For this question I need the ICD-10-CM, CPT, or ICD-10-CPS medical codes AND a brief description on how to look them in

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For this question I need the ICD-10-CM, CPT, or
ICD-10-CPS medical codes AND a brief description
on how to look them in a the appropriate coding books for the
Primary Diagnosis, Primary procedure, Secondary Diagnosis, and
Secondary procedure for this case study.
16-1. CASE STUDY
History and Physical CC: Intractable chest pain. HPI: The
patient is a very pleasant 80-year-old man who was admitted because
of intractable chest pain in the setting of a new ischemic EKG
finding and a positive troponin of 28. While in the Emergency Room,
he was given sublingual nitroglycerin and experienced partial
relief of chest burning. EKGs at the time of admission were
significant for ST depressions in the precordial leads and ST
elevations in the inferior leads (leads III and aVF). Initial
cardiac enzymes measurements were significant for initial troponin
of 1.71. The patient was admitted to the cardiac intensive care
unit.
Past medical/surgical history: Previous MI 20 years ago, PVD
with right carotid endarterectomy, COPD with chronic bronchitis,
gout, BPH, hypertension, hearing impairment, CAD with stent in
circumflex coronary artery. Social history: Widower. Retired. No
alcohol or tobacco use. Family in the area. Family history: No
significant family history. Allergies: NKDA. Review of systems:
Constitutional: No fever or chills. Appetite is good. No change in
weight. Neuro: No headaches, seizures, or syncope. HEENT: No vision
changes. Hearing impairment and has hearing aids. CV: Per HPI.
Respiratory: Mild SOB. No hemoptysis. Chronic bronchitis. GI: No
abdominal pain, dysphagia, or heartburn. GU: Nocturia ×2.
Skin/Skeletal: Benign. Physical Examination: Vitals: Afebrile. HR
120, BP 109/62, RR 20. General: In obvious distress from chest
pain. HEENT: PERRL, EOMI. Trachea is central. Neck is supple
without masses. Chest: Bibasilar crackles. CV: RRR. Abd: Bowel
sounds present. No suprapubic tenderness. Ext: WNL. GU/Rectal:
Deferred. Skin/Musculoskeletal: Benign. Neuro: A&O ×3.
Assessment/Plan: Patient is admitted to CCU to rule out MI.
Discharge Summary Diagnoses/Problems: 1. Coronary artery disease.
2. Previous myocardial infarction 20 years ago. 3. Peripheral
vascular disease, status post right carotid endarterectomy. 4.
Chronic obstructive pulmonary disease/chronic bronchitis. 5. Gout.
6. Benign prostatic hypertrophy. 7. Hearing impairment, requiring
hearing aids. 8. Nonsystolic heart failure. 9. Hypertension. 10.
Stent in circumflex coronary artery. Procedures: Transthoracic
echo. History, Major Findings, and Hospital Course: Brief history:
The patient is a very pleasant 80-year-old man with the
above-stated medical history who was admitted because of
intractable chest pain in the setting of a new ischemic EKG finding
and a positive troponin of 28. While in the Emergency Room, he was
given sublingual nitroglycerin and experienced partial relief of
chest burning. EKGs at the time of admission were significant for
ST depression in the precordial leads and ST elevation in the
inferior leads (leads III and aVF). Initial cardiac enzyme
measurements were significant for initial troponin of 1.71. At this
point, the patient was admitted to the cardiac intensive care unit.
Chest pain was completely resolved with aspirin, Plavix, heparin,
and a nitroglycerin drip. In addition, when antiplatelet agents
were initiated, the patient developed frank hematuria through his
Foley catheter. He was started on continuous bladder irrigation and
ultimately was followed in the cardiac intensive care unit. The CCU
course was significant for a peak troponin of 48.43. In addition, a
lipid profile revealed total cholesterol of 99, along with
triglycerides of 108, HDL of 45, and LDL of 32. The patient was
treated appropriately with aspirin, high-dose statin, ACE
inhibitor, and intravenous heparin, as well as a glycoprotein
IIb/IIIa inhibitor, for approximately 18 hours. The initial 24-hour
CCU course was significant for sinus bradycardia alternating with
junctional bradycardia; discontinuation of beta blockers was
required, as was close observation for possible transvenous
pacemaker placement. However, intrinsic heart rate improved such
that no device was necessary. In addition, hematuria continued such
that urology consult was called and continuous bladder irrigation
was continued. This hematuria was interpreted by the urologic
consultant as secondary to traumatic Foley catheter placement.
Close monitoring revealed a stable hematocrit that required no
transfusions of packed red blood cells. In addition, hospital
course was complicated by minor congestive heart failure
exacerbation, which required the use of intravenous diuresis; this
was tolerated very well. The patient’s laboratory data were
significant for marked hyponatremia with sodium in the 120s. Workup
for this hyponatremia included CAT scan of the chest and the head,
which was unremarkable for any thoracic masses or lung masses and
provided no evidence of intracranial disease that could explain the
possible diagnosis of syndrome of inappropriate ADH secretion.
Urine sodium was found to be 13 with urine osmoles of 362, serum
osmoles of 280, and serum sodium of 130. The patient had a
transthoracic echo that revealed an estimated left ventricular
ejection fraction of 45% to 50% with inferior wall akinesis.
Posterior wall akinesis was also noted, as was severe lateral wall
hypokinesis. The septum was noted to be mildly hypertrophied and
measured 1.6 cm. No evidence of intracavitary obstruction was
found. The patient’s CCU course was significant for the development
of atrial fibrillation that required resumption of Coumadin prior
to discharge. Condition at discharge: Stable. Adverse drug
allergies: None. Allergies: No known drug allergies. Complications
of procedure: None.
Discharge Medications: Aspirin 325 mg by mouth daily
Atorvastatin 80 mg by mouth at bedtime Clopidogrel 75 mg by mouth
daily Doxazosin 2 mg by mouth at bedtime Nitroglycerin sublingual
0.4 mg every 5 minutes whenever necessary ×3 for chest pain Senna 1
tablet by mouth daily Toprol XL 100 mg by mouth daily Gemfibrozil
600 mg by mouth daily Coumadin 5 mg by mouth daily Discharge
Instructions: Diet: The patient was seen by Nutrition, who gave
explicit advice and instructions regarding a cardiac-friendly diet
that is low fat, low cholesterol, and low sodium. Activity: As
tolerated. Follow-up Care: The patient was given a follow-up
appointment with Cardiology. Electrocardiogram Report Indication
for study: N/A. Ventricular rate: 45 bpm Atrial rate: 45 bpm PR
interval: 142 ms QRS duration: 113 ms QT interval: 496 ms QTc
interval: 429 ms P axis: −49 degrees R axis: 89 degrees T axis: 111
degrees JUNCTIONAL BRADYCARDIA. LATERAL INFARCT, AGE UNDETERMINED.
INFERIOR-POSTERIOR INFARCT, POSSIBLY ACUTE. ACUTE MI. ABNORMAL EKG.
Transthoracic Echocardiogram Indication for study: Acute MI,
anterior wall. Interpretation summary: A two-dimensional
transthoracic echocardiogram was performed. The study was
technically limited. Limited views were obtained. The study was
viewed and interpreted by the undersigned attending with the
resident/fellow. Limited study for LVF. Left ventricular systolic
function is mildly reduced. Estimated LVEF is 45% to 50%. Inferior
wall akinesis is present, as are posterior wall akinesis and severe
lateral wall hypokinesis. Transmitral Doppler pattern cannot be
evaluated because of absence of atrial contraction. The septum is
moderately hypertrophied, measuring 1.6 cm. No evidence of
intracavitary obstruction is apparent. Heart rate: 84 bpm. Left
ventricle: The left ventricle is normal in size. There is no
thrombus. The septum is moderately hypertrophied, measuring 1.6 cm.
No evidence of intracavitary obstruction is found. Estimated LVEF
is 45% to 50%. Unable to evaluate transmitral Doppler pattern
because of absence of atrial contraction. Left ventricular systolic
function is mildly reduced. Posterior wall akinesis is present, as
are severe lateral wall hypokinesis and inferior wall akinesis.
Right ventricle: The right ventricle is normal in size and
function. Atria: Left atrial size is normal. Right atrial size is
normal. Mitral valve: The mitral valve is normal. No mitral valve
stenosis is evident. Tricuspid valve: The tricuspid valve is
normal. No tricuspid stenosis is noted. Trace tricuspid
regurgitation is apparent. Unable to estimate RVS. Aortic valve:
Mild focal aortic valve calcification is seen. The aortic valve is
trileaflet, and the aortic valve opens well. No valvular aortic
stenosis. Pulmonic valve: Pulmonic valve leaflets are thin and
pliable; valve motion is normal. No pulmonic valvular stenosis is
noted. Pericardium/Pleura: Trace pericardial effusion. No pleural
effusion. M-mode 2D measurements and calculations: IVSD: 1.6 cm
LVEDD: 5.2 cm Lids: 4.2 cm LVP WD: 0.93 cm Chest AP Portable Reason
for examination: Dyspnea. Comparison: None. Discussion: Cardiac
silhouette is enlarged. Perihilar opacities and increased
interstitial markings within both lungs likely related to pulmonary
edema. Portions of both lung bases are not included on today’s
study. Apical pleural thickening is noted. Defibrillator pad
overlies the left hemithorax. Thoracic CT Reason for examination:
Chest pain and mediastinal fullness. Technique: The study was done
without intravenous contrast. Findings: Dilated aorta with aortic
arch measuring 4.4 cm in diameter. Borderline pulmonary
hypertension with main pulmonary artery measuring 36 mm and right
pulmonary artery measuring 32 mm. Mild congestive changes with
small bilateral effusions. No evidence of pulmonary neoplasm. No
evidence of pleural abnormality. No evidence of pneumonia.
Impression: Widened mediastinum due to arteriosclerosis of the
aorta. Addendum: The patient also has calcification of coronary
arteries with stent in circumflex coronary artery. Impression: No
evidence of a neoplasm. Arteriosclerosis Progress Notes Day Patient
was admitted because of intractable chest pain and new ischemic EKG
changes. Patient has been ruled in for an NSTEMI. Evidence of
hematuria is present in Foley. This is likely due to traumatic
Foley placement. Irrigate Foley. Check lipid panel and order echo.
Day Patient no longer has chest pain. Chest x-ray shows pulmonary
edema that is likely due to mild exacerbation of his congestive
heart failure. Will diurese. Also noted per labs is low sodium at
127. Continue medical management of NSTEMI. Day Overnight, patient
went into atrial fib. No chest pain. COPD is stable. Echo results
are in the chart. Discontinue Foley. Begin Coumadin. Day Patient
admitted with NSTEMI. No complaints. Tolerating regular diet. Chest
with a few bibasilar crackles. Hyponatremia is improved, likely
secondary to CHF. No evidence of SIADH. Patient is ready for
discharge home with his family.