ohn0disaster
Guest
Ok I'm needing a bit of help with how to code a dx. I pulled pertinent info from the note and left out the "blah blah blah" of it all.
subjective:
patient comes today for followup. eating and sleeping well. no major complaints. no chest pain. no fatigue. no shortness of breath except for when she tries to exert herself then she gets very short-winded. no orthopnea at night. the patient recently had a stress test done and the patient has pending followup with a cardiologist.
final impression:
1) inconclusive lexiscan stress test
2) abnormal myocardial perfusion scan with mild anteroseptal reversible ischemia with an ejection fraction of 57% and clinical correlation was recommended.
final assesment:
anteroseptal myocardial ischemia, pending evaluation by the cardiologist for further followup.
subjective:
patient comes today for followup. eating and sleeping well. no major complaints. no chest pain. no fatigue. no shortness of breath except for when she tries to exert herself then she gets very short-winded. no orthopnea at night. the patient recently had a stress test done and the patient has pending followup with a cardiologist.
final impression:
1) inconclusive lexiscan stress test
2) abnormal myocardial perfusion scan with mild anteroseptal reversible ischemia with an ejection fraction of 57% and clinical correlation was recommended.
final assesment:
anteroseptal myocardial ischemia, pending evaluation by the cardiologist for further followup.