Case Study 8: Cardiovascular Disorder; a 63 y/o Hispanic woman with PMH of CAD

- Reports increasingly weak over the last couple of weeks and unable to do her housework
- c/o swelling of ankles and feet by late afternoon (she cant wear shoes) and has nocturnal
dieresis x4
- daughter took her to MD because heaviness of chest on and off over the last few days;
denies discomfort
- VS: 146/92, 96, 37C
- IV D5W KVO at right forearm

Labs: Na 134 mmol/l, K 3.5 mmol/L, Cl 103 mmol/L, HCO3 23 BUN 13 mg/dl, Crea 1.3 mg/dl,
WBC 8.3 thou/cmm, platelet 162 thou/cmm, Hct 33.9%, Hgb 11.7 g/L

PT/ INR, PTT, and UA are pending

Coronary artery disease

Clinical Information
A disease in which there is a narrowing or blockage of the coronary arteries (blood
vessels that carry blood and oxygen to the heart). Coronary artery disease is usually
caused by atherosclerosis (a build up of fatty material and plaque inside the coronary
arteries). The disease may cause chest pain, shortness of breath during exercise, and heart
attacks. The risk of coronary artery disease is increased by having a family history of
coronary artery disease before age 50, older age, smoking tobacco, high blood pressure,
high cholesterol, diabetes, lack of exercise, and obesity.
A thickening and loss of elasticity of the walls of arteries that occurs with formation of
atherosclerotic plaques within the arterial intima.
Age, lifestyle, diet, and gene related degeneration of arteries due to deposition of lipoid
plaques (atheromas) on inner arterial walls; main cause of coronary artery disease, a
leading cause of death.
An imbalance between myocardial functional requirements and the capacity of the
coronary vessels to supply sufficient blood flow. It is a form of myocardial ischemia
(insufficient blood supply to the heart muscle) caused by a decreased capacity of the
coronary vessels.
Atherosclerosis is a disease in which plaque builds up inside your arteries. Plaque is a
sticky substance made up of fat, cholesterol, calcium, and other substances found in the
blood. Over time, plaque hardens and narrows your arteries. That limits the flow of
oxygen-rich blood to your body and can lead to serious problems, including
o coronary artery disease. These arteries supply blood to your heart. When they are
blocked, you can suffer angina or a heart attack.
o carotid artery disease. These arteries supply blood to your brain. When they are
blocked you can suffer a stroke.
o peripheral arterial disease. These arteries are in your arms, legs and pelvis. When
they are blocked, you can suffer from numbness, pain and sometimes infections.
atherosclerosis usually doesn't cause symptoms until it severely narrows or totally blocks
an artery. Many people don't know they have the disease until they have a medical
emergency.a physical examination, imaging and other diagnostic tests can tell if you have
it. Treatments include medicines, and medical procedures or surgery. Lifestyle changes
can also help. These include following a healthy diet, getting regular exercise,
maintaining a healthy weight, quitting smoking, and managing stress.
Build-up of fatty material and calcium deposition in the arterial wall resulting in partial or
complete occlusion of the arterial lumen.
Coronary artery disease (cad) is the most common type of heart disease. It is the leading
cause of death in the United States in both men and women.cad happens when the arteries
that supply blood to heart muscle become hardened and narrowed. This is due to the
buildup of cholesterol and other material, called plaque, on their inner walls. This buildup
is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result,
the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain
(angina) or a heart attack. Most heart attacks happen when a blood clot suddenly cuts off
the hearts' blood supply, causing permanent heart damage. Over time, cad can also
weaken the heart muscle and contribute to heart failure and arrhythmias. Heart failure
means the heart can't pump blood well to the rest of the body. Arrhythmias are changes in
the normal beating rhythm of the heart.
Deposition of cholesterol and lipid in the inner layer of the blood vessel
Narrowing of the coronary arteries due to fatty deposits inside the arterial walls. The
diagnostic criteria may include documented history of any of the following: documented
coronary artery stenosis greater than or equal to 50% (by cardiac catheterization or other
modality of direct imaging of the coronary arteries); previous coronary artery bypass
surgery (cabg); previous percutaneous coronary intervention (pci); previous myocardial
infarction.
Thickening and loss of elasticity of the coronary arteries, leading to progressive arterial
insufficiency (coronary disease).
Applicable To
Atherosclerotic cardiovascular disease
Coronary (artery) atheroma
Coronary (artery) atherosclerosis
Coronary (artery) disease
Coronary (artery) sclerosis
Use Additional
code, if applicable, to identify:
coronary atherosclerosis due to calcified coronary lesion (I25.84 )
coronary atherosclerosis due to lipid rich plaque (I25.83 )
Type 2 Excludes
atheroembolism (I75.- )
atherosclerosis of coronary artery bypass graft(s) and transplanted heart (I25.7- )
Mortality Data
Between 1999-2007 there were 1,880,822 deaths in the United States where ICD-10
I25.1 was indicated as the underlying cause of death [source: cdc.gov ]
Weakness
Clinical Information
A sign or symptom of weakness and diminished or absent energy and strength.
Clinical sign or symptom manifested as debility, or lack or loss of strength and energy.
Physical weakness, lack of strength and vitality, or a lack of concentration.
The property of lacking physical or mental strength; liability to failure under pressure or
stress or strain. (wordnet)
Weakness; lack of energy and strength.
Applicable To
Asthenia NOS
Type 1 Excludes
age-related weakness (R54 )
muscle weakness (M62.8- )
senile asthenia (R54 )
Edema, unspecified
Clinical Information
(eh-dee-ma) swelling caused by excess fluid in body tissues.
Abnormal fluid accumulation in tissues or body cavities. Most cases of edema are present
under the skin in subcutaneous tissue.
Accumulation of an excessive amount of watery fluid in cells or intercellular tissues.
Edema means swelling caused by fluid in your body's tissues. It usually occurs in the
feet, ankles and legs, but it can involve your entire body. Causes of edema include
o eating too much salt
o sunburn
o heart failure
o kidney disease
o liver problems from cirrhosis
o pregnancy
o problems with lymph nodes, especially after mastectomy
o some medicines
o standing or walking a lot when the weather is warm
to keep swelling down, your health care provider may recommend keeping your legs
raised when sitting, wearing support stockings, limiting how much salt you eat or taking a
medicine called a diuretic - also called a water pill.
Pathological transudate within one or more tissues.
Swelling from excessive accumulation of serous fluid in tissue.
Applicable To
Fluid retention NOS
Description Synonyms
Body fluid retention
Edema
Edema (swelling)
Edema (swelling), arms and legs
Edema of foot
Pedal edema
Pedal edema (foot swelling)
Peripheral edema
Mortality Data
Between 1999-2007 there were 27 deaths in the United States where edema was indicated as
the underlying cause of death [source: cdc.gov ]
Diuresis / other polyuria
Clinical Information
Urination of a large volume of urine with an increase in urinary frequency, commonly seen in
diabetes (diabetes mellitus; diabetes insipidus).
Applicable To
Polyuria NOS
Description Synonyms
Polyuria
Polyuria (excessive urination)
ICD-10-CM R35.8 is grouped within Diagnostic Related Group(s) (MS-DRG v30.0):
695 Kidney & urinary tract signs & symptoms with mcc
696 Kidney & urinary tract signs & symptoms without mcc
Convert ICD-10-CM R35.8 to ICD-9-CM
The following ICD-10-CM Index entries contain back-references to ICD-10-CM R35.8:
Discharge (from)
excessive urine R35.8
Diuresis R35.8
Polyuria R35.8
Secretion
urinary
excessive R35.8
Urine
discharge, excessive R35.8
secretion
excessive R35.8
Basic Metabolic Panel
Why Get Tested?
To give your health care provider important information about the current status of your kidneys
as well as electrolyte and acid/base balance and level of blood glucose
When is it ordered?
A BMP may be ordered as part of a routine health exam.
The panel is also often ordered in the hospital emergency room setting because its components
give doctors important information about the current status of a person's kidneys, electrolyte and
acid/base balance, and blood glucose and calcium levels. Significant changes in these test results
can indicate acute problems, such as kidney failure, insulin shock or diabetic coma, respiratory
distress, or heart rhythm changes.

Creatinine
Why Get Tested?
To determine if your kidneys are functioning normally and to monitor treatment for
kidney disease
When to Get Tested?
Routinely as part of a comprehensive or basic metabolic panel; when your doctor
suspects that you are suffering from kidney dysfunction or when you are acutely or
chronically ill with a condition that may affect your kidneys and/or be worsened by
kidney dysfunction; at intervals to monitor treatment for kidney disease or kidney
function while on certain medications
Glucose
Why Get Tested?
To determine if your blood glucose level is within a healthy range; to screen for, diagnose, and
monitor high blood glucose (hyperglycemia) or low blood glucose (hypoglycemia), diabetes, and
pre-diabetes; to check for glucose in your urine
When to Get Tested?
Blood glucose: as part of a regular physical, when you have symptoms suggesting hyperglycemia
or hypoglycemia, and during pregnancy; if you are diabetic, self-checks up to several times a day
to monitor blood glucose levels
Urine glucose: usually as part of a urinalysis
Sample Required?
A blood sample drawn from a vein in your arm or a drop of blood from a skin prick; sometimes a
random urine sample is used. Some diabetic patients may use a continuous glucose monitor,
which is a small sensor wire inserted beneath the skin of the abdomen that measures blood
glucose every five minutes.
Test Preparation Needed?
In general, it is recommended that you fast - nothing to eat or drink except water - 8 hours before
having a blood glucose test. In persons with diabetes, glucose levels are often checked both
while fasting and after meals to provide the best control of diabetes. For random, timed, and
post-meal glucose tests, follow your doctor's instructions.

What does the test result mean?
Blood Glucose
High levels of glucose most frequently indicate diabetes, but many other diseases and conditions
can also cause an elevated blood glucose. The following information summarizes the meaning of
the test results. These are based on the clinical practice recommendations of the American
Diabetes Association.
Fasting Blood Glucose
Glucose Level Indication
From 70 to 99 mg/dL (3.9 to 5.5 mmol/L) Normal fasting glucose
From 100 to 125 mg/dL (5.6 to 6.9 mmol/L)
Impaired fasting glucose (pre-
diabetes)
126 mg/dL (7.0 mmol/L) and above on more than one testing
occasion
Diabetes
White Blood Cell Count
Why Get Tested?
To screen for or diagnose a variety of conditions that can affect white blood cells (WBC) such as
an infection, inflammation or a disease that affects the production or survival of WBCs; to
monitor treatment of a blood disorder or to monitor therapy that is known to affect WBCs
When to Get Tested?
As part of a complete blood count (CBC), when you have a routine health examination; when
you have any number of signs and symptoms that may be related to a condition affecting WBCs
such as infection, inflammation, or cancer; when you have a condition or are receiving treatment
that is known to affect WBCs
Adult 4,500-11,000 white blood cells per microliter (mcL)
Platelet Count

Why Get Tested?
To determine the number of platelets in a sample of your blood as part of a health exam; to
screen for, diagnose, or monitor conditions that affect the number of platelets, such as a bleeding
disorder, a bone marrow disease, or other underlying condition
When to Get Tested?
As part of a routine complete blood count (CBC); when you have episodes of unexplained or
prolonged bleeding or other symptoms that may be due to a platelet disorder
It may be ordered when a person has signs and symptoms associated with low platelets or a
bleeding disorder such as:
Unexplained or easy bruising
Prolonged bleeding from a small cut or wound
Numerous nosebleeds
Gastrointestinal bleeding (which can be detected in stool samples)
Heavy menstrual bleeding
Small red spots on the skin (petechiae)may sometimes look like a rash
Small purplish spots on the skin (purpura) caused by bleeding under the skin
Testing may also be done when it is suspected that an individual has too many platelets. An
excess of platelets can cause excessive clotting or sometimes bleeding if the platelets are not
functioning properly. However, people with too many platelets often have no signs or symptoms
so the condition may be found only when a platelet count is done as part of a health check or for
other reasons.
Adult 150,000-450,000/microliter
Hemoglobin

Why Get Tested?
To evaluate the hemoglobin content of your blood as part of a general health checkup; to screen
for and help diagnose conditions that affect red blood cells (RBCs); if you have anemia or
polycythemia, to assess the severity of these conditions and to monitor response to treatment
When to Get Tested?
With a hematocrit or as part of a complete blood count (CBC), which may be ordered as part of a
general health screen; when your doctor suspects that you have a condition such as anemia
(decreased hemoglobin) or polycythemia (increased hemoglobin); at regular intervals to monitor
disease or response to treatment
PT and INR

Why Get Tested?
To check how well the blood-thinning medication (anticoagulant) warfarin (COUMADIN

) is
working to prevent blood clots; to help detect and diagnose a bleeding disorder
When to Get Tested?
When you are taking warfarin or when your doctor suspects that you may have a bleeding
disorder
A prolonged PT means that the blood is taking too long to form a clot. This may be caused by
conditions such as liver disease, vitamin K deficiency, or a coagulation factor deficiency. The PT
result is often interpreted with that of the PTT in determining what condition may be present.
Interpretation of PT and PTT in Patients with a Bleeding or Clotting Syndrome
PT result ptt result Examples of conditions that may be present
Prolonged Normal
Liver disease, decreased vitamin K, decreased or defective factor VII, chronic
low-grade disseminated intravascular coagulation (DIC), anticoagulation drug
(warfarin) therapy
Normal Prolonged
Decreased or defective factor VIII, IX, or XI, von Willebrand disease (severe
type), presence of lupus anticoagulant
Prolonged Prolonged Decreased or defective factor I, II, V or X, severe liver disease, acute DIC
Normal
Normal or
slightly
prolonged
May indicate normal hemostasis; however, PT and PTT can be normal in
conditions such as mild deficiencies in other factors and mild form of von
Willebrand disease. Further testing may be required to diagnose these
conditions.
PTT
Why Get Tested?
As part of an investigation of a possible bleeding disorder or thrombotic episode; to monitor
unfractionated (standard) heparin anticoagulant therapy
When to Get Tested?
When you have unexplained bleeding or blood clotting; when you are on unfractionated
(standard) heparin anticoagulant therapy; sometimes as part of a pre-surgical screen
Urinalysis
Why Get Tested?
To screen for metabolic and kidney disorders and for urinary tract infections (UTIs)
When to Get Tested?
During a routine physical or when you have symptoms of a UTI, such as abdominal pain, back
pain, frequent or painful urination; as part of a pregnancy check-up, a hospital admission, or a
pre-surgical work-up