College

HISTORY

**Chief Complaint:**
- SOB with diaphoresis and EKG en route to hospital showing 3-4 mm ST segment elevations in V4 through V6 with T-wave inversion in V4 through V6 and an inferior wall MI of indeterminate age.

**History of Present Illness:**
- This is a 71-year-old female with a long-standing history of heart problems since the age of 48 who was admitted to the coronary care unit to rule out acute lateral wall myocardial infarction.
- She began developing chest pain, shortness of breath, and diaphoresis about 5 days ago and was brought by ambulance, where an EKG showed ST elevation and T-wave inversion in V4 through V6 and an inferior wall MI of indeterminate age.
- She was started on nitrates and diltiazem with relief of her symptoms.

**Past Medical History:**
- Illnesses: Peptic ulcer disease, documented by endoscopy.
- Long-standing renal failure, although this has never been clearly documented in her prior hospital records, and her records from Japan are unavailable.
- Aortic aneurysm documented by abdominal CT in her most recent hospitalization, as well as previous cardiac catheterization at that time.
- No history of diabetes, cough, fever, paroxysmal nocturnal dyspnea, or hypercholesterolemia.

**Medications:**
- Amphojel 30 mL p.o. q.i.d.
- Carafate 1 g q.i.d.
- FeSO4 325 mg t.i.d.
- Halcion 0.125 mg p.o. h.s. p.r.n.
- Pepcid 20 mg 2 q.h.s.

**Social History:**
- The patient was born in the United States but lived in Japan most of her life.

**Family History:**
- There is no family history of heart disease.

**Review of Systems:**
- Except as noted in HPI, noncontributory.

PHYSICAL EXAMINATION

**Vital Signs:**
- Blood pressure: 130/90
- Respiratory rate: 20
- Heart rate: 95
- Temperature: 98

**HEENT:**
- Normocephalic, atraumatic. PERRLA. Fundi positive for AV nicking and narrowing. No flame-shaped hemorrhages are seen.

**Neck:**
- Supple. Jugular venous distention at 10 cm. No carotid bruits.

**Heart:**
- Soft S1. Normal S2. S3 and S4 present. No murmurs.

**Lungs:**
- Coarse, wet rales to halfway.

Answer :

The patient has symptoms indicative of an acute lateral wall myocardial infarction (MI) with an EKG showing ST segment elevations and T-wave inversion.

ICD-10 Coding for Myocardial Infarction

  • The main subject of this case is a 71-year-old female patient experiencing symptoms consistent with a myocardial infarction (MI), also known as a heart attack.
  • Her EKG shows 3-4 mm ST segment elevations and T-wave inversion in leads V4 through V6, indicative of an acute lateral wall MI.
  • The ICD-10 code for an acute lateral wall myocardial infarction is I21.29. This code is used for documenting an MI characterized by the sudden blockage of blood flow to the heart, which can result in significant tissue damage if not treated promptly.
  • The patient's history of heart problems, along with her presenting symptoms including chest pain, shortness of breath (SOB), and diaphoresis, align with the clinical presentation of an acute MI.

Common Symptoms and Diagnosis

  • Patients with acute MI often present with retrosternal pain, dyspnea, irregular heartbeat, and diaphoresis.
  • Symptoms can sometimes be mistaken for other conditions like anxiety or indigestion, making differential diagnosis critical.
  • An EKG is a vital tool for diagnosing MI, showing characteristic changes such as ST segment elevation and T-wave inversion.
  • Blood tests measuring cardiac enzymes like creatine kinase MB and cardiac troponin also support the diagnosis.

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