I am stuck on 2 questions can you help me
I am stuck on 2 questions can you help me out first one needs 11 diagnosis codes, and 13 ICD 10 PCS procedure codes, second one needs 24 Diagnosis codes and 8 ICD 10 PCS procedure codes I only have 5,5 and 10 5
First One
Inpatient
Patient Case Number: IP11-Winston, Scheana
Patient Name: Scheana Winston DOB: 09-15-69 Sex: F
Date of Admission: 06-01-XX Date of Discharge: 06-07-XX
Discharge Summary
Discharge Diagnoses
1. SAH
2. Nonruptured cerebral aneurysm 3.Crohns Disease
4. Htn
5. Hypothyroidism
6. Protein calorie malnutrition 7.Hydrocephalus
8.Pack a day cigarette smoker
History of Present Illness:
49 y/o female presents to Emergency Department with a severe headache. In the ER, the patient was found to
have subarachnoid hemorrhage. Pt admitted to inpatient for further work-up and treatment.
Hospital Course:
Pt was admitted. On 06-01-XX, EVD was inserted and underwent coiling of LPCOM and basilar apex artery.
Pt remained in NSICU until cleared for transfer on 06-06-XX. Upon arrival to floor, pt was ambulatory
without assistance. For this reason, pt was not seen by PT/OT. Pt was ambulating in hallway independently
without any devices. On POD#6, pt was cleared for d/c home. Pt is ambulating independently, tolerating po
diet. Pt is to take Nimodipine for 7 more days.
Medical History: Crohns disease, htn, hypothyroidism
Surgical History: Thyroidectomy
Vitals:
Temperature 97.8°F
Pulse 88
Respirations 18
Blood Pressure 140/80
SpO2 100% on room air
Physical Examination General: AAO x 3 NAD
Resp: CTA B respirations regular, easy
CVS: RRR +S1 S2
Abd: +BS ND NT soft
Ext: No LE edema, negative Hamans incision: benign, no erythema, edema, drainage
/
Head: sutures intact
Neuro: CN II-XII intact
Discharge Plan: To home with family
Patient Discharge Condition: Stable
Electronically Signed By: Janette Stewart, MD
Emergency Department
Date of Service: 06-01-XX
Primary Care Physician: Gwen Sullivan, MD
Chief Complaint: Severe headache
History of Present Illness:
This is a 49-year-old female who came in secondary to severe headache. The headache started suddenly at 5
PM yesterday. Its located in the back of her head and goes to her neck into the bilateral ears. She stated that
the pain was unusual for her as she had a feeling of plugging in her ears. She describes the pain as a 9/10.
There were some mild visual changes. Patient denied any nausea, vomiting, photophobia, fevers, chills. There is
no recent trauma. She went to XYZ Hospital and at that time a CT scan of the brain was performed and
showed a subarachnoid hemorrhage. She was transferred here for further neurosurgical evaluation and
monitoring.
Review of Systems:
I have performed a complete review of systems with the pertinent positives and negatives documented in the
history of present illness. All other systems are negative.
Medical History: Crohns disease, htn, Hypothyroidism
Surgical History: Thyroidectomy
Allergies: NKDA
Social History: Smokes 1ppd cigarettes
Family History: Non-contributory
Vitals:
Temperature 98.9°F
Pulse 80
Respirations 17
Blood Pressure 120/78
SpO2 98%
Physical Examination General: No acute distress, Alert.
/
HEENT: Atraumatic, normocephalic, extraocular muscles intact, pupils equal and round, external
examination of the ears and nose are normal, oropharynx is moist.
Neck: There was some mild nuchal rigidity, trachea midline. Cardiovascular: Regular rate. Regular rhythm.
No murmurs. Lungs: Clear to auscultation bilaterally. No wheezing or rhonchi. Abdomen: Soft, nontender,
nondistended, no rebound or guarding.
Neurologic: Speech is normal, no focal neurologic deficits, sensation is intact. Cranial nerves II through XII
are intact negative finger to nose testing. Speech is normal. There is no facial asymmetry.
Musculoskeletal: No deformity, no swelling.
Skin: Warm, dry, no rashes.
Psychiatric: Cooperative, makes normal eye contact.
Extremities: No edema, pulses are palpable.
Laboratory Data (last 24 hours):
C BC/Coag
WBC: 16.89*
Hgb: 11.1* Hct: 34.9* Platelet: 394
Protime: 10.7
INR: 0.9
PTT: 30.5
Blood Type: O+ Antibody Screen: Negative
C hemistry:
Glucose Level: 118* BUN: 9
Creatinine: 0.6
eGFRA: 129.11
eGFR: 106.70
BUN/CREAT Ratio: 15
Sodium Level: 137
Potassium Level: 3.4* Chloride: 103
CO2: 21*
Calcium: 8.2*
I maging Data
CT Angiography Head/Neck Impression: There is 0% stenosis. Aneurysms of the basilar tip and right
internal carotid artery.
ED Course/Medical Decision Making
This is a 49-year-old who came in secondary to a headache. She has subarachnoid hemorrhage. The patients
CBC showed some mild leukocytosis and anemia. Her chemistry showed mild hypokalemia. The patient was
monitored multiple times and had frequent reexaminations neurosurgery as well as myself. Her neurologic
examination appears to be stable. The plan is for intensive care monitoring and possible intervention. At this
time, our goal is to control the blood pressure less than 140 systolic. They are going to start Keppra for seizure
prophylaxis in the intensive care unit.
Critical care time: 35 minutes. I did a critical care time for the initial stabilization, reevaluation, arranging for
admission, speaking with consultants, and for potential of acute decompensation secondary to subarachnoid
hemorrhage.
Final Impression: SAH
/
Final Disposition: Admitted to Inpatient
Electronically Signed By: Adam Holliday, MD
History & Physical
Date of Service: 06-01-XX
Chief Complaint: SAH
History of Present Illness:
The patient is a 49-year-old female who presented with sudden onset of acute headache and nausea to XYZ
Hospital for evaluation and was found that she has a subarachnoid hemorrhage, therefore, she was transferred
here to ABC Hospital for higher level of care.
Medical History: Crohns disease, htn, hypothyroidism
Family History: Non-contributory
Social History: Smokes cigarettes, 1ppd
Medications: Metoprolol, Lisinopril, Levothyroxine, Methotrexate, Sulfasalazine
Review of Systems: See history of present illness for pertinent positives.
Vitals:
Temperature 97.8°F
Pulse 88
Respirations 18
Blood Pressure 140/70
SpO2 98% on room air
Physical Examination
Neurologic: The patient is awake, alert, and oriented to person, place, time. Cranial nerves 2-12 are grossly
intact. She has some nuchal rigidity. Motor strength is 5/5 bilateral upper and lower extremities. Sensation is
intact to pain and touch. Reflexes are bilaterally symmetrical.
I maging Data
CT of the head demonstrated some subarachnoid hemorrhage near the basal cisterns and paraventricular
assistance. A subsequent CT angiogram of head and neck was performed and demonstrated a basilar apex
aneurysm as well as right posterior communicating artery aneurysm. There are minimal temporal horns
bilaterally without any gross evidence of hydrocephalus.
M edical Decision Making/Assessment & Plan
This is a 49-year-old female with subarachnoid hemorrhage. CT angiogram shows basilar apex aneurysm as
well as right posterior communicating artery aneurysm. At this time, we recommend admitting the patient to
the neuroscience ICU, q 1h neuro checks, subarachnoid hemorrhage protocol and will plan for cerebral
/
angiogram with possible intervention for definitive treatment of aneurysm at 7:00 in the morning. I have
discussed this with Dr. Daniel Smith, my attending physician, and he is in agreement with plan.
Electronically Signed By: Candice Smiley, MD
Progress Note
Date of Service: 06-02-XX
Subjective: POD #1, SAH, s/p coiling of right ICA aneurysm
History of Present Illness:
Mrs. Winston is a 49 y/o female, transferred from XYZ Hospital for severe headache. She underwent CT scan
of the brain that showed a subarachnoid hemorrhage. She underwent angiogram and subsequent coiling of the
basilar artery aneurysm and coiling of the right ICA aneurysm. She is feeling overall well, mild lower neck pain.
She has no headache. She has no tingling, numbness sensation or focal weakness in her body. No nausea, no
vomiting. On presentation, she feels overall okay other than the pain and discomfort in the neck area.
Review of Systems:
The patient has no headache. She does have neck pain. No tingling, numbness sensation or focal weakness in
her body. No chest pain, no shortness of breath, orthopnea, PND or palpitations. No coughing, no wheezing,
no hemoptysis. No abdominal pain, no nausea, no vomiting, no change in bowel movement or blood in the
stool. No frequency, urgency or dysuria. No skin rash, itching or scratching marks. No congestion of nose or
postnasal drainage. No fever, no chills, no sweats.
Medications: Metoprolol, Lisinopril, Sulfasalazine, Methotrexate
Allergies: NKDA
Medical History: Crohns disease, htn, hypothyroidism
Surgical History: Thyroidectomy Family History: Non-contributory Vitals:
Temperature 98.9°F
Pulse 78
Respirations 18
Blood Pressure 130/60
SpO2 100%
Physical Examination
General Appearance: This patient is lying down in bed in no acute distress.
HEENT: Head atraumatic, normocephalic. Throat is normal. Tongue is moist.
Neck: Supple.
Chest: Clear to auscultation bilaterally anteriorly.
Heart: Normal S1, S2. No heaves.
Abdomen: Soft. Bowel sounds present No organomegaly.
Extremities: No edema.
Neurologic: She is alert and oriented x 3. Cranial nerves 2-12 are grossly intact. Power 5/5 bilaterally in upper
and lower extremities. Sensation is intact.
Musculoskeletal: No swelling, coldness, edema or tenderness.
/
Skin: No rash, itching or scratching marks.
Assessment/Plan:
1. POD #1. Subarachnoid hemorrhage. S/p coiling of basilar, right ICA aneurysm.
2. Pain, controlled.
3. Hypertension. Blood pressure currently controlled on nimodipine tab. We will monitor.
Electronically Signed By: Derek Samuels, MD
Progress Note
Date of Service: 06-03-XX
Subjective: POD #2, SAH, s/p coiling of right ICA aneurysm
History of Present Illness:
Mrs. Winston is a 49 y/o female, transferred from XYZ Hospital for severe headache. She underwent CT scan
of the brain that showed a subarachnoid hemorrhage. She underwent angiogram and subsequent coiling of the
basilar artery aneurysm and coiling of the right ICA aneurysm. She POD #3 and is feeling well. No headache
nausea or vomited noted.
Review of Systems:
The patient has no headache. She does have neck pain. No tingling, numbness sensation or focal weakness in
her body. No chest pain, no shortness of breath, orthopnea, PND or palpitations. No coughing, no wheezing,
no hemoptysis. No abdominal pain, no nausea, no vomiting, no change in bowel movement or blood in the
stool. No frequency, urgency or dysuria. No skin rash, itching or scratching marks. No congestion of nose or
postnasal drainage. No fever, no chills, no sweats.
Medications: Metoprolol, Lisinopril, Sulfasalazine, Methotrexate
Allergies: NKDA
Medical History: Crohns disease, htn, hypothyroidism
Surgical History: Thyroidectomy Family History: Non-contributory Vitals:
Temperature 97.5°F
Pulse 68
Respirations 17
Blood Pressure 128/60
SpO2 100%
Physical Examination
General Appearance: This patient is lying down in bed in no acute distress. HEENT: Head atraumatic,
normocephalic. Throat is normal. Tongue is moist. Neck: Supple.
Chest: Clear to auscultation bilaterally anteriorly.
Heart: Normal S1, S2. No heaves.
Abdomen: Soft. Bowel sounds present No organomegaly.
Extremities: No edema.
/
Neurologic: She is alert and oriented x 3. Cranial nerves 2-12 are grossly intact. Power 5/5 bilaterally in upper
and lower extremities. Sensation is intact.
Musculoskeletal: No swelling, coldness, edema or tenderness.
Skin: No rash, itching or scratching marks.
Assessment/Plan:
1. POD #2, Subarachnoid hemorrhage. Status post coiling of basilar, right ICA aneurysm.
2. Hypertension, controlled on Nimodipine tab. We will monitor.
Electronically Signed By: Derek Samuels, MD
Progress Note
Date of Service: 06-04-XX
Subjective: POD #3, SAH, s/p coiling of right ICA aneurysm
History of Present Illness:
Mrs. Winston is a 49 y/o female who underwent CT scan of the brain that showed a subarachnoid
hemorrhage. She underwent angiogram and subsequent coiling of the basilar artery aneurysm and coiling of
the right ICA aneurysm on 06-01-XX. She is feeling overall well, mild lower neck pain. She has no headache.
She has no tingling, numbness sensation or focal weakness in her body. No nausea, no vomiting. On
presentation, she feels overall okay other than the pain and discomfort in
Review of Systems:
The patient has no headache. She does have neck pain. No tingling, numbness sensation or focal weakness in
her body. No chest pain, no shortness of breath, orthopnea, PND or palpitations. No coughing, no wheezing,
no hemoptysis. No abdominal pain, no nausea, no vomiting, no change in bowel movement or blood in the
stool. No frequency, urgency or dysuria. No skin rash, itching or scratching marks. No congestion of nose or
postnasal drainage. No fever, no chills, no sweats.
Medications: Metoprolol, Lisinopril, Sulfasalazine, Methotrexate
Allergies: NKDA
Medical History: Crohns disease, htn, hypothyroidism
Surgical History: Thyroidectomy Family History: Non-contributory Vitals:
Temperature 98.2°F
Pulse 82
Respirations 22
Blood Pressure 136/70
SpO2 100%
Physical Examination
General Appearance: This patient is lying down in bed in no acute distress. HEENT: Head atraumatic,
normocephalic. Throat is normal. Tongue is moist. Neck: Supple.
Chest: Clear to auscultation bilaterally anteriorly.
Heart: Normal S1, S2. No heaves.
/
Abdomen: Soft. Bowel sounds present No organomegaly.
Extremities: No edema.
Neurologic: She is alert and oriented x 3. Cranial nerves 2-12 are grossly intact. Power 5/5 bilaterally in upper
and lower extremities. Sensation is intact.
Musculoskeletal: No swelling, coldness, edema or tenderness.
Skin: No rash, itching or scratching marks.
Assessment/Plan:
1. POD #3 Subarachnoid hemorrhage. Status post coiling of basilar, right ICA aneurysm.
2. Hypertension, controlled on Nimodipine.
3. Crohns disease, controlled on Sulfasalazine and Methotrexate. Continue to monitor.
4. Hypothyroidism, stable.
Electronically Signed By: Derek Samuels, MD
Progress Note
Date of Service: 06-05-XX
Subjective: POD #4, SAH, s/p coiling of right ICA aneurysm
History of Present Illness:
Mrs. Winston was seen at bedside today. She denies confusion, dizziness, or n/v. She is ambulating well.
Review of Systems:
The patient has no headache. She does have neck pain. No tingling, numbness sensation or focal weakness in
her body. No chest pain, no shortness of breath, orthopnea, PND or palpitations. No coughing, no wheezing,
no hemoptysis. No abdominal pain, no nausea, no vomiting, no change in bowel movement or blood in the
stool. No frequency, urgency or dysuria. No skin rash, itching or scratching marks. No congestion of nose or
postnasal drainage. No fever, no chills, no sweats.
Medications: Metoprolol, Lisinopril, Sulfasalazine, Methotrexate
Allergies: NKDA
Medical History: Crohns disease, htn, hypothyroidism
Surgical History: Thyroidectomy Family History: Non-contributory Vitals:
Temperature 97.6°F
Pulse 70
Respirations 16
Blood Pressure 127/68
SpO2 100%
Physical Examination
General Appearance: This patient is lying down in bed in no acute distress. HEENT: Head atraumatic,
normocephalic. Throat is normal. Tongue is moist. Neck: Supple.
Chest: Clear to auscultation bilaterally anteriorly.
/
Heart: Normal S1, S2. No heaves.
Abdomen: Soft. Bowel sounds present No organomegaly.
Extremities: No edema.
Neurologic: She is alert and oriented x3. Cranial nerves 2-12 are grossly intact. Power 5/5 bilaterally in upper
and lower extremities. Sensation is intact.
Musculoskeletal: No swelling, coldness, edema or tenderness.
Skin: No rash, itching or scratching marks.
Assessment/Plan:
1. POD #4. Subarachnoid hemorrhage. S/p coiling of basilar, right ICA aneurysm.
2. Pain, controlled.
3. Hypertension. Blood pressure currently controlled on nimodipine tab. We will monitor.
Electronically Signed By: Derek Samuels, MD
Progress Note
Date of Service: 06-06-XX
Subjective: POD #5, SAH, s/p coiling of right ICA aneurysm
History of Present Illness:
Mrs. Winston was seen at bedside today. She denies confusion, dizziness, or n/v. She is ambulating well and
has been transferred from NSICU.
Review of Systems:
The patient has no headache. She does have neck pain. No tingling, numbness sensation or focal weakness in
her body. No chest pain, no shortness of breath, orthopnea, PND or palpitations. No coughing, no wheezing,
no hemoptysis. No abdominal pain, no nausea, no vomiting, no change in bowel movement or blood in the
stool. No frequency, urgency or dysuria. No skin rash, itching or scratching marks. No congestion of nose or
postnasal drainage. No fever, no chills, no sweats.
Medications: Metoprolol, Lisinopril, Sulfasalazine, Methotrexate
Allergies: NKDA
Medical History: Crohns disease, htn, hypothyroidism
Surgical History: Thyroidectomy Family History: Non-contributory Vitals:
Temperature 98.6°F
Pulse 78
Respirations 18
Blood Pressure 120/70
SpO2 100%
Physical Examination
General Appearance: This patient is lying down in bed in no acute distress. HEENT: Head atraumatic,
normocephalic. Throat is normal. Tongue is moist. Neck: Supple.
Chest: Clear to auscultation bilaterally anteriorly.
/
Heart: Normal S1, S2. No heaves.
Abdomen: Soft. Bowel sounds present No organomegaly.
Extremities: No edema.
Neurologic: She is alert and oriented x3. Cranial nerves 2-12 are grossly intact. Power 5/5 bilaterally in upper
and lower extremities. Sensation is intact.
Musculoskeletal: No pint swelling, coldness, edema or tenderness.
Skin: No rash, itching or scratching marks.
Assessment/Plan:
1. POD #5. Subarachnoid hemorrhage. S/p coiling of basilar, right ICA aneurysm. Transferred from NSICU.
2. Hypertension, controlled on Nimodipine.
3. Hypothyroidism.
4. Crohns disease
Electronically Signed By: Derek Samuels, MD
Progress Note
Date of Service: 06-07-XX
Subjective: POD #6. Patient seen and examined at bedside. C/o mild headaches this morning. The patient
c/o loss of left peripheral visual field deficit however, she had these symptoms prior to her SAH. Denies
confusion, dizziness, n/v.
Vitals:
Temperature 100°F
Pulse 100
Respirations 20
Blood Pressure 140/70
SpO2 100% on room air
I maging Data
CT Angiography of Head and Neck Impression: There is 0% stenosis. Aneurysms of the basilar tip and
right internal carotid artery. I have personally viewed this examination and agree with the interpretation.
US TCD Complete Impression: No sonographic evidence of vasospasm.
CXR, 1 View Impression: Central venous catheter tip in right atrium. Recommend retraction of 5 cm.
Findings were discussed over the phone to patients nurse by Dr. Knight on 06-01-XX. I have personally
viewed this entire examination and agree with the interpretation.
CT of Head or Brain w/o Contrast Impression: Interval placement of ventriculostomy tube, in the right
lateral ventricle position. No acute process. Senescent changes. I have personally viewed this examination and
agreed with the residents interpretation.
US TCD Complete Impression: No sonographic evidence of vasospasm.
/
US TCD Complete Impression: Findings suggestive of vasospasm in the right greater than left middle
cerebral arteries.
US TCD Complete Impression: No sonographic evidence of vasospasm.
US TCD Complete Impression: Elevated velocity right middle cerebral artery. Continued follow-up
recommended.
CT of Head/Brain w/o Contrast: Interval decompression of the ventricles. Previously seen small amount of
blood in the posterior horn of the lateral ventricles cannot be visualized and study is otherwise unchanged.
CT of Head/Brain w/o Contrast: Interval removal of right frontal ventriculostomy catheter without
hydrocephalus.
Assessment/Plan:
49 y/o female, s/p SAH day POD#6, s/p right PCOM and Basilar apex aneurysm coiling
? EVD out
? CT head from the evening was negative for acute intracranial process. Ventricles are normal size
? C/w Nimodipine for vasospasm ppx for 9 more days
? C/w Sulfasalazine and Methotrexate for Crohns
? c/w ambulation
? F/u PT/OT
? Patient seen with Dr. Knight this morning. Patient is cleared to go home today. Insurance cleared her for
Nimodipine. Patient can continue to take for 7 more days. Patient is neurologically intact and is medically
stable from our standpoint.
? F/u with Dr. Knight in the office in 1 week for suture removal.
Electronically Signed By: Mary Greene, MD
Consultation
Date of Service: 06-01-XX
Chief Complaint: Headache
Reason for Consultation: ICU Management
History of Present Illness:
Mrs. Winston is a 49 y/o old woman with an extensive past medical history, as documented below, who
presented to ABC Hospital after transfer from XYZ Hospital for a severe headache. The patient was evaluated
in the Emergency Room and underwent CT Scan which revealed a subarachnoid hemorrhage. The patients
case was discussed with Neurosurgery and the patient was transferred here for neurological monitoring and
potential intervention. The patient complains of headache, but is hemodynamically stable.
Medical History: Htn, Crohns Disease, Hypothyroidism
Medications: Methotrexate, Sulfasalazine, Metoprolol, Lisinopril, Nimodipine
Allergies: NKDA
Review of Systems:
Constitutional: No fever, No chills, No sweats, No weakness, No fatigue, No weight loss. Eye: No redness or
eye pain, No recent visual problem, No discharge.
/
Ear/Nose/Mouth/Throat No decreased hearing, No ear pain, No ear discharge, No epistaxis, No nasal
congestion, No sinus pain, No sore throat, No tinnitus, No vertigo.
Respiratory: As in HPI, Denies orthopnea, No pleuritic pain.
Cardiovascular: No calf pain, No chest pain, No palpitations, No claudication, No orthopnea, No peripheral
edema, No varicose veins.
Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, No heartburn, No abdominal pain,
No hematemesis, No dysphagia, No jaundice, No melena.
Genitourinary: No dysuria, No hematuria, No frequent urinary tract infections, No urinary incontinence, No
urinary urgency.
Hematology/Lymphatics: No anemia, No bruising tendency, No bleeding tendency, No swollen lymph
glands.
Endocrine: No excessive thirst, No polyuria, No cold intolerance, No heat intolerance, No change in hair
texture, No flushing.
Musculoskeletal: No back pain, No pint pain, No muscle pain, No muscle weakness, No claudication, No
gait disturbance, No joint swelling.
Integumentary: No rash, No pruritus, No dryness, No skin lesion. Neurologic: No weakness, No altered
mental status, No numbness, No dizziness, No memory loss, No seizure, No syncope, No vertigo.
Psychiatric: No anxiety, No depression, No memory difficulties, No sleeping problems, No substance abuse.
Vitals:
Temperature 99.1°F
Pulse 70
Respirations 17
Blood Pressure 120/80
SpO2 99%
Physical Examination
General Impression: Alert and oriented x 3, not in acute distress, speaks in full sentences without difficulty
Integument Grossly intact, no rash, no lesions
HEENT: Normocephalic atraumatic, extra-ocular movements intact
Cardiovascular: Heart regular rate and rhythm, S1 & S2 audible, no murmurs, rubs or gallops Chest Lungs
have mild expiratory wheezing throughout b/l lung fields and a prolonged expiration, no rhonchi, no rales
Abdomen: Bowel sounds present, abdomen soft, non-tender, non-distended, no organomegaly
Skin: Intact with no visualized rashes
Psych: Normal affect and mood
I maging Data
CT Angiography of Head and Neck Impression: There is 0% stenosis. Aneurysms of the basilar tip and
right internal carotid artery: I have personally viewed this examination and agree with the interpretation.
Assessment:
1. SAH
2. Crohns Disease
3. HTN
4. Hypothyroidism
5. PCM w/ Albumin of 3.3, BMI 16.2
6. Cerebral aneurysm
Plan
/
? The patient presents to the Neuroscience Intensive Care Unit s/p operative intervention.
? Start q 1hr neurological checks with direct communication to Neurosurgery should any change in clinical
status occur.
? The patients blood pressure will be titrated to a goal parameter of SBP < 140 as determined by
Neurosurgery.
? Start Keppra seizure prophylaxis, Nimodipine for vasospasm prophylaxis.
? DVT Prophylaxis to be started once agreeable by NSG
Thank you for involving us in the care of this patient.
Electronically Signed By: Jeffrey Salazar, MD
Consultation
Date of Service: 06-02-XX
Reason for Consultation: Medical Management
Chief Complaint: SAH
History of Present Illness:
This is a 49-year-old lady who came into the hospital, transferred from XYZ Hospital for severe headache. She
underwent CT scan of the brain that showed a subarachnoid hemorrhage. She underwent angiogram and
subsequent coiling of the basilar artery aneurysm and coiling of the right ICA aneurysm. She is feeling overall
well, mild lower neck pain. She has no headache. She has no tingling, numbness sensation or focal weakness in
her body. No nausea, no vomiting. On presentation, she feels overall okay other than the pain and discomfort
in the neck area.
Review of Systems:
The patient has no headache. She does have neck pain. No tingling, numbness sensation or focal weakness in
her body. No chest pain, no shortness of breath, orthopnea, PND or palpitations. No coughing, no wheezing,
no hemoptysis. No abdominal pain, no nausea, no vomiting, no change in bowel movement or blood in the
stool. No frequency, urgency or dysuria. No skin rash, itching or scratching marks. No congestion of nose or
postnasal drainage. No fever, no chills, no sweats.
Medications: Metoprolol, Lisinopril, Sulfasalazine, Methotrexate
Allergies: NKDA
Medical History: Crohn’s disease, htn, hypothyroidism
Surgical History: Thyroidectomy Family History: Non-contributory Vitals:
Temperature 98.9°F
Pulse 78
Respirations 18
Blood Pressure 130/60
SpO2 100%
Physical Examination
/
General Appearance: This patient is lying down in bed in no acute distress. HEENT: Head atraumatic,
normocephalic. Throat is normal. Tongue is moist. Neck: Supple.
Chest: Clear to auscultation bilaterally anteriorly.
Heart: Normal S1, S2. No heaves.
Abdomen: Soft. Bowel sounds present No organomegaly.
Extremities: No edema.
Neurologic: She is alert and oriented x3. Cranial nerves 2-12 are grossly intact. Power 5/5 bilaterally in upper
and lower extremities. Sensation is intact.
Musculoskeletal: No swelling, coldness, edema or tenderness.
Skin: No rash, itching or scratching marks.
Assessment/Plan:
1. Subarachnoid hemorrhage. Status post coiling of basilar, right ICA aneurysm.
2. Pain, controlled.
3. Hypertension. Blood pressure currently controlled on nimodipine tab. We will monitor.
Electronically Signed By: Derek Samuels, MD
Operative Report
Date of Service: 06-01-XX
Preoperative Diagnosis: SAH, Cerebral aneurysms, left posterior communicating artery, the basilar apex
aneurysm.
Postoperative Diagnosis: SAH, Cerebral aneurysms: left posterior communicating artery, the basilar apex
aneurysm.
Procedure Performed:
1. Cerebral angiography, the following vessels were catheterized: Right external carotid artery, right common
carotid artery, left internal carotid artery, left vertebral artery, basilar artery, and the left intracranial internal
carotid artery.
2. A 3D angiography of the left common carotid artery reconstructed on a separate workstation.
3. Coil embolization of the basilar apex aneurysm.
4. Coil embolization of the left posterior communicating artery aneurysm.
5. Total number of angiogram through existing catheter x 8.
6. Infusion of nitroglycerin for the treatment and prevention of catheter-induced vasospasm. 7.Right femoral
closure.
Surgeon: Blake Daniels, MD Assistant: Stanley Baker, MD Indication:
The patient is a 49 y/o female with multiple intracranial aneurysms and evidence of subarachnoid hemorrhage.
She was brought to ABC Hospital today for cerebral angiography to definitively identify these aneurysms as
well as coil embolization of aneurysms. All risks and benefits for procedure were explained to the patient as
well as family. They understand that there can be no guarantees and they gave consent to the procedure.
Anesthesia: General
Description of Procedure:
The patient was brought to the angiography suite and placed in supine position on the angiography table.
Right groin region was cleaned, prepped and draped in the usual sterile fashion. Lidocaine 1% without
/
epinephrine was used to provide local anesthetic and subsequently a 6-French sheath was placed in the right
femoral artery. We then advanced a Simmons 2 diagnostic glide catheter into the descending aorta and
reconstituted in the arch. The following vessels were catheterized: Right common carotid, right external
carotid, left internal carotid artery, left vertebral artery. Multiple DSA images was obtained. A 3D angiography
of the left internal carotid artery as well as the left vertebral artery was performed and was reconstructed on a
separate workstation. We subsequently exchanged
the diagnostic catheter to a Neuron 6-French 053 x 105 cm guiding catheter, which was then advanced into the
distal vertebral artery. Then, using SL-10 microcatheter with Synchro 2 soft microwire inside the microcatheter
was advanced into the basilar artery and subsequently, the basilar apex aneurysm was catheterized. The patient
also received heparinization during the procedure as well. the aneurysm was coiled. Angiogram through
existing catheter was performed after each coil insertion.
Then after the microcatheter was removed, a final angiogram through existing catheter was performed and
demonstrated no thromboembolic event. Subsequently, the guiding catheter was removed and a diagnostic
glide catheter was again inserted into the descending aorta. It was reconstituted in the aortic arch and the left
common carotid artery was catheterized. This was then exchanged to 053 6-French x 105 cm Neuron guiding
catheter, which was advanced into the distal internal carotid artery using an SL-10 45-degree tip microcatheter
with Synchro 2 soft microwire. The left posterior communicating a
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