I need the codes of this case. OCATION: Outpatient, Clinic PATIENT: Warren Johnson ATTENDING PHYSICIAN: Ronald Green, M.

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I need the codes of this case.
OCATION: Outpatient, Clinic
PATIENT: Warren Johnson
ATTENDING PHYSICIAN: Ronald Green, M.D.
CONSULTING PHYSICIAN: James Noonar, M.D.
REASON FOR ADMISSION: Ischemic heart disease.
HISTORY: Dr. Green has asked me to evaluate and advise on
treatment options for this patient. Mr. Johnson is a
61-year-old male with known ischemic heart disease who has
previously had placement of a stent within a vein graft to the RCA.
He has had a recent stress test, ordered by Dr. Green, which was
abnormal and therefore required a repeat angiography. He underwent
a cardiac angiogram which demonstrated an in-stent occlusion within
the vein graft of the RCA. We have been asked to see the patient in
consultation specifically to discuss the role of coronary artery
brachytherapy.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY:
Significant for:
1. Atherosclerotic heart disease.
2. Mitral insufficiency.
3. Congestive heart failure.
4. Complete heart block with placement of a dual-chamber
pacemaker.
5. Dyslipidemia.
6. Gastroesophageal reflux disease.
7. Legally blind.
PAST SURGICAL HISTORY:
Significant for:
1. Laparoscopic cholecystectomy.
2. ERCP.
3. Placement of a dual-chamber pacemaker.
4. Remote tonsilloadenoidectomy.
PRESENT MEDICATIONS: Please see medication sheet.
SOCIAL HISTORY: The patient is retired from construction. He
denies the use of tobacco and alcohol products at this time.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Significant for an abnormal stress test which
prompted the angiogram performed yesterday. He denies any fevers,
chills or sweats, shortness of breath, chest tightness,
light-headedness, dizziness or syncope. Review of systems otherwise
negative.
EXAMINATION: Weight 180 pounds, pulse 72, respiratory rate 18.
Head is normocephalic, atraumatic. Auricular canals and tympanic
membranes are clear and intact bilaterally. Eyes: EOMI, PERRLA,
visual fields are full to confrontation. Oral cavity pink and moist
without mucosal lesions. Neck supple with midline trachea without
adenopathy, thyromegaly, or JVD. Lungs are clear to auscultation
and percussion. Heart is regular without murmur. Abdomen is soft
without hepatosplenomegaly, mass, tenderness, rebound or guarding.
Back and extremities have normal muscular strength, deep tendon
reflexes, and light touch without evidence of cyanosis, clubbing,
edema, or focal reproducible tenderness.
IMPRESSION: Patient with known atherosclerotic disease who has
had placement of a coronary stent within the vein graft of the RCA
who presents with an abnormal angiogram with total obstruction
within the coronary stent.
RECOMMENDATIONS: This is a 61-year-old male with known history
of native coronary artery disease with complete obstruction of a
coronary stent within the vein graft of the right coronary artery.
We do believe he would be a candidate for coronary artery
brachytherapy if he has a successful angioplasty. We have discussed
the indications, goals and side effects of coronary artery
brachytherapy with the patient. He appears to understand and has
vocalized a desire to proceed with this treatment option.
If Dr. Green agrees and wishes me to do so, the patient will be
scheduled for this treatment at the soonest available date.