Question Answered PATIENT: CALLMAN, DELMAR ACCOUNT/EHR #: CALLDE001 DATE: 10/18/18… PATIENT: CALLMAN, DELMAR ACCOUNT/EHR #: CALLDE001 DATE: 10/18/18 Referring Cardiologist: Simon R. Blackman, MD Primary Physician: Curtis Le Fran, MD Office Consultation CHIEF COMPLAINT: Referral from Dr. Blackman for evaluation for aortic valve replacement due to aortic insufficiency HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old black male who relates a history of increasing fatigue as well as occasional palpitations. He denies chest pain, orthopnea, PND, pedal edema, syncope, or presyncope. The patient has a 3-month history of a known cardiac murmur. This has been evaluated through Dr. Blackman’s office. Transesophageal echocardiogram was performed on June 8 at Gaston Medical Center by Dr. Blackman, which showed PA 36/25, mean wedge 19. There is no significant gradient across the aortic value. The left main coronary artery is free of stenosis. The LAD is free of stenosis. The circumflex is free of stenosis. The right coronary artery is free of stenosis. There are no anomalous coronaries noted. Ejection fraction was noted to be 40%. The LV was markedly dilated. The aortic root injection demonstrated severe aortic regurgitation. Because of these findings, the patient is referred for evaluation for aortic valve replacement. PAST HISTORY PAST MEDICAL HISTORY: History of fractured ankles, secondary ALLERGIES: No known drug allergies MEDICATIONS: Zestril 20 mg p.o. qd; Alprazolam p.r.n. dose unknown FAMILY HISTORY: Father has an unknown heart problem. Older brother has had a stroke. Mother has a history of high blood pressure. SOCIAL HISTORY: The patient has a 30-pack/year history of cigarette smoking. He continues to smoke. He relates daily vodka intake of 2-3 oz. He also relates marijuana use. He works as a delivery driver. REVIEW OF SYSTEMS: Hematopoietic: The patient denies chronic anemia, easy bruising, or previous blood transfusion reaction. HEENT: He denies chronic headaches or sinus problems or dental problems. RESPIRATORY: The patient denies chronic cough, wheeze, sputum production, hemoptysis, TB, or pneumonia. CARDIAC: See HPI. He denies varicose veins or claudication. GASTROINTESTINAL: He denies nausea, vomiting, hematemesis, or melena. GENITOURINARY: He denies dysuria, urgency, frequency, hematuria. MUSCULOSKELETAL: The patient denies acutely swollen, painful, or warm joints or history of DVT. ENDOCRINE: The patient denies diabetes mellitus or thyroid disease. NEUROLOGIC: The patient denies stoke, TIA, amaurosis fugax, and syncope. Page 50PHYSICAL EXAMINATION: Well-developed, well-nourished male in no apparent distress. Ht 5’7″, wt 157 lb., BP 150/60, P 60 and regular, R 18 and unlabored, T 98.3. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light and accommodation bilaterally. Sclerae nonicteric, conjunctivae pink. Oral mucosa is well hydrated and pink. NECK: The trachea is midline. There is no jugular venous distension. Carotid pulses are bilateral without bruit. There is no thyromegaly noted. CHEST: The lungs are clear to auscultation and percussion. Excursion is satisfactory. Chest wall is nontender. HEART: Regular rate and rhythm. Grade III/VI systolic murmur heard at the base. Grade III/VI diastolic murmur heard at the apex and at the base. ABDOMEN: Positive bowel sounds, nontender, no organomegaly detected. Abdominal aorta is nonenlarged. There is no abdominal bruit heard. EXTREMITIES: Radial pulses are bilateral. Femoral pulses are with water hammer pulse. Pedal pulses are intact. There is no peripheral edema, clubbing, or cyanosis noted. NEUROLOGIC: The patient is alert and oriented x3. The affect is appropriate. No motor deficits are seen. IMPRESSION: Severe aortic insufficiency DISCUSSION AND PLAN: The patient was seen and evaluated by me. Records were reviewed. However, the echocardiogram did not accompany the patient nor did the cardiac catheterization. This will be reviewed at a later date. Aortic valve replacement, device options, autologous blood donation, alternatives, risks, and imponderables were discussed in detail with the patient and his wife. The patient understands and wishes to proceed. We will consult Dr. Blackman perioperatively for medical evaluation and treatment of medical management problems.What CPT Codes and ICD-10 Codes would go for this case study? Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

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