9-3. CASE STUDY History and Physical CC: Dizzy. HPI: Patien t is taking BP meds
ID: 3508347 • Letter: 9
Question
9-3. CASE STUDY History and Physical CC: Dizzy. HPI: Patien t is taking BP meds only when feels dizzy. She has been dizzy for the past sitive for vertigo-lasts for 10 to 15 minutes. Vision comes and goes. for 1 year. No fever/chills. Has No LOC. Po Tinnitus x2 months. Hearing is stable. Headache daily lost 45 pounds in 2.5 fatigued. No suicidal ideation. Has arthritis pain. years because of poor appetite. She is sleeping well but is Past medical history: Hypertension, arthritis, history of breast cancer Social history: No tobacco, alcohol, or illicits. Retired and lives alone. Allergies: NKDA. Medications: Diazide 37.5/25 mg daily and Percocet prn. ROS: Negative except for HPl. PHYSICAL EXAMINATION: Vitals: T 98.5, HR 125, RR 18, BP 146/9I, Sao2 97% on RA. General: No acute distress. Normal affect. HEENT: PERRL. EOMI. Oropharynx clear, no nystagmus. Neck is soft, nontender, and nondistended 42 Chapter 9 Symptoms, Signs, and Abnormal Clinical FindingsExplanation / Answer
9.3a
Hypertension with vertigo
9.3b
Patient was stable and feeling better
9.3c
Arthritis, Depression, Gastric related issues and nutritional imbalance
9.3d
As per POA people will think that something is wrong with her brain, as per that doctors will suspect for any tumors, or any cerebro-spinal vascular pressure.
9.3e
CT Scan
9.3f
Check her serum protein, Hb, and electrolysis. Since she has cancer history now presented with loss of appetite so meet gastroenterologist to undergo colonoscopy to look for any tumors.
9.3g
MS-DRG - 304 for hypertension
9.3h
Yes, ICD-10-CM Official Guidelines for principal diagnosis
9.3i
Yes
9.3J
Psychological depression
9.3k
Yes, physician should know her mental status, as she complaints of depression.
9.3L
Nifedipine Xl is used for hypertension, it is a calcium channel blocker
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