HCS 214 Week 2 Cardiovascular System—Analyzing a Progress Note

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 HCS 214 Week 2 Cardiovascular System—Analyzing a Progress Note
 

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Cardiovascular System – Analyzing a Progress Note

 

Part 1

 

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

 

This patient was transported to the Emergency Room and is being assessed by the E.R. 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, arteriosclerosis, and hypertension. He used nitroglycerin SL x2 with moderate relief. His wife called 911 and he was transported to St. Simms Emergency.

 

While in the Emergency the patient had a subsequent similar episode. A 12 lead EKGnegative, cardiac enzymes negative. Patient noted burning in the chest during the episode. Patient admitted to 24 hour observation.

 

Plan to rule out an acute coronary syndrome. 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 signs every hour, cardiac stress test in the morning.

 

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

 

Sue Green, DO

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
 

 
 

 

Definition
 

 
 

 

Sources
 

 
 

 

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Part 2

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
Medical code
Example: Angina pectoris 

 

In this example, I20.9 was 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.

 

I24.0 Code does not use the word angina.

 

K55.1 Code was not chosen because it talks about the intestines. This is not discussed in the doctor’s note.

 

J02.0 Code 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 

 

I24.0 Acute myocardial infarction

 

K55.1 Chronic vascular insufficiency of intestine

 

J02.0 Streptococcal sore throat

 
Hypertension
O2.839 Unspecified renal disease in pregnancy, without mention of hypertension, unspecified as to episode of care or not applicable 

 

I87.309 Chronic venous hypertension without complications of unspecified lower extremity

 

O12.00 Edema or excessive weight gain in pregnancy

 

I10 Unspecified Essential hypertension
Angina
I27 Other pulmonary heart disease 

 

I26 Pulmonary embolism

 

I20.8 Other form of angina pectoris

 

K22.6 Gastroesophageal laceration-hemorrhage syndrome
 

 

References
 

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

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

 

 
 
 
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