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?