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University of Phoenix Material

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 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. 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 |

|1. | | |

|2. | | |

|3. | | |

|4. | | |

|5. | | |

|6. | | |

|7. | | |

|8. | | |

|9. | | |

|10. | | |

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 |I20.9 Other form of angina pectoris |

| | |

|In this example, I20.9 was chosen as a correct code because it |I24.0 Acute myocardial infarction |

|matches the doctor’s diagnosis as it discusses angina. | |

| |K55.1 Chronic vascular insufficiency of intestine |

|Let’s examine why the other codes are not appropriate to use. | |

| |J02.0 Streptococcal sore throat |

|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. | |

|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



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