Atient Name Lauren Assignment Help: How to Answer This Question
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Original Question
atient Name: Lauren Weissman DOB: 07-12-66 Ordering Physician: Melinda Tanner, MD Gender: F Interpreting Physician: Kenneth Sanders, MD Date of Service: 12-01-XX Indication: R/O intracardiac thrombus, persistent afib Exam: Transesophageal Echocardiogram followed by cardioversion History: Lauren Weissman has history of atrial fibrillation status post catheter-based ablation. She had recurrence of atrial fibrillation and persisted. This happened more than 6 months after the ablation. The patient was recommended to undergo TEE. Description of Procedure: After obtaining informed consent, the patient was brought to the cardiac electrophysiology lab. The patient was prepped and draped in the usual fashion. An Omniplane probe was utilized to intubate the esophagus and images were obtained at multiple levels. Findings: The patient arrived at the lab in persistent atrial fibrillation. There was evidence of biatrial enlargement of moderate degree. The left ventricle is mildly hypertrophied with preserved left ventricular function. Right ventricle was within normal limits. Aortic valve was trileaflet with mild degree of sclerosis. Mitral valve was structurally normal with trace to mild degree of mitral regurgitation. Tricuspid valve was structurally normal with minimal tricuspid regurgitation. The PA pressure was within normal limits. Visualized portions of the aorta within normal limits. Pericardium was within normal limits. There is no evidence of intracardiac thrombus. Impression: Cardiomegaly. Mitral, aortic and tricuspid valve disorders. Give the correct CPT and ICD-10 codes.
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