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.
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 Sources1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.
Medical term Medical codeExample: 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 hypertensionAngina I27 Other pulmonary heart disease
I26 Pulmonary embolism
I20.8 Other form of angina pectoris
K22.6 Gastroesophageal laceration-hemorrhage syndrome