Echcardiogram: One Question The patient presented to Dr. Elhart with complaints

Question

Echcardiogram: One Question

The patient presented to Dr. Elhart with complaints of chest discomfort. A 2-D Doppler and color-flow Doppler were performed at the local hospital in the outpatient cardiology department, and Dr. Elhart monitored the echocardiography.

LOCATION: Outpatient, Hospital PATIENT: Herbert Gillford PHYSICIAN: Marvin Elhart, MD STUDY: The study is 2-D and a color-flow Doppler echocardiography. INDICATION FOR STUDY: Sinus bradycardia Chamber dimension by M-mode: 1. The left atrial diameter is 62 mm (millimeter), which is consistent with moderate atrial enlargement. 2. The aortic root is 39 mm. 3. Left ventricular diastolic diameter is 75 mm; systolic diameter is 65 mm. 4. Shortening fraction is 13%. 5. Ejection fraction is estimated at 26%. 6. Wall thickness is 7 mm.

DOPPLER: 1. Mild aortic insufficiency. The peak velocity across the aortic valve was estimated at 2 m/second. There is no evidence of significant aortic stenosis.

2. There is eccentric jet of mitral insufficiency. The E-velocity is estimated at 1.1 m/second, and that certainly corresponds with severe mitral insufficiency. There did not appear to be any significant mitral stenosis, even though the opening was decreased due to low cardiac output state.

3. There is moderate tricuspid insufficiency. The RV (right ventricle) systolic pressure could not be estimated because of incomplete spectral envelopes.

4. Mild pulmonary insufficiency without stenosis. 2-D ECHO (ECHOCARDIOGRAM):

1. Mild to moderate left ventricular enlargement. The overall left ventricular systolic function is severely depressed, and ejection fraction is estimated at 15% to 20%.

2. There is severe global hypokinesia. The inferoposterior segment appears to be akinetic. The wall thickness is normal.

3. Right ventricle, right atrium, and aortic root are within the normal limits. The left atrium is moderately dilated.

4. The mitral valve is minimally thickened, and the excursion is decreased and most likely is due to low cardiac output state rather than mitral stenosis. The aortic valve is fibrocalcific without significant stenosis. The tricuspid valve is unremarkable.

5. There is no pericardial effusion.

CONCLUSION: 1. Thisisamarkedlyabnormalechocardiogramthatrevealsthepresence of mild to moderate left ventricular enlargement with severe global left ventricular systolic dysfunction due to valvular insufficiency. 2. Mild aortic insufficiency. 3. Severe mitral insufficiency. RECOMMENDATIONS: 1. I would suggest aggressive medical therapy with the use of ACE inhibitors, diuresis, and possible ACE inhibitors. SBE (subacute bacterial endocarditis) prophylaxis.

SERVICE CODE(S):

ICD-10-CM DX CODE(S)

Explanation / Answer

SERVICE CODE(S): CPT code 93306- Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler and color flow Doppler echocardiography

ICD-10-CM DX CODE(S):

108.3: Combined rheumatic disorders of mitral, aortic and tricuspid valve

108.8: Other rheumatic multiple valve diseases (Pulmonary insufficiency)

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