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Medical Billing and Coding, ICD-10-CM, ICD-10-PCS, CPT, HCPCS, etc.
Viewing:  Mar 20, 2018

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Patient Information

Notes/EMR  (Paste notes here.)

ASSESSMENT: Chest pain.ASSESSMENT: The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".ASSESSMENT: The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck and left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath and diaphoresis. He states that he has had nausea and 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour. Acute Inferior Myocardial Infarction.ASSESSMENT: The patient is moderately obese but he is otherwise well developed and well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates without gait abnormality or difficulty.Normocephalic / atraumatic head. Pupils are 2.5 mm, equal round and react to light bilaterally. Extra-ocular muscles are intact bilaterally. External auditory canals are clear bilaterally. Tympanic membranes are clear and intact bilaterally.Neck: No JVD. Neck is supple. There is free range of motion and no tenderness, thyromegaly or lymphadenopathy noted.Pharynx: Clear, no erythema, exudates or tonsillar enlargement.Chest: No chest wall tenderness to palpation. Lungs: Clear to auscultation bilaterally. Heart: irregularly-irregular rate and rhythm no murmurs gallops or rubs. Normal PMIAbdomen: Soft, non-distended. No tenderness noted. No CVAT.Skin: Warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.Extremities: No gross visible deformity, free range of motion. No edema or cyanosis. No calf / thigh tenderness or swelling.ASSESSMENT:The patient's chest pain improved after the sublingual nitroglycerine and completely resolved with the Nitroglycerin Drip at 30 ug / Minute. He tolerated the TPA well. He was transferred to the CCU in a stable condition


Recommendations  (Click on a code to Choose it.)

E11.9 - Type 2 diabetes mellitus without complicationsView Code Info
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R07.89 - Other chest painView Code Info
R07.9 - Chest pain, unspecifiedView Code Info
R10.2 - Pelvic and perineal painView Code Info
R11.10 - Vomiting, unspecifiedView Code Info
R50.81 - Fever presenting with conditions classified elsewhereView Code Info
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R53.81 - Other malaiseView Code Info
R54 - Age-related physical debilityView Code Info
R61 - Generalized hyperhidrosisView Code Info
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