complaints of chest discomfort

complaints of chest discomfort get help at

complaints of chest discomfort

 

The patient presented to Dr. Elhart with complaints of chest discomfort. A 2-D Doppler and color-flow Doppler were performed at the local hospital in the outpatient cardiology department, and Dr. Elhart monitored the echocardiography.

LOCATION: Outpatient, Hospital PATIENT: Herbert Gillford PHYSICIAN: Marvin Elhart, MD STUDY: The study is 2-D and a color-flow Doppler echocardiography. INDICATION FOR STUDY: Sinus bradycardia Chamber dimension by M-mode: 1. The left atrial diameter is 62 mm (millimeter), which is consistent with moderate atrial enlargement. 2. The aortic root is 39 mm. 3. Left ventricular diastolic diameter is 75 mm; systolic diameter is 65 mm. 4. Shortening fraction is 13%. 5. Ejection fraction is estimated at 26%. 6. Wall thickness is 7 mm. complaints of chest discomfort

DOPPLER: 1. Mild aortic insufficiency. The peak velocity across the aortic valve was estimated at 2 m/second. There is no evidence of significant aortic stenosis.

2. There is eccentric jet of mitral insufficiency. The E-velocity is estimated at 1.1 m/second, and that certainly corresponds with severe mitral insufficiency. There did not appear to be any significant mitral stenosis, even though the opening was decreased due to low cardiac output state.

3. There is moderate tricuspid insufficiency. The RV (right ventricle) systolic pressure could not be estimated because of incomplete spectral envelopes.

4. Mild pulmonary insufficiency without stenosis. 2-D ECHO (ECHOCARDIOGRAM): complaints of chest discomfort

1. Mild to moderate left ventricular enlargement. The overall left ventricular systolic function is severely depressed, and ejection fraction is estimated at 15% to 20%.

2. There is severe global hypokinesia. The inferoposterior segment appears to be akinetic. The wall thickness is normal. complaints of chest discomfort

3. Right ventricle, right atrium, and aortic root are within the normal limits. The left atrium is moderately dilated.

4. The mitral valve is minimally thickened, and the excursion is decreased and most likely is due to low cardiac output state rather than mitral stenosis. The aortic valve is fibrocalcific without significant stenosis. The tricuspid valve is unremarkable.

5. There is no pericardial effusion.complaints of chest discomfort

CONCLUSION: 1. Thisisamarkedlyabnormalechocardiogramthatrevealsthepresence of mild to moderate left ventricular enlargement with severe global left ventricular systolic dysfunction due to valvular insufficiency. 2. Mild aortic insufficiency. 3. Severe mitral insufficiency. RECOMMENDATIONS: 1. I would suggest aggressive medical therapy with the use of ACE inhibitors, diuresis, and possible ACE inhibitors. SBE (subacute bacterial endocarditis) prophylaxis.

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S):__________________________________

Discussion

This patient was referred for the symptom of sinus bradycardia (R00.1); but there are more definitive diagnoses available based on the test results. In the Conclusion section of the report, the physician indicates “left ventricular enlargement with severe global left ventricular systolic dysfunction due to valvular insufficiency.” The ventricular enlargement and dysfunction are “due to” another more specific condition (valves are not functioning properly) and therefore neither the enlargement nor the dysfunction are reported separately. The physician indicated both aortic and mitral insufficiency and, in the Doppler section of the report, he indicated tricuspid and pulmonary insufficiency. No specific cause for these conditions was specified, so each of the conditions must be reported. complaints of chest discomfort

There are two codes required to report these diagnoses. In the Index of the ICD-10-CM, reference the main term “Insufficiency” and subterms “mitral, with, aortic valve disease”, which is coded to I08.0; however, “tricuspid [valve] disease” is also documented. A combination code describing combined rheumatic disorders of mitral, aortic, and tricuspid valves is assigned. Although documentation does not indicate that the multiple valve diseases are rheumatic in nature, the “Includes” note under category I08 states that this category also includes multiple valve diseases that are unspecified, therefore, I08.3 is assigned. In the “Doppler” section of the report, the physician indicates that the patient also has tricuspid and pulmonary insufficiencies. The pulmonary valve insufficiency is reported with I08.8. complaints of chest discomfort