Cardiovascular System – Analyzing A Progress Note

Part 1

Using the following progress note,definethe highlighted terms within the chart provided.

This patient was transported to the emergency department and is being assessed by the emergency doctor on call.

Progress Note:

Patient is a 43 y.o. male who presents with history of one episode of severe chest pain mid-chest at 08:00 today. He describes the pain as burning, tightness, squeezing pressure that radiates to the left arm. The episode lasted for approximately 10 minutes. The patient has a history of tobacco use,angina,cardiomegaly, andhypertension. He used nitroglycerin SL x2 with moderate relief. His wife called 911 and he was transported to St. Simms Emergency.

While in Emergency the patient had a subsequent similar episode. A 12 leadEKGnegative,cardiac enzymesnegative. Patient noted burning in the chest during the episode. Patient admitted to 24-hour observation.

Plan to rule out an acute coronary syndrome andpulmonary embolism. Treat with Aspirin 81mg daily, Nitroglycerine 0.4mg SL for chest pain. May repeat every 5 minutes x3 dose, start Nexium 20mg.EKG,chest x-ray,vital signsevery hour,cardiac stress testin the morning.

Impression: Angina, Hypertension, Tobacco use disorder,CAD.

Sue Green, DO

*Do not forget to include the sources for your definitions.

40 Points: 1 point for Medical term, 2 points for Definition, and 1 point for Sources

Medical termDefinitionSources
1.  
2.
3.
4.
5.
6.
7.
8.
9.
10.

Part 2

Using the information in the progress note,decidewhich code correctly represents the diagnosis. Underline the code of your choice.

30 points: 10 for each correct answer.

Medical termMedical code
Example: Angina pectoris In this example,I20.9was chosen as a correct code because it matches the doctor’s diagnosis as it discusses angina. Let’s examine why the other codes are not appropriate to use. I24.0Code does not use the word angina. K55.1Code was not chosen because it talks about the intestines. This is not discussed in the doctor’s note. J02.0Code was not chosen because it talks about a Streptococcal sore throat. This is not discussed in the doctor’s note.I20.9 Other form of angina pectoris I24.0Acute myocardial infarction K55.1Chronic vascular insufficiency of intestine J02.0Streptococcal sore throat 
Cardiomegaly A18.84 Tuberculosis of heart I42.1Obstructive hypertrophic cardiomyopathy I51.7Cardiomegaly B33.24Viral Cardiomyopathy
Pulmonary embolismI27 Other pulmonary heart disease I26Pulmonary embolism I20.8Other form of angina pectoris K22.6Gastroesophageal laceration-hemorrhage syndrome

References

Centers for Medicare & Medicaid Services (23 Oct. 2015). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.”

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