syncope, 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. Physical Examination: 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 youassign?
[Answered]: syncope, palpitations, dyspnea on exertion,…
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