Using the ICD-10-CM code book, assign the proper diagnosis code to the following: Case Study 2
Emergency Room Visit-Physician's Note
S: This 75-year-old patient. Was shoveling snow when he became short of breath. His wife insisted that he come to the emergency room to be evaluated. He states that he has had no other symptoms.
O: HEENT: Normal
CHEST: Normal heart rate, no significant findings; EKG normal
LUNGS: Clear, no congestion
ABDOMEN: Soft, nontender; no organ enlargement
LABS: All returned normal
A: Shortness of breath, ruled out MI.
P: Instructed to see his primary care provider for full physical examination.
A) R07.0
B) R07.1
C) R07.2
D) R07.3