This is my first coding experience with this procedure. Please help. Notes are below.
Procedure(s):
Coronary Angiography
ps/ao/cor
vent/atrial
Coronaries NO V-Gram
Indications: Chest Pain
Diagnostic Technique: After obtaining informed consent, the Right Groin wasa anesthetized using Lidocaine 2%. Intravascular access was established via the Right Femoral Artery using the modified Seldinger technique. A 6 French sheath was placed over the wire. LCA angiography visualized with JL 4.0 in multiple views. RCA angiography visualized with JR 4.0 in multiple views. Pressures were recorded across the aortic valve using a pigtail catheter. LV gram not performed because of elevated EDP. The sheath was secured to be pulled in recovery.
Contrast: Omnipaque 50mL
Procedural Med
Versed 1 mg IV pre-pro
Versed 1 mg IV pre-pro
Fentanyl 50mcg IV pre-pro
Fentanyl 25mcg IV pre-pro
Versed 1 mg IV pre-pro
Fentanyl 25mcg IV pre-pro
Versed 1 mg IV during
Fentanyl 50mcg IV during
Morphine 1 mg IV during
Notroglycerin 0.4 mg SL during
No complications.
State: RM AIR REST
Coronary Dominance: Right
Findings:
*Left Main Coronary Artery - The LMCA is normal and is short.
* Left Anterior Descending - Proximal LAD is normal. The MId LAD has mild luminal irreg. w/ 30% stenosis. The Distal LAD is normal. The 1st Diagonal is normal as well as the mid and distal vessel. The 2nd Diagonal is small. The 3rd Diagonal is small.
*Circumflex - The Proximal Circumflex has mild luminal irreg. w/ 20% stenosis. The 1st Marginal has diffuse luminal irreg. w/ 50% stenosis.
*Right Coronary Artery - The Mid RCA has mild luminal irreg. w/ 20 - 30% stenosis before the RV branch and 30 - 40% after the RV Branch. The Right PDA is normal. The 1st RPL is normal. The 3rd RPL is normal.
Procedure(s):
Coronary Angiography
ps/ao/cor
vent/atrial
Coronaries NO V-Gram
Indications: Chest Pain
Diagnostic Technique: After obtaining informed consent, the Right Groin wasa anesthetized using Lidocaine 2%. Intravascular access was established via the Right Femoral Artery using the modified Seldinger technique. A 6 French sheath was placed over the wire. LCA angiography visualized with JL 4.0 in multiple views. RCA angiography visualized with JR 4.0 in multiple views. Pressures were recorded across the aortic valve using a pigtail catheter. LV gram not performed because of elevated EDP. The sheath was secured to be pulled in recovery.
Contrast: Omnipaque 50mL
Procedural Med
Versed 1 mg IV pre-pro
Versed 1 mg IV pre-pro
Fentanyl 50mcg IV pre-pro
Fentanyl 25mcg IV pre-pro
Versed 1 mg IV pre-pro
Fentanyl 25mcg IV pre-pro
Versed 1 mg IV during
Fentanyl 50mcg IV during
Morphine 1 mg IV during
Notroglycerin 0.4 mg SL during
No complications.
State: RM AIR REST
Coronary Dominance: Right
Findings:
*Left Main Coronary Artery - The LMCA is normal and is short.
* Left Anterior Descending - Proximal LAD is normal. The MId LAD has mild luminal irreg. w/ 30% stenosis. The Distal LAD is normal. The 1st Diagonal is normal as well as the mid and distal vessel. The 2nd Diagonal is small. The 3rd Diagonal is small.
*Circumflex - The Proximal Circumflex has mild luminal irreg. w/ 20% stenosis. The 1st Marginal has diffuse luminal irreg. w/ 50% stenosis.
*Right Coronary Artery - The Mid RCA has mild luminal irreg. w/ 20 - 30% stenosis before the RV branch and 30 - 40% after the RV Branch. The Right PDA is normal. The 1st RPL is normal. The 3rd RPL is normal.