Tmatthews
Contributor
Can I get an opinion on this report and the codes you would use?
PROCEDURES PERFORMED:
-- Abdominal aortography.
SUMMARY:
-- AORTA:
-- Infrarenal abdominal aorta: Normal.
-- LEFT LOWER EXTREMITY VESSELS:
-- Left tibio-peroneal: There was a 100 % stenosis.
-- RIGHT LOWER EXTREMITY VESSELS:
-- Mid right popliteal: There was a 100 % stenosis.
-- COMPLETION:
-- The sheath was removed. Hemostasis was successful at the left femoral
artery access site using a closure device ( Mynx).
DISPOSITION: The patient left the catheterization laboratory in stable
condition. The patient has been instructed to follow up with Marc Warner,
MD on 22-Apr-2015 at 2:00.
HISTORY: The patient has hypertension. There was no history of chronic
lung disease or diabetes.
AORTA: Infrarenal abdominal aorta: Normal.
LEFT LOWER EXTREMITY VESSELS: Left tibio-peroneal: There was a 100 %
stenosis.
RIGHT LOWER EXTREMITY VESSELS: Mid right popliteal: There was a 100 %
stenosis.
PROCEDURE: The risks and alternatives of the procedures and conscious
sedation were explained to the patient and informed consent was obtained.
The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile
fashion. A timeout was performed prior to the start of the case.
-- Left femoral artery access. The puncture site was infiltrated with 2 %
lidocaine. The vessel was accessed using the modified Seldinger technique,
a wire was threaded into the vessel, and a sheath was advanced over the
wire into the vessel.
-- Abdominal aortography. A catheter was placed and contrast was
injected.
HEMOSTASIS: The sheath was removed. Hemostasis was successful at the left
femoral artery access site using a closure device ( Mynx).
COMPLICATIONS:
There were no adverse outcomes.
No complications occurred during the cath lab visit.
Estimated blood loss: minimal.
Specimens removed: none.
PROCEDURE COMPLETION: The patient tolerated the procedure well. TIMING:
Test started at 09:58. Test concluded at 10:25. RADIATION EXPOSURE:
Fluoroscopy time: 4.48 min. Fluoroscopy dose: 0.13 Gray.
CONTRAST GIVEN: Visipaque 110 ml.
Prepared and E-signed by
Signed 16-Apr-2015 10:54:57
HEMODYNAMIC TABLES
Pressures: Baseline
Pressures: - HR: 81
Pressures: - Rhythm:
Pressures: -- Aortic Pressure (S/D/M): 213/82/47
Outputs: Baseline
Outputs: -- CALCULATIONS: Age in years: 67.49
Outputs: -- CALCULATIONS: Body Surface Area: 1.48
Outputs: -- CALCULATIONS: Height in cm: 155.00
Outputs: -- CALCULATIONS: Sex: Female
Outputs: -- CALCULATIONS: Weight in kg: 50.80
PROCEDURES PERFORMED:
-- Abdominal aortography.
SUMMARY:
-- AORTA:
-- Infrarenal abdominal aorta: Normal.
-- LEFT LOWER EXTREMITY VESSELS:
-- Left tibio-peroneal: There was a 100 % stenosis.
-- RIGHT LOWER EXTREMITY VESSELS:
-- Mid right popliteal: There was a 100 % stenosis.
-- COMPLETION:
-- The sheath was removed. Hemostasis was successful at the left femoral
artery access site using a closure device ( Mynx).
DISPOSITION: The patient left the catheterization laboratory in stable
condition. The patient has been instructed to follow up with Marc Warner,
MD on 22-Apr-2015 at 2:00.
HISTORY: The patient has hypertension. There was no history of chronic
lung disease or diabetes.
AORTA: Infrarenal abdominal aorta: Normal.
LEFT LOWER EXTREMITY VESSELS: Left tibio-peroneal: There was a 100 %
stenosis.
RIGHT LOWER EXTREMITY VESSELS: Mid right popliteal: There was a 100 %
stenosis.
PROCEDURE: The risks and alternatives of the procedures and conscious
sedation were explained to the patient and informed consent was obtained.
The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile
fashion. A timeout was performed prior to the start of the case.
-- Left femoral artery access. The puncture site was infiltrated with 2 %
lidocaine. The vessel was accessed using the modified Seldinger technique,
a wire was threaded into the vessel, and a sheath was advanced over the
wire into the vessel.
-- Abdominal aortography. A catheter was placed and contrast was
injected.
HEMOSTASIS: The sheath was removed. Hemostasis was successful at the left
femoral artery access site using a closure device ( Mynx).
COMPLICATIONS:
There were no adverse outcomes.
No complications occurred during the cath lab visit.
Estimated blood loss: minimal.
Specimens removed: none.
PROCEDURE COMPLETION: The patient tolerated the procedure well. TIMING:
Test started at 09:58. Test concluded at 10:25. RADIATION EXPOSURE:
Fluoroscopy time: 4.48 min. Fluoroscopy dose: 0.13 Gray.
CONTRAST GIVEN: Visipaque 110 ml.
Prepared and E-signed by
Signed 16-Apr-2015 10:54:57
HEMODYNAMIC TABLES
Pressures: Baseline
Pressures: - HR: 81
Pressures: - Rhythm:
Pressures: -- Aortic Pressure (S/D/M): 213/82/47
Outputs: Baseline
Outputs: -- CALCULATIONS: Age in years: 67.49
Outputs: -- CALCULATIONS: Body Surface Area: 1.48
Outputs: -- CALCULATIONS: Height in cm: 155.00
Outputs: -- CALCULATIONS: Sex: Female
Outputs: -- CALCULATIONS: Weight in kg: 50.80