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#14577 - 11/19/11 06:27 PM ATHP Quiz 18 Reports 4 Chart Note #030503
sln Offline
Seasoned Gabber

Registered: 10/30/11
Posts: 94
Loc: ar
I am stumped on where to apply rule 113 under Objective on Chart Note #030503 Maria Ortiz.
I have applied rule 113.... See below

Cardiac catheterization data:
I: Right atrial mean pressure was 5, RV 29/4 with end-diastolic of 7.
II: PA pressure of 31/13 with mean of 17.
III: Peak pulmonary capillary wedge pressure was a mean of 9.
IV: Left ventricle was 136/0 with mean end-diastolic of 16.
V: Descending aorta 136/58.
VI: Cardiac output was 4.3 with an index of 2.9.
VII: ABG O2 was 4.2. Pulmonary vascular resistance was 149.
VIII: Systemic vascular resistance was 1358.
IX: The end-diastolic volume was 88 with an index of 15.
X: The systolic volume was 62 with an index of 41.
XI: Ejection fraction was 70%.
XII: Ventriculography revealed normal wall motion with mild catheter induced mitral regurgitation.
There was no evidence of aortic stenosis or regurgitation or mitral stenosis.
XIII: Coronary angiography revealed a 50% lesion in the LAD.
The circumflex has diffuse luminal irregularities.
The right coronary system shows mild luminal irregularities with a 30% diameter reduction in the midregion.
XIV: There is a 90% stenosis of the proximal portion of the obtuse marginal coronary artery.

Is this correct?
confused

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#14582 - 11/20/11 08:51 AM Re: ATHP Quiz 18 Reports 4 Chart Note #030503 [Re: sln]
caw Offline
Supreme Gabber

Registered: 06/10/11
Posts: 383
Loc: Indiana
sln, look on page AK-65 of your Course 3 book. That is a good example of how this quiz should look.

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#14591 - 11/20/11 01:39 PM Re: ATHP Quiz 18 Reports 4 Chart Note #030503 [Re: caw]
sln Offline
Seasoned Gabber

Registered: 10/30/11
Posts: 94
Loc: ar
Like this?

Name: Maria Ortiz
#030503

PROBLEM #2 Cardiac catheterization.

SUBJECTIVE

OBJECTIVE
On physical examination, the patient is a well-developed elderly Latin-American female in no apparent distress. EKG showed normal sinus rhythm and a rate of 70. Axis 0 degrees. The intervals were normal. There was left ventricular hypertrophy present with repolarization abnormality consisting of ST depression of less than a 0.50 mm with T-wave inversions in V4-V6.
Cardiac catheterization data:
I: Right atrial mean pressure was 5, RV 29/4 with end-diastolic of 7.
II: PA pressure of 31/13 with mean of 17.
III: Peak pulmonary capillary wedge pressure was a mean of 9.
IV:Left ventricle was 136/0 with mean end-diastolic of 16.
Descending aorta 136/58. Cardiac output was 4.3 with an index of 2.9. ABG O2 was 4.2. Pulmonary vascular resistance was 149. Systemic vascular resistance was 1358.
I: The end-diastolic volume was 88 with an index of 15.
II: The systolic volume was 62 with an index of 41.
III: Ejection fraction was 70%.
Ventriculography revealed normal wall motion with mild catheter induced mitral regurgitation. There was no evidence of aortic stenosis or regurgitation or mitral stenosis. Coronary angiography revealed a 50% lesion in the LAD. The circumflex has diffuse luminal irregularities. The right coronary system shows mild luminal irregularities with a 30% diameter reduction in the midregion. There is a 90% stenosis of the proximal portion of the obtuse marginal coronary artery.

ASSESSMENT
Etiology: Atherosclerotic.
Anatomy: One vessel coronary disease, circumflex.
Physiology: Angina pectoris.
Functional classification: NYHA class I.
CCVS class II.

PLAN
The patient is considered to be a good candidate for PTCA.



______________________________________
Anne Jones, MD

D: 11-17-2011
T: 11-18-2011
AJ:SLN


Edited by sln (11/20/11 02:20 PM)

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#14592 - 11/20/11 05:15 PM Re: ATHP Quiz 18 Reports 4 Chart Note #030503 [Re: sln]
caw Offline
Supreme Gabber

Registered: 06/10/11
Posts: 383
Loc: Indiana
Is your book different than mine?? There aren't any numbers on my page AK-65.

Cardiac catheterization data: Right atrial mean pressure was 5, RV 29/4 with end-diastolic of 7. PA pressure 31/13 with mean of 17. Peak pulmonary.....(continue on with this paragraph. Start new paragraph with:)
Cardiac output was 4.3 with....
Ventriculography revealed (new paragraph)
Coronary angiography revealed (new paragraph)

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#14594 - 11/20/11 08:39 PM Re: ATHP Quiz 18 Reports 4 Chart Note #030503 [Re: caw]
sln Offline
Seasoned Gabber

Registered: 10/30/11
Posts: 94
Loc: ar
My Ak-65 is Report 4 Chart note, Tommy Francis.

Oh my!! after reviewing this and looking at Rule 113, I now realize what I was doing wrong. I was using the example on AK-54 thinking I needed to have the Roman numerals. Thank you so much for your help.. confused
blush

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