Reference no: EM133201808

Need CPT and ICD code for the following case:

Location: Outpatient, Hospital

PATIENT: Raymond Quest

SURGEON:  James Noonar, M.D.

RADIOLOGY: Morton Monson, M.D.

PROCEDURE: Transesophageal echocardiogram

INDICATION: To evaluate the patient for the presence of atrial thrombi prior to his cardioversion

DESCRIPTION OF PROCEDURE: Informed consent was obtained. The patient was premedicated with intravenous Versed and fentanyl. The throat was anesthetized with Hurricaine spray. After adequate sedation and local anesthesia were obtained, the transesophageal echocardiogram was performed in the usual manner.

FINDINGS: CARDIAC CHAMBER: The left atrium was dilated. The left atrial appendage was dilated. There was no evidence of atrial thrombi. The left ventricle was normal sized. There was moderate diffuse hypokinesis. The overall left ventricular systolic function was moderately reduced with an ejection fraction of about 30%, markedly better than her echocardiogram from a couple of days ago. The right atrium and right ventricle were markedly dilated. The aortic root was normal sized.

VALVES: The mitral valve was mildly thickened but opened normally. There was mild aortic sclerosis without stenosis. The tricuspid valve was grossly normal. The pulmonic valve was also normal.

DOPPLER AND COLOR DOPPLER INTERROGATION revealed the presence of moderate mitral insufficiency and also moderate tricuspid insufficiency.

CONCLUSION:

1. No evidence of atrial thrombi

2. Dilated left atrium

3. Dilated right atrium and right ventricle

4. Moderate mitral and moderate tricuspid insufficiency