ML20203F103
| ML20203F103 | |
| Person / Time | |
|---|---|
| Site: | 07002996 |
| Issue date: | 12/28/1998 |
| From: | Campbell V NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| 467042, NUDOCS 9902180050 | |
| Download: ML20203F103 (18) | |
Text
l x- . . i u.s. NUCLEAR kEGilLAToRY CoMMISslON MATERIALS LICENSE Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Pubhc Law 93-438), and Titre 10, Code l of Federal Regulations, Chapter I, Parts 30,31,32,33,34,35,36,39. 40, and 70, and in reliance on statements and representations hrrOtofore made by the licensee, a license is hereby issued authorizing the licensee to receive, acquire, possess, and transfer byproduct, i source, and special nuclear material designated below; to use such material for the purpose (s) and at the place (s) designated below; to l d;hcr er transfer such material to persons authonzed to receive it s.1 accordance with the regulations of the appbcable Part(s). This hcense I shall be deemed to contain the conditions specified in Section 183 of the Atomic Energy Act of 1954, as amenced, and is subject to all l applicable rules, regulations, and orders of the Nue; ear Regu!atory Commission now or hereaMer in effect and to any conditions specified I below.
Licensee in accordance with letter dated November 12,1998
- 1. D:partment of Veterans Affairs 3. License number SNM-1936 is amended in
'; C its entirety to read as follows:
- 2. V.A. Medical Center .
V 4. Eipiration date May 31,2007 9
1601 Perdido Street
.-"? 5. Docket No.'070-02996 1
l N:w Orleans, Louisiana 70146: Reference No.
- 6. Byproduct, soure sind/or specialD 7. Chemical and/or physical form 8. Maximum smount that licensee may ruclear material /r7 ' [ pos'sess at any one time under this
'+ / a~ heense Plutonium (Principal 5 A. .26 grams (6 individual A. ,ed @ ce radionuclide Pu-238,)_. y, j ,, yources not to exceed 210 1 W
+ v h@u milligrams each, I 7c.Q.
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B. Plutonium (Principal g B. Meale.TSource,;*/ :J '/') B. J1.50 grams (6 individual radionuclide Pu-238)% , % <
.'fsources not to exceed 250 M f4 - . milligrams each) .
C % &)' 7 ,79 <
- 9. Auth( ted use -
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A. As a component of Medtronic Model 9000 nuclear-powered pacemaker for clinical evaluation purposes. This license authorizesfosiession of th'e pa'$emaker for purposes of explantation, recovery and disposal, but not for implantation.
B. As'a component of Coratomic Model C-101-P nuclear-powered pacemakers for clinical evaluation /
purposea. This license authorizes possession of the pacemaker for purposes of explantation, /
recovery and disposal, but not for implantation.
il, CONDITIONS l
l 10. Licensed material shall be used only at the licensee's facility located at 1601 Perdido Street, New l Orleans, Louisiana.
- 11. A. The physicians responsible for follow-up, explanation, and return of nuclear-powered pacemakers to the manufacturec for proper disposal are Juan Escarfuller, M.D.
B. The Radiation Safety Officer for this license is Carl L. Gaspard.
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' NRC FORM 374A u.S. NUCLEAR REGULATORY CoMMISSloN PAGE 2 of 2 PAGEs
~
Ucense Number SNM-1936 l
' m or R.r.r.nce number MATERIALS LICENSE SUPPLEMENTARY SHEET 070-02996 ,
Amendment No. 04
- 12. The specified possession limit includes all licensed material possessed by the licensee under this license whether in storage, implanted in patients, or otherwise in use.
l 13. The licensee shall continue patient follow-up and replacement procedures for the nuclear pacemaker during the life of the patient. Procedures for recovery and authorized disposal of the nuclear pacernaker by retum to the manufacturer shall be followed upon the death of the patient.
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- 14. Except as specifically provided otherw ;sy :rt tids license, icpnsee shall conduct its program in accordance with the statements,p"U.S. Nuclear Regulatory Commi any enciosures, listed below, he unless the statements, repre'sen ations, and procedures in the license #s application and correspondence are more restrictive than the regulations. ,
D 4 l A. Letter dated MarctS28,1
- 8. Letter dated May 2h 1984 ()
- g. ;
C. Letter with enchsups dated i D. Letter dated November 12,19 ,
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FOR THE U.S. NUCLEAR REGULATORY COMMISSION DEC 2 81993 .. /
Date _
Byl,DML/ ' AgA't ._ _
Viviar H. Campbell, Sdnim Radiation Spccialist
! Nuclear Materials Licensing Branch Region IV l Arlington, Texas 76011 j
r- '
ONITED STATES
.[;;
- g NUCLEAR REGULATORY COMMISSION '
E REGION IV 0,, 611 RYAN PLAZA DRIVE, sulTE 400
% ,d[' ARLINGTON. TEXAS 76011-8064 December 28,1998 Department of Veterans Affairs ATTN: John D. Church, Jr.
Medical Center Director 1601 Perdido Street i New Orleans, Louisiana 70146
SUBJECT:
LICENSE AMENDMENT Please find enciosed License No. SNM-1936. You should review this license carefully and be sure that you understand all conditions. If you have any questions, you may contact the reviewer who signed your license at (817) 860-8143.
NRC expects licensees to conduct their programs with meticulous attention to detail and a high standard of compliance. Because of the serious consequences to employees and the public which can result from failure to comply with NRC requirements, you must conduct your program involving radioactive materials in accordance with the conditions of your NRC license, representations made in your license application, and NRC regulations. In particular, note that you must:
- 1. Opowe in accordance with NRC regulations 10 CFR Part 19, " Notices, Instructions and Rt no:r3 a Workers: Inspection and Investigations," 10 CFR Part 20, " Standards for Proistwo Against Radiation," and other applicable regulations.
- 2. Possess radioactive material only in the quantity and form indicated in your license.
- 3. Use radioactive material only for the purpose (s) indicated in your license.
- 4. Notify NRC in writing of any change in mailing address (no fee required if the location of radioactive material remains the same).
- 5. Request and obtain written NRC consent before transferring your license or any right thereunder, either voluntarily or involuntarily, directly or indirectly, through transfer of control of your license to any person or entity. A transfer of control of your license includes not only a total change of ownership, but also a change in the controlling interest in your company whether it is a corporation, partnership, or other entity. In addition, appropriate license amendments must be requested and obtained for any other ,
planned changes in your facility or program that are contrary to your license or contrary l to represcritations made in your license application, as well as supplemental correspondence thereto, which are incorporated into your license. A license fee may be .
charged for the amendments if you are not in a fee-exempt category. i l 6. Maintain in a single document decommissioning records that have been certified for l completeness and accuracy listing all the following items applicable to the license:
- Onsite areas designated or formerly designated as restricted areas as defined in 10 CFR 20.3(a)(14) or 20.1003.
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~ - - .- - . -. - - . - - . _ = - - ..
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- Department of Veterans Affairs- l l
- Onsite areas, other than restricted areas, where radioactive materials in j quantities greater than amounts listed in Appendix C to 10 CFR 20.1001-20.2401 have been used, possessed, or stored.
l
- Onsite areas, other than restricted areas, where spills or other unusual occurrences involving the spread of contamination in and around the facility, equipment, or site have occurred that required reporting pursuant to 10 CFR 30.50(b)(1) or (b)(4), including areas where subsequent cleanup procedures have removed the contamination. !
1
- Specific locations and radionuclide contents of previous and current burial areas within the site, excluding radioactive material with half-lives of 10 days or less, depleted uranium used only fer chielding or as penetrators in unused munitions, or sealed sources authorized for use at temporary job sites.
- Location und description of all contaminated equipment involved in licensed opemtions that la to remain onsite after license termination.
- 7. Submit a complete renewal application with proper fee, or termination request at least 30 days before the expiration date on your license. You will receive a reminder notice approximately 90 days before the expiration date. Possession of radioactive material after your license expires is a violation of NRC regulations.
- 8. Request termination of your license if you plan to permanently discontinue activities involving radioactive material.
You will be periodically inspected by NRC. Failure to conduct your program in accordance with NRC regulations, license conditions, and representations made in your license application and supplemental correspondence with NRC will result in enforcement action against you. This could include issuance of a notice of violation; imposition of a civil penalty; or an order suspending, modifying, or revoking your license as specified in the " General Statement of Policy and Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG 1600, Rev.
- 1. j Thank you for your cooperation. f-Si erely, j JMr .
Vivian H. ampbell Senior Radiation Specialist Nuclear Materials Licensing Branch Docket: 070-02996 License: SNM-1936 Control: 467042
Enclosures:
As stated i
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Department of Veterans Affairs !
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DOCUMENT NAME: P:\ ,
To reconve oosw of document, Indicate in box: 'C" = Copy without enclosures *E' = Copy with enclosures 'N' = No coy RIV:NMSB1 s VHCampbell 9/Y/98 l OFFICIAL RECORD COPY 1
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DEPARTMENT OF VETERANS AFFAIRS 9
I Veterans Health Administration ,
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National Health Physics Program -
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2200 Fort Roots Drive t North Little Rock, AR 72114
'* t} $ 1 8 j3
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l In Reply Refa To: 598/l15HP/NLR Nos ember 19,1998 l
U.S. Nuclear Regulatory Commission Region IV, Division ofNuclear Material Safety )
611 Ryan Plaza Drive, Suite 400 i Arlington, TX 76011-8064 !
The enclosed correspondence from the New Orleans, Louisiana VA Medical Center, License
- SNM-1936, has been received and is forwarded to your office for processing. If there are questions, please contact the facility.
Please provide a copy of any correspondence relative to licensing actions for this Medical Center to:
National Health Physics Program (115HP/NLR)
Veterans Health Administration Nonh Little Rock, AR 72114 1
1 Si cerely, ,
d b E. Lynn McGuire Director, National Health Physics Program h
AR7042
E = T DEPARTMENT OF VETERANS AFFAIRS ,
Medical Center 1601 Perdido Street New Orleans LA 70146 l
~
) ' NOV 121998 '
' In Reply Refer To: 629/NE18
- Ms. Vivian.H. Campbell t- !
Senior Health Physicist 7 >;i U.S. Nuclear Regulatory Commission-
, Division of Nuclear Material Safety D, q) i ' NOV 2 4 I393 Region IV '
l 1611 Ryan Plaza Drive, Suite 400 ~~'
r, Arlington, TX 76011-8064 "'
.THRU: Mr. Lvnn McGuire NHPP,, Southern Region -
j 2200 Fort Roots Drive
-Bldg. 33 (ll5HP/NLR) '
North Little Rock, AR 72114
Dear Sir:
Request an amendment to NRC License No. SNM-1936, VA Medical Center, New Orleans, Louisiana, as follows:
To change the physician involved in the program who will be responsible to follow nuclear pacemaker patients l
~from Michael Ian Prior, M.D. to Juan Escarfuller, M.D. !
Also, please remove Salem F. Sayegh, M.D. from the license. !
.There are no other' condition changes from the original commitment.
'Dr.'Escarfuller's curriculum vitae.is enclosed.
If you should.have any-questions, please contact the
~
Radiation Safety Officer, Mr. Carl L. Gaspard, at'(504) 589-5233.
ncerely yours,
)
ohn D. Church, Jr. .
edical Center. Director-Enclosure-o, ,
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$- k 467042
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CURRICULUM VITAE Name: JUAN A. ESCARFULI.ER, MD, FACC, FACP
.. Birthday: January 8,1945 Birthplace:
Villa Vasquez, Montecristi, Dominicen Republic Wife: Maria kurdes Wong Valle Children: Juan, Patricia, Carlos, Raul, Marcella, and Sebastian Office Address: 3525 Pr>tania Street, Suite 319 New Orleans. Louisiana 70115 Telephone / far (504) 897 3232 / (504) 897 7852 llorac Address: 1013 Burdette Street New Orleant, buisiana 70118 Telephone / Fat (504) 866 3758 / (504) 861 2735 DEGREES -
Colegio Don Dosco, Santo Don ing Dominican Republic 'High Schoou May 1963 Universidad Autonoma de Santo Domingo, Santo Domingo, Dominican Repcbli:
. Degree: M.D.
Dates of Attendance: January 8,1964 D:: ember,1970 Date ofGraduation: February 25,1971 Doctoral Thesis: Clinical Management of Acute GI Bleeding Due to Ruptured Sophageal Varices with Intravenous Pitressin. ,
December,1970 i
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' Student delegate ar.d merr.ber, Unive.rs.;ty General A:sembly.
1965-1970
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Student &!egate and member, Medicas Sciences Faculty Asembly.
1965 1970 Student delegate and member, Technical Council of the Medical Sciences Faculty.
1966 1970 POST GHADUATE TRAINING Internship:
Internal Medicine: S.B. Gautier Hospital, Santo Domingo, Dominican Republic February 1,1971 - January 31,1972 Residency:
InternalMedicine: S D.Gautierllospital.
Santo Domingo, Dominican Repubhc February 1,1972 -June 30,1972 Rotating intemship: MacNeal Memorialllospital, (6 months int. Med) Berwyn, Illinois (Abraham Linco;a School of Medicine afliliated hosptal)
July 1,1972 - June 30,1973 INTERNAL MEDICINE RESIDENCY lewiI Touro Infirmary-Tulane University Program July 1,1973 June 30,1974 levelII Touro Infirmary-Tulane University Program July 1,1974 -June 30,1975 L4veIIII -
Touro Infirmary-Tulane University Program .
July 1,1975. June 30,1976 C _ _ .
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CARDIOLOGY FELLOWSIIIP LevelI
' Touro Infirmary-Tulane University Program July 1,1976 -June 30,1977 IevelII Touro infirmary-Tulane University Program July 1,1977 - June 30,1978 I
EXAMS AND SPECIALTY DOARD ACCREDITATIONS
- ECFMG No.1632973 September 15,1971 FLEX June,1975 i
ABIM -InternalM:6 cine June 22,1977 VQE October,1979 -
ABIM - Cardiovascular Subspecialty November,1981 LICENSES
_ District of Columbia #8305 State oflouisiana #40 SIR O
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FELLOWSHIPS AND MEMBERSIIIPS -
American College of Physicians American College of Cardiology :
Interamerican College of Physicians aM Surgeons i
American Geriatrics Society l American Heart Association of Louisiana, Inc.
New Orleans Academy ofInternal Medicine Amencan Association for the Advancement of Science l
leuishna State Medical Society l' 4
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Orleans Parish Medical Society j
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i PAST AND PRESENT POSITIONS I Science Teacher (Chemistry, Biology ud Anatomy), '
Cobgio San Luis Gonzaga, Santo Domingo, {
i Dommican Republic (All fourlevels ofHigh School) 1966 - 1970 President / Founder, Dominican Associaton of Teachers, Santo Domingo, Dominican Republic December 1970 General Secretary, Medical Association of the Dominican Institute of Social Security 1971 - 1972 Chief Resident, Internal Medicine
, Touro Infirmary-Tulane University Program New Orleans, Louisiana, USA 1976 -1977 StaffCardiologist Touro Infirmary, New Orleans, Louisia'na -
July 17,1978 - December 1984 l Assistant Clinical Professor of Medicine Tulane University School of Medicine New Orleans, Louisiana December 1978 - present i
Director, Cardiac Catheterization Laboratory, Touro Infinnary, New Orleans, Louisiana October 1,1983 - December 1984 (Resigned) i i
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Li}qNOV 2 A i Hispanic American Medical Association ofleuisiana,Inc. Founder April 1989 President 1991 1993 Director, Cardiovascular Diagnostic Laboratory, New Orleans, Louisiana December,1984 -present Director,'the Kenner Clinic, ' 3321 Florida Ave. Kenner,lasisiana 70065 December 1,191,6 - December 2,1993 Vice Chairman, Department of Medicine, St. Jude Medical Center, Kenner, Louisiana ; 1991 - 1993 President, Medical Staff,
~ New Orleans GeneralHospital, New Orleans, louisiana Installed, February 13,1992 ; .,.. .. +,q 9y President, Alliance for Intemational '
Medical Graduates, February,1992 -present Medical Director, Medfirst Health Plaris ofIouisiana,Inc. ' July,1994 -present i I.anguages. Spanish and English. l C5 2; _= _ ,,,, _;zxiv =-r -~- f*";_? - D M??T?::?2 2~G : -
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- ll NRC FOAM 374 1 po-m U,s. NUCLEAR RE2VLATO*;Y COMMfS$CN '" 1 2
- E No. 03 MATERIALS LICENSE l
Pursuant to the Atomic Energy Act of 1954, as amended, the Energy Reorganization Act of 1974 (Public Law 93-438). and Ti 1 Code of Federal Regulations, Chapter I. Parts 30: 31. 32. 33, 34, 35. 39. 40 and 70, and in reliance on statements and representatio f 1 t l made by the licensee. a license is hereby issued authonzing the licensee to receive. acquire, possess. and transfer byproduct. I s nuclear material designated below; to use such matenal for the purpose (s) and at the placets) designated below; to deliver or transfer such m to persons authonzed to receive it in accordance with the regulations of the applicable Part(s). This license shall be deemed to contain the conditions j specified in Section 183 of the Atomic Energy Act of 1954, as amended. and is subject to all applicable rules, regulations and orders of the Nuc p
] R:gulatory Commission now or hereafter m effect and to any conditions specified below.
p i L 1 In accordance with letter dated 1 1 Department of Veterans Affairs July 13,1994 1 1.
- 3. Ucense number SNM-1936 is amended in I
{ its entirety to read as follows: j i
) 2. V.A. Medical Center
[ 1 1601 Perdido Street 4. Expiration date May 31, 2007 l New Orleans, Louisiana 70146 [
] 5. Docket or 't l
070-02996 l Reference No ! ! l 6. Byproduct, source, and/or 7. Chemical and/or physical l special nuclear material form
- 8. Maxtmum amount that licensee lLl may possess at any one time ;L l under this license l A. Plutonium (Principal A. Sealed Source A. 1.26 grams (6 1
) radionuclide Pu-238) individual sources not to exceed 210 ilt i )
1 milligrams each) ;t 1 B. Plutonium (Principal B. Sealed Source B. 1.50 grams (6 L
'L 1 radionuclide Pu-238) individual sources I l
l not to exceed 250 l 1 milligrams each) i l L 1 E 1 ' a 9. Authorized use 't t 1 I 1 A. As a component of Medtronic Model 9000 nuclear-powered pacemaker for clinical t l 1 evaluation purposes. This license authorizes possession of the pacemaker for purposes of explantation, recovery and disposal, but not for implantation. 5{, j B. As a component of Coratomic M'odel C-101-P nuclear-powered pacemakers for C L l clinical evaluation purposes. This license authorizes possession of the i 1 pacemaker for purposes of explantation, recovery and disposal, but not for t I implantation. L t L i CONDITIONS 1 E I 10. Licensed material shall be used only at the licensee's facility located at 1601 t i Perdido Street, New Orleans, Louisiana. ,C 1 1 1 l 11. A. The physicians responsible for follow-up, explanation, and return of nuclear-l powered pacemakers to the manufacturer for proper disposal are Michael Ian f 3 l Prior, M.D. and Salem F. Sayegh, M.D. 1 i
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m ygnorummwwwwwwwwwwwwwwwwwwwwwww_wwwwwwwwwwwwwwwwwwaa 1 FORM 374 A U.S. NUCLEAR CE GULAT6RY 'COMklSSloN PAGE 7 OF PQGES
' 9 g Lrense Number -
1 l N SNM-1936 ; p MATERIALS LICENSE Docket or Reference Number ! p SUPPLEMENTARY SHEET N 070-02996 f ljl N j l! Amendment No. 03 ii N N !8( N li !
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N 11. (Continued) N B. lE g E g The Radiation Safety Officer for this license is Carl L. Gaspard. I gi 4 N I y Ei,
- 12. The specified possession limit includes all licensed material possessed by the I g
g licensee under this license whether in storage, implanted in patients, or otherwise I y in use. !g , g l 13. The licensee shall continue patient follow-up and replacement procedures for the nuclear pacemaker during the life of the patient. Procedures for recovery and '
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y authorized disposal of the nuclear pacemaker by return to the manufacturer shall be l g followed upon the death of the patient. g g I
- 14. Except as specifically provided otherwise in this license, the licensee shall I (E E conduct its program in accordance with the statements, representations, and 1 8
E procedures contained in the documents, including any enclosures listed below. The iU ' E U.S. Nuclear Regulatory Commission's regulations shall govern un,less the statements, 8 1 representations, and procedures in the licensee's application and correspondence are U more restrictive than the regulations. i I A. Letter dated March 28, 1984 E I B. Letter dated May 21, 1984 i i E N C. Letter with enclosures dated July 13, 1994 i U N E i N 1 E
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FOR T NUCLEAR REGULATORY COMMISSION E N E N t E ! Date MAY I 4 I9g7 ByUrch . h k
;N Yivian H'. Camptell' N {N Nuclear Materials Licensing Branch i E
N Region IV U i N Arlington, Texas 76011 i E N U i lN lN in ' ju
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r 0 P Nuclear Pacemaker Review i A review of the remaining pacemaker patient who received nuclear pacemakers was conducted on 09/23/98. Halstead, George - 237-46-7796 - Patient was seen in Cardiology Pacemaker Clinic on 07/15/98. The pacemaker was functioning well. Patient is scheduled to return to Clinic on 01/06/99. M L. / - Carl L. Gaspard, Radiation Safety Officer Olga arcia, M.D.- Chai person,. Radiation Safety Committee , l i r L
- t. ., c MEDICAL. RECORD PROGRESS NOTES j
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'y M Allergies: l /gi 8/ ,
Nur:: .g Focus: hp M[ g gf Q Fpj N V/ 9y / i Medications
- Clinical Proarass Note:
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Labs / Diagnostic: Tcsts: _ MEDTRONIC 9790 PROGRAl#GR 98910128 7/15/98 12:30 Copyright (c) Medtronic. Inc. 1993
.........__.---- MEASURED VALUES REPORT --------------- Page 1 of 1 Pacemaker Model: Spectrax SK 5984/85
- Averag+ ..:aes: Collected: 7/15/98 12:30
_ Pacing Rata Pulse Width h 1.04 as 6 4.7 6 7 &#m Clinic app pacing Interval 865 as ear.swrs .og=r.ac. aron y, ,,,, , HALSTEAD. GEORGE i .J7 46-7706 Os****ti
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l Tttent Names HALSTEAD, GEORGE
, [ l DOS: APR 11.1931 PID: 237 46 7796 Ssas n VAMC NOLA . -
Clinic = PAEMAKER EligibtLity: SC LESS THAN 501 CARDIOLOGY i Appc. DT/ Timer JUL 15',1990e13:00 SC Condit.fone: SC%: 30% Means Test Cat: N
*SYCHOSIS 30%
3 P S PROVIDER P S PROVIDER i l AO: No IR NO POWS NO EC: NO ' ~ T~
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I n e a & & JJIRf PATIENT h a i<..... m o Intermediate Exam 99213 C"i) c m p<engrWRMAgueAge l Brief Exam 99201 Extended Exam 99214 t..] Prev, seed Counset 15 min 99401 Lleited Exam 99202 Conprehensive Exam 99215 r"3 Prov. feed Counsel 30 min 99402 C:' Int rmodlete Exam 99203 - O M N AONSULTATitBIS M M ffdfM Nome Health Review 99375 tz, Extended Exam 99204 "I BRIEF EXAM 99241 r "J Telephone Brief 99371 r-Comprehensive Exam 99205 .2 LIMITED EXAM 99242 C Telephone Intermodlete 99372 E' MMWIiMAGLJ2MMIENCZ2ff3 INTERMEDIATE EXAM 99243 t] Telephonr Lengthy 99373 L.; Brief Exam 99211 "1 EXTENDED EXAM 99244 O C & P EXAM 99456 r-Linited Exam 99212 COMPREHENSIVE EXAM 99245 t. '3 pucy ! nu < NURSE ECHOCARDIOGRAPHY PACEMAKER ANALTSis IEFLUENZA IleRJN!ZATION 90724 TRANSTHORACIC . 93303 DUAL CHAISER W/0 REPRO 93731 PNEUMOCOCCAL IMMUNIZATION 90732 TRANSTHORACIC W/ IMAGE DOC 93307 'O DUAL CHApeER, TELEPHONE 93733 .. CARD 10 GRAPHY TRANSES0PHAGEAL 93312 ... $!NGLE CHAMBER, W/0 REPRO 93735 ELECTROCARD10 GRAM, COMP. 93000 DOPPLER EXAM, HEART 93320
~~
SINGLE CHAMBER, TELEPHONE 93736 ECG MONITOR / REPORT, 24 HR$ 93224 DOPPLER COLOR FLOW 93325 '.~" ECG, RHYTHM W/ REPORT 93040 TRANSTHORACIC, REST / STRESS 93350 .Z STRESS TEST 93015
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P S DIAGNOSIS CODE ADD P S DIAGNOSIS C3)E ADD
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- r. AV BLOCK 3RD DEGREE 426.0
~. ; ANGINA, STA8LE 413.9 '
- m. ... , t BUNDLE BRANCH BLOCK, LT 426.2 ANGINA, UNSTABLE 411.1 BUNDLE BRANCM BLOCK, RT 426.4
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..: CAD /ASHD 414.00 c..: . Ci"."'.;' CONDUCTION DISORDER 426.9 NYPERTENSIVE HRT DIS 402.90 ..
PAROK ATRIAL ~ACNYCARDIA 427.0 L ; ZUldam._.MENTRIULat DTSFLNICT!WIJ%h~MCL.a? ' VPC/APC 427.60
, .3 HEART FAILURE, RIGHT 428.0 ...: n $1CK SINUS SYNDROIE 427.81 2
! HYPERTENSION 401.9 VENT DYSFUNCTION 425.4
- LEFT HEART FAILURE 428.1 1"' VENTRICULAR FIBRILLATION 427.41
~.2 $/P HEART TRANSPLANT V42.1 ... s !] VENT TACMYCARDIA 427.1 aw 77%???M .I_J VAL.MEAR DISEASETMLV Q.Wt. " . r . S/P PACEMAKER V45.00
. . . Z; AORT 1C STENOSI$ 424.1 ..
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RHELMAT AORTIC STENOS!$ 395.0 i. ; COPD 496. , i" ATRIAL SEPTAL DEFECT 745.5 PULMONARY EMe0LISM 415.11
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.?] MITRAL STENOSIS 394.0 . c.2 RESPIRATORY FAILURE 799.1 l MITRAL VALVE PROLAPSE RHEUMATIC HEART DIS 424.0 396.90 aMnETGdM22W18tMER^Etid%srA "3 n DYSPEPSIA 536.8
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.... ...- 5/P VALVE PROSTHESIS V43.3 :...; L"2 ESOPHAGEAL REFLUX 530.81 -
TZ ..XNME E. AllRYTISt!A/CCBNILICTION2MI#.u.EE Ad~"~ ^ I' ESOPHAGIT!$ 530.10 i'"' ARRYTHMIA, UNSPEC. 427.9 C'] PEPTIC ULCER 533.90
- . ATRIAL FIBRILLAfl0N 427.31 ATRIAL FLUTTER 427.32
,' AV BLOCK 1ST DEGREE 426.11 J
!.> AV BLOCK 2ND DEGREE 426.12 Diegneels ICD-F. Cades
, b 467042 i P S ADD i -
Station: 629 HALSTEAD, GEORGE 237-46 7796 VA FORM 10 0360 APR 1994}}