Image transcription text LOCATION: Outpatient, Clinic PATIENT:

Image transcription text LOCATION: Outpatient, Clinic PATIENT: Warren Johnson ATTENDING PHYSICIAN: Ronald Green, M.D. CONSULTING PHYSICIAN: Jam… Show more 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 other wise negative. EXAMINATION: Weight 180 pounds, pulse 68, respiratory rate 20, Head is normocepalic 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 reproductive 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 know 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. Assign appropriate CPT and ICD-10-CM codes: CPT ICD-10-CM

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