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CPC sample question # 2


Preoperative Diagnosis: Complete heart block.

Postoperative Diagnosis: Mobitz Type II heart block.

Anesthesia: Moderate conscious sedation.

Description of procedure(s): The patient was taken to the operating room and placed on the table in the supine position. After laryngeal mask anesthesia, the patient’s left chest was prepped and draped in the usual sterile fashion. A longitudinal incision was made beneath the clavicle down to the pectoral fascia. A prepectoral fascial pocket was fashioned inferomedially and superolaterally. Using fluoroscopic guidance and a percutaneous technique, an atrial lead was placed in the right atrium and screwed in place. A ventricular lead was placed in the floor of the right ventricle. It was screwed in place. Atrial threshold was 1.2 V; width 0.5 milliseconds; current was 3.0 mA; resistance was 489 ohms, and P waves were 11.7 mV and stable. Slew rate was 2.2 V/sec. Ventricular threshold was 0.5 V; width 0.5 milliseconds; current was 3.0 mA; resistance was 663 ohms, and R waves were 11.7 mV and stable. Slew rate was 3.30 V/sec. These leads were connected to a pulse generator. The pulse generator was placed in the floor of the antibiotic irrigated pocket and secuted using silk suture. The leads were secured using multiple silk sutures. The wound was irrigated and closed with layers of Vicryl and subcuticular Vicryl to the skin.

The patient tolerated the procedure well and was transferred to the recovery room in good condition. Fluoroscopy showed good lead position and no evidence of pneumothorax or fluid collection in the left chest. All spong, needle, and instrument counts were correct. Blood loss was minimal.

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