UPMCJAM XCCU CCU 10 PORTERFIELD, CAROL R COLEMAN MD, SILVIA E General

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1 UPMCJAM XCCU CCU 10 PORTERFIELD, CAROL R COLEMAN MD, SILVIA E General Medicine 72 years 10/2/1945 Female AROMATORIO Patient is admitted with acute anterior MI, DES stent LAD. Ejection fraction on echo 7/20 was percent. Patient is a tobacco user., Now on statin beta blocker, ACE inhibitor and encouraged not to smoke. Patient underwent a platelet therapy. Findings and Conclusions LV: EDP = 23 mmhg, severe anterior and apical hypokinesis, EF = 33%, no aortic valve gradient RCA: Large, dominant vessel, minor ectasia throughout, with no areas of narrowing, terminal branches normal, RPDA septals supply LAD septals retrograde Left main coronary: Normal Circumflex: Small, non-dominant vessel, normal OM1 branch of the circumflex: Large vessel, smooth, focal 30% proximal narrowing, otherwise normal Ramus artery: Moderately large vessel, smooth, focal, eccentric 55% proximal narrowing, otherwise normal LAD: Large vessel, 8 mm long 100% proximal occlusion with initially TIMI 0 flow LAD PCI: 6 XB 3 guide, 14-gauge Prowater wire placed distally, PTCA with a 2.5 x 12 mm Trek balloon, placement of a proximal LAD 3 x 18 mm DES, expanded to 14 atm with a 3 x 15 mm NC Trek balloon, no residual LAD stenosis, thrombus, or dissection, TIMI 3 flow restored into an otherwise normal LAD, with no change in any other portion of the left coronary artery Catheterization 7/19/18: Findings and Conclusions LV: EDP = 23 mmhg, severe anterior and apical hypokinesis, EF = 33%, no aortic valve gradient RCA: Large, dominant vessel, minor ectasia throughout, with no areas of narrowing, terminal branches normal, RPDA septals supply LAD septals retrograde Left main coronary: Normal Circumflex: Small, non-dominant vessel, normal OM1 branch of the circumflex: Large vessel, smooth, focal 30% proximal narrowing, otherwise normal Ramus artery: Moderately large vessel, smooth, focal, eccentric 55% proximal narrowing, otherwise normal LAD: Large vessel, 8 mm long 100% proximal occlusion with initially TIMI 0 flow LAD PCI: 6 XB 3 guide, 14-gauge Prowater wire placed distally, PTCA with a 2.5 x 12 mm Trek balloon, placement of a proximal LAD 3 x 18 mm DES, expanded to 14 atm with a 3 x 15 mm NC Trek balloon, no residual LAD stenosis, thrombus, or dissection, TIMI 3 flow restored into an otherwise normal LAD, with no change in any other portion of the left coronary artery

2 FINAL IMPRESSIONS: 01) Nondilated left ventricle with severely hypokinetic entire anterior septum and mid and distal anterior wall and moderately decreased systolic function. The estimated left ventricular ejection fraction is 30-35%. 02) Normal right ventricle size. The right ventricle has normal function. 03) Mild tricuspid regurgitation. 04) There is an impaired relaxation pattern consistent with diastolic dysfunction grade 1. Assessment: Anterior wall myocardial infarction, PCI with drug-eluting stent Ejection fraction on echo percent Tobacco use History of cerebral aneurysm and coiling Will recommend LifeVest, may need ICD depending on degree of recovery. ~~~~~~~~~~~~~~~~~~~~~~ Eugene Ross room Patient is no code. Patient admitted with syncopal episode. Concern regarding dehydration, hypovolemia, alcohol excess. Initial blood pressures were low. Monitor unremarkable. Has history of atrial fibrillation and is on anticoagulants. Has had previous trials sotalol, heart inversions. History of obesity/sleep apnea, improved with weight loss. Additional history of hypertension, dyslipidemia, previous catheterization demonstrating nonobstructive coronary disease, and Echocardiogram 7/20/18 revealed normal ejection fraction, mild pulmonary hypertension with PA pressure of 50, ascending aorta measuring 4.3 cm. BAL was 216. Troponins negative 2 Assessment: Syncope? Dehydration History of myocardial disease

3 Hypertension Ascending aortic aneurysm, follow serially Hyperlipidemia Discourage alcohol use, encourage hydration. MICHAELS, DONNA F ** Allergies ** 83Y (5/7/1935) F X2NE/ Inpatient 07/18/18 (2.7) **Falls L2** FIN: Patient admitted with non-st elevation MI with drug-eluting stent to left circumflex on 7/18. Ejection fraction preserved. Had brief atrial fibrillation at time of procedure. Mild renal dysfunction. Patient has chronic anemia. Cautious about possibility of triple therapy/ anticoagulant. 7/18: Findings and Conclusions LV: EDP = 30 mmhg, normal systolic function, EF = 60%, no aortic valve gradient RCA: Moderately large, dominant vessel, smooth, focal 20% proximal stenosis, otherwise normal Left main coronary: Normal LAD: The LAD and its branches are normal Ramus artery: Moderate caliber vessel, normal throughout its course Circumflex: 100% proximal occlusion with TIMI 0 flow PCI circumflex: 6 XB 3 guide, a 14-gauge Prowater wire was advanced beyond the proximal CX occlusion into a large OM branch, then PTCA with a 2.5 x 15 mm Trek balloon, placement of a 2.75 x 23 mm DES extending from the proximal CX into the proximal portion of the first large OM branch, jailing the moderate caliber AV continuation of the CX, post stent dilatation to 12 atm with a 2.75 mm NC balloon, final angiographic images reveal a widely patent proximal CX which bifurcates into a small-moderate caliber jailed AV groove branch, which is normal, and a large OM1 branch which is widely patent in the stented segment, a stepdown distal to the stent is noted with TIMI 3 flow, no thrombus or dissection, and no other narrowings except for moderate disease in the distal branches of the OM1

4 Echo 7/18/18: FINAL IMPRESSIONS: 01) Technically difficult study. 02) Normal left ventricle size. Wall thickness is increased consistent with mild left ventricular hypertrophy. The left ventricle has normal systolic function. The estimated left ventricular ejection fraction is 60-65%. 03) Normal right ventricle size. The right ventricle has normal function. Transition to Plavix off Brilinta. Has some dyspnea, possibly fluid related received diuretic. Myocardial infarction Status post drug-eluting stent Heart failure resolving Hypertension Hyperlipidemia Recent nausea, weakness, SIADH June Paroxysmal atrial fibrillation observed at times the procedure on 7/18. History of cardioversion November Janet Clark 264 bed 2 Patient transferred from Horizon and had left heart catheterization after an abnormal stress test. Findings ejection fraction 60%. RCA dominant with 45% stenosis, 90% narrowing of midportion of the right posterior lateral CA. LAD moderate disease 45% proximal. Left circumflex mild disease. Plan medical therapy, preventive measures ``````````````````````````

5 Johnson, James, Admitted with orthopnea and chest tightness. Has history of stenting of RCA in 2003, by passive IMA LAD 2005, her mental stent Has allergy to aspirin has been on Plavix throughout. Creatinine is Patient refused Lasix drip. March 2018 Demonstrated patent stents, and IMA graft with moderate mid vessel stenosis of mid left circumflex. In addition to renal artery stenting has history of carotid disease. He has a history of Medtronic ICD and cardiac myopathy ejection fraction percent. His left renal artery stenosis with stenting.echo of May 2018 quantified ejection fraction at 25 percent He was placed on a Lasix drip and Lisinopril and clonidine reduced, discontinued hydralazine and Imdur., Monitoring blood pressures. Congestive heart failure ejection fraction 25% Hypertension, pressures elevated difficult to control. Renal dysfunction History of carotid disease History of renal artery stenting Coronary disease with bypass and multiple stents Trial of twice a day Lasix. Hawkes, Charlene, room Admitted with urosepsis, obstructing ureteral stone and status post stent placement 7/15. Non- ST elevation MI identified with peak troponin of 2, ejection fraction 45% on echo. HAI improving, planning cath. Urosepsis NSTEMI

6 Plan catheterization 7/23. Sanchez,, Jaime Patient admitted with dyspnea, edema has history of nonischemic myopathy, ICD, persistent atrial fibrillation on Eliquis. Placed on Lasix and dobutamine drip. Coreg being held. Potassium being supplemented. CHF Cardiomyopathy Atrial fibrillation AK I Ongoing assessment of volume overload, use of Lasix/to be any drips. Pavlick, Raymond, Patient admitted with syncope versus seizure. Was treated recently for mitral valve endocarditis and a perirectal abscess. The buttocks were completed 7/17. At the time of his TEE the EF was percent, mitral valve vegetation still seen on echo with reduced ejection fraction. Pharmacologic stress test was abnormal There is a resting perfusion abnormality in the basal inferior wall, consistent with prior infarction in the dominant coronary artery distribution with mild residual ischemia. In addition there is moderate size mild intensity anterior wall reversible defect could be consistent with ischemia. with recommendation of left heart catheter. Potential for catheter on Monday 7/23. Left ventricular dysfunction persisting Echo 7/18: 1) Moderately dilated left ventricle with akinetic inferior wall and posterior wall and severely decreased systolic function. The estimated left ventricular ejection fraction is 25-30%. 02) The right ventricle has normal function.

7 03) Calcified and non-restricted aortic valve. 04) Moderate mitral regurgitation. 05) Mitral valve mass consistent with vegetation. 06) Moderate tricuspid regurgitation. 07) The left atrium is severely enlarged. 08) The right atrium is moderately enlarged. 09) Borderline pulmonary hypertension; the estimated pulmonary artery systolic pressure is 45 mmhg. 10) Diastolic function could not be assessed due to atrial fibrillation. 11) Trivial pericardial effusion seen. Recent endocarditis with mitral valve vegetation, still present on repeat echo. EEG This abnormal EEG is indicative of mild diffuse nonspecific cerebral dysfunction. No seizure or seizure tendency is seen. Left ventricular dysfunction Moderate mitral rotation Endocarditis, vegetation noted on mitral valve Abnormal stress test fixed defect of inferior wall, ischemia anteriorly. Syncope? Seizure? Rule out malignant arrhythmia, EEG unremarkable except for diffuse cerebral dysfunction, no seizure Atrial fibrillation chronic Popp, Robert Patient initially admitted for AKA of left leg, was found to have atrial fibrillation with RVR surgery held, patient hydrated and rate controlled. Anticoagulation initiated. Patient has a history of bypass and a mechanical aortic valve. Status post TAA repair. Has history of severe peripheral vascular disease. History of COPD. Echo 7/17 revealed ejection fraction 60%, mild mitral regurgitation, mild prosthetic aortic stenosis, mean gradient of 10. Status post left AKA Atrial fibrillation

8 History of bypass/mechanical aortic valve History of TAA repair COPD Continue anticoagulation, rate control strategy. Pavelek, Margaret, Patient followed by Dr. Aromatorio in the office, last seen May At that time was seen in follow-up regarding a syncopal episode. Patient has a history of hypertension, hyperlipidemia, diastolic dysfunction, previous TIA due to APL antibody syndrome review smoker stopped 10 years ago. Patient has history of previous syncope while in Florida may have related to dehydration. Diagnostics including CT of neck head and MRI were unremarkable. Has additional history of hypothyroidism, hyperlipidemia, obesity, hypertension. She was evaluated in the emergency room having passed out at home, with her husband, apparently lost consciousness for about 1 minute. There was a report of vomiting? Aspiration. Blood pressure in the ER 146/77 with a room air sat 97%. Rest x-ray and CT of head unremarkable. Patient has reported recurrent episodes of dizziness. She previously has had an echo, stress test, EEG and previous brain MRI. EKG personally reviewed demonstrates sinus rhythm without acute changes.

Common Codes for ICD-10

Common Codes for ICD-10 Specialty: Cardiology *Always utilize more specific codes first. ABNORMALITIES OF HEART RHYTHM ICD-9-CM Codes: 427.81, 427.89, 785.0, 785.1, 785.3 R00.0 Tachycardia, unspecified