A SMART design is important to the success of a project. This design allows a project manager to structure a project and track its performance as it is implemented. Develop a goal
Please indicate 3 ICD-10 CM diagnosis codes and 5 ICD-10 PCS procedure codes from the operative report included below;
Inpatient OP Note
Patient Case Number: IPSX06-Benet, Francine
Patient Name: Francine Benet DOB: 02-15-62 Sex: F
Date of Service: 03-13-XX Surgeon: Harvey Gooding, MD
Pre-Operative Diagnosis
CHF
Post-Operative Diagnosis
CHF; renal failure
Procedure Performed: Left heart catheterization
Anesthesia: Conscious sedation Complications: None
Procedures Performed:
Left heart catheterization.
Left ventriculography was not performed secondary to renal dysfunction.
Coronary angiography.
Intravascular ultrasonography of the left anterior descending pre and post procedure.
Percutaneous transluminal coronary angioplasty of the left anterior descending artery.
Approximately 70 mL of low contrast was used.
Clinical Indication:
The patient recently had stenting of the proximal and mid left anterior descending artery and presented with congestive heart failure with renal failure. Cardiac catheterization was recommended in order to confirm sizing and deployment of the stent.
Description of Procedure:
The patient was premedicated with Valium and Benadryl. The right wrist was prepped and draped in the usual sterile fashion after the Barbeau test was found to be normal. A 6-French sheath was advanced with no difficulty into the right radial artery. The patient was given heparin and nitroglycerin per protocol. A 5-French pigtail catheter was advanced without difficulty using a glidewire into the left ventricular cavity.
Pressure recorded from the left ventricle was 125/22. Left ventriculography was not
performed secondary to renal insufficiency. Pullback from the left ventricle reveals there is no AO/LV pressure gradient.
Coronary Angiography:
Diagnostic angiography of the left coronary artery system was performed using a 5-French TIG catheter. This revealed that the patient has a large caliber left main coronary artery that is short. There is no disease along the course of the left main coronary artery. The left anterior descending artery is a large vessel that wraps around the apex of the heart. There is a stented region in the proximal and mid left anterior descending artery. It appears that it may be under deployed or undersized. Its vessel appears to be patent. The left circumflex coronary artery is a large nondominant system that appears to have no narrowing a long its course. Diagnostic angiography of the right coronary artery was performed using a 5-French AR1 catheter. This revealed that the patient has a large caliber right coronary artery that is a dominant vessel.
There is no disease along the course of this system.
Intravascular Ultrasonography:
A decision was made to proceed with intravascular ultrasonography. A 6-French JL3.5 guide was used. A BMW wire was advanced with no difficulty into the left anterior descending artery and intravascular ultrasound catheter was then advanced into the left anterior descending artery and pullback was performed from just beyond the stented area proximally. This reveals that the left. anterior descending artery just beyond the stented area is a 3.3 to 3.5 mm vessel. The stent itself was a 3-mm vessel and it appears that most of the stent is under deployed as it was just deployed at 9 atmospheres. A decision was made to dilate the stent further. A 3.25 noncompliant balloon was advanced into the stented area and after careful positioning under fluoroscopic guidance, this was deployed at 18 atmospheres for 30 seconds. It was then pulled back into the more proximal portion of the stent and this was dilated to 18 atmospheres for 30 seconds. Intravascular ultrasonography post balloon inflation indicates that the stent is of better size and is closer to the size of the actual vessel.
The more proximal stent struts where the plaque burden was largest was deployed and was found to be 3-mm in size. We managed to avoid the major septal perforator coming off of the area just proximal to the stent and this was then left alone.
Immediately after the procedure, angiography revealed an excellent result with 0% residual stenosis without dissection or tear. The patient tolerated this well. The guide catheter was removed. The HemoBand was removed from the right radial site and a pressure bandage was applied with immediate hemostasis.
Impression:
Elevated left ventricular end-diastolic pressure at 22.
Undersized stent in the mid left anterior descending artery that was post-dilated with a 3.25 balloon to 18 atmospheres both proximally and distally.
A total of 70 mL of contrast dye was used with a maximum allowable contrast of over 180 mL.
Electronically Signed By: Harvey Gooding, MD
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