Secondary Diagnosis Include ICD10 Code Cite the most current Clinical Practice Guideline: (parap. Question
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Secondary Diagnosis Include ICD10 Code Cite the most current Clinical Practice Guideline: (paraphrase what is contained in the guideline you chose that led you to this diagnosis?) The secondary diagnosis is hypertension
Julietta Romanski 70 years old female Chart 022022601 Hello Julietta, what can I do for you today? Just a little tired lately. I had this scrape on my elbow. It happened when I fell out in the garden when I was planting tomatoes. I washed it with soap and water the day it happened but it was slow to heal. That was about 2 1/2 months ago. Did you try any OTC topical antibacterial ointments? Yes, and I kept it clean with soap & water. I went to the emergency room about 2 months ago because I was experiencing dizziness and blurred vision. They ran some tests and said I needed to follow up with primary care. They checked my elbow and I took antibiotics for 14 days and the cut healed. It is just a small scar now. What happened at the emergency room? Were you able to find out what the results were? I have a picture of the information on my phone. I will check the hospital portal. There were some abnormal lab results. Your blood sugar was elevated according to the summary. Your blood pressure was 160/82. Yes, I do have a prescription for my sugar but I don’t take it every day. I don’t remember the name. General overview of patient: complete a brief General Overview in outline document for today’s HPI. Current medications: Vitamin D, OTC Capsaicin topical for L knee pain, declined COVID vaccine. PMH: Lap chole about 10 years ago, fractured ulna age 10 bike accident, 2 live births, NSVD. FH: married 45 years, 1 daughter, no health issues, siblings: 1 sister endometrial cancer-survivor, Mother deceased breast cancer, Father deceased 68 years old unknown cause. SH: Retired Xray Tech, no illicit drug use, 1-2 glasses of wine weekends. No tobacco or illicit drug use. © 2022 Chamberlain University. All Rights Reserved. Allergies: Penicillin/hives Vital signs: BP 166/86; pulse 80, regular; respiration 18, regular Height 5’0, weight 180 pounds. Recheck Blood pressure 164/86. HEENT: head normocephalic. Eyes clear without exudate. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Neck supple. Anterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. CV: S1 and S2 RRR no murmurs. Lungs: Bilaterally clear to auscultation, respirations unlabored. Abdomen: soft, nontender with positive bowel sounds present; no organomegaly; no abdominal bruits. No CVAT. Derm: Right elbow small pink scar 1cmx1cm +pedal pulses bilaterally
SCIENCE
HEALTH SCIENCE
NURSING
NURSING NR 601
Secondary Diagnosis Include ICD10 Code Cite the most current Clinical Practice Guideline: (parap
