. Dr. Kapadia was present, close to the room, and was very helpful
in managing the patient. He remained throughout the ACLS protocol, while
he was on the regular floor helping assisting the patient with ACLS
protocol. Initially, the ER physicians also assisted in the ACLS
protocol. This process lasted more than an hour on the floor and
subsequently another 30 to 45 minutes on the ICU floor.
Would you code for a discharge outpatient 99217 and critical care?
Appreciate any help?
Thanks.