Insert Title - University of Phoenix



Cardiovascular System – Analyzing a Progress NotePart 1Using 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.40 Points: 1 point for Medical term, 2 points for Definition, and 1 point for SourcesMedical termDefinitionSources1.2. 3. 4. 5. 6. 7.8.9.10.Part 2Using 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. Medical termMedical codeExample: Angina pectorisIn 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 pectorisI24.0 Acute myocardial infarctionK55.1 Chronic vascular insufficiency of intestineJ02.0 Streptococcal sore throatCardiomegalyA18.84 Tuberculosis of heartI42.1 Obstructive hypertrophic cardiomyopathy I51.7 CardiomegalyB33.24 Viral CardiomyopathyPulmonary embolismI27 Other pulmonary heart diseaseI26 Pulmonary embolismI20.8 Other form of angina pectorisK22.6 Gastroesophageal laceration-hemorrhage syndromeReferencesCenters for Medicare & Medicaid Services (23 Oct. 2015). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download