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WESTWARD HOSPITAL 591 Chester Road Masters, FL 33955 DISCHARGE CLINICAL RESUME PATIENT: DRYLER, ARTHUR DATE OF ADMISSION: 06/03/23 DATE OF DISCHARGE: 06/06/23 ADMITTING DIAGNOSIS: Ischemia, transient ischemic attack, rule out myocardial infarction, arrhythmia DISCHARGE DIAGNOSES: Transient ischemic attack (TIA) Hyperlipidemia Coronary artery disease, status post coronary artery bypass graft and cardioversion Urinary tract infection CONSULTATIONS: Dr. Jenson for neurology and Dr. Balmer for cardiology PROCEDURES: Echocardiogram, TEE, Thallium stress test COMPLICATIONS: None INFECTIOUS: None HISTORY: Eighty-one-year-old white male with significant history of coronary artery disease, status post coronary artery bypass graft 3 years ago and cardioversion in February 2016, who presented with difficulty speaking. He stated that he had difficulty obtaining the right words when he spoke. This lasted about 15 minutes; however, when the patient came to the emergency room he was completely okay. He did not have any deficits. The patient was admitted and consultants were called in to provide evaluation of possible TIA with rule out cardiac source. Carotid Doppler was done. Echocardiogram was done. This showed dilated left ventricle, severe global left ventricular dysfunction, estimated ejection fraction 20% and left atrial enlargement, mitral annular calcification with severe mitral regurgitation, aortic sclerosis with moderate aortic insufficiency, and severe tricuspid regurgitation with estimated pulmonary study pressure of 70 mm. Thallium stress test was uneventful. Persantine infusion protocol and no clinical EKG changes of ischemia and radionuclide showed fixed defect anteroseptal, anteroapical, and adjacent inferior wall with hypokinesis; no ischemia seen. The ejection fraction was calculated 40%. CT of the brain showed white matter ischemic changes and atrophy, no acute intracranial abnormalities. MRI showed extensive periventricular white matter ischemia changes. MRA was normal. EKG was within normal limits, showing sinus bradycardia with average of 50 to 56. The patient went to TEE to rule out cardiac source. The TEE was not conclusive and there was no hypokinesis, as described in the previous echocardiogram, and it was considered the patient needs to have lifetime Coumadin because of previous events. The hospital course was uneventful. He never presented with any other new deficit or any new symptoms. Today, the patient is asymptomatic; vital signs are stable. Monitor shows sinus rhythm, and he is discharged in stable condition to be followed by Dr. Curran in 1 week, by Dr. Jenson in 2 weeks, and by Dr. Balmer in 2 weeks. He will have home health nurse to inject him Lovenox until PT and INR reach therapeutic levels of 2/3. He will be on Coumadin 5 mg po qd, and home health nurse will draw PT and INR daily until Dr. Roman thoroughly assesses the patient. He will receive the last dose of Bactrim today for urine; however, urine culture has been negative. Rudolph Langer, MD cc. Karyn Curran, MD Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. The number of spaces provided does not indicate the number of codes required to accurately report this encounter. What is/are the correct diagnosis code(s)?

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