Case #1 History of Present Illness: The patient is 42 year old Caucasian male with no prior cardiac history. He presented to the emergency room at Green River Hospital complaining of chest pain. This morning he notices some numbness and pain in his left arm. Later in the day he developed pressure in the chest. This gradually worsened throughout the morning until shortly before lunch when he was rating the pain at 8/10 in severity and decided to go to the emergency room for evaluation. When he arrived at the hospital he was given sublingual nitroglycerin and the pain improved to 4/10 and has stayed at that level since then. He denies any prior cardiac history. Risk factors for coronary disease include hypertension. He is currently taking Lisinipril for his hypertension. The patient’s lipid status is unknown. He has a history of tobacco abuse. He stopped smoking four years ago. The patient is unaware of any thromboembolic disease in the family. He denies any drug use. The initial EKG in the emergency room showed some subtle ST elevation in an inferolateral distribution. His initial cardiac enzymes showed a CK of 253, MB fraction of 36, and troponin 0.24. He is being seen now for possible left heart catheterization and ongoing care. At the time of this exam, he was rating his pain at 4/10 in severity. Past Surgical History: The patient had had an adenoidectomy.
Medications: He is on a heparin and nitroglycerin drip. He was given Lopressor and aspirin in the emergency department.
Social History: The patient denies current tobacco use, but smoked previously for 10 years. He drinks alcohol on occasion. He denies drug use. Family History: There is no known heart disease in the family.
Review of Systems: Significant for the arm and chest pain mentioned above The patient denies fevers, chills, unusual bleeding, rashes, headache, visual changes, dizziness, Page 3 of 5syncope, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, shortness of breath, wheezing, abdominal pain, nausea, vomiting, diarrhea, hematochezia, melena, dysuria, or hematuria. No allergies.
Vital Signs: Pulse is 103 and regular, blood pressure 129/89, respiratory rate 18.
General Appearance: This is a Caucasian male who is awake, alert, and oriented, and who appears uncomfortable.
HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Oropharynx is clear.
NECK: There is no JVD, thyromegaly, lymphadenopathy, or bruit.
Lungs: Clear to auscultation bilaterally without wheeze, rhonchi, or crackle.
Heart: Reveals regular rate and rhythm without murmur, rub, or gallop.
Abdomen: Soft, nontender, nondistended with good bowel sounds.
Extremities: Revel no lower extremity edema. Pulses are 2+ throughout.
Neurologic: Cranial nerves II-XII are grossly intact. Strength is 5/5 in all four extremities.
Laboratory: EKG shows normal sinus rhythm with minimal ST elevation in an inferolateral distribution. Chest x-ray shows no active disease. Hemoglobin 12 12.8, hematocrit 38, white count, 16.3, platelets 273, sodium 139, potassium 3.6, chloride 108, bicarbonate 21, BUN 8, creatinine 0.5, glucose 138, calcium 8.8, D-dimer negative, CK 253, C-MB 36.4, troponin 0.24
Assessment and Plan: Acute inferolateral myocardial infarction. The patient is continuing to complain of pain at 4/10. His EKG is certainly abnormal and his enzymes have already bumped. The case was discussed with Dr. James who agrees that a left heart catheterization is indicated.
Alex assigned codes: I21.2 and Z87.891 Are these codes correct; why or why not? If incorrect, what specific code(s) would you assign?