Cardiovascular system

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 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, and hypertension. 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 lead EKG negative, 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 and pulmonary 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 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.

Part 2

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

30 points: 10 for each correct answer.

References

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

Copyright© 2019 by University of Phoenix. All rights reserved.

Copyright© 2019 by University of Phoenix. All rights reserved.