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What is the rationale for this case? What is the rationale for the ICD-10-CM codes for...

What is the rationale for this case? What is the rationale for the ICD-10-CM codes for the case? Admited: 1/2/20XX Discharged: 1/2/20XX HISTORY OF PRESENT ILLNESS: This patient is a 31-year-old male, who was brought to the Emergency Department on the afternoon of admission following an apparent syncopal episode, which occured one time. He states that he had been in Chicago with his family. He started driving home and he has no recollection of events from that time until he was brought by EMS to the Emergency Department. He states he has been under "a great deal of stress" over the past several days and has been "existing on root beer and cigarettes" for the past 4-5 days. He denies any nausea, vomiting or diarrhea. He has had no fever or chills. He states he has had a dry cough over the last several days, but otherwise has felt pretty much his normal self. Vital signs in the Emergency Department showed blood pressure 151/96, pulse 110, respirations 22 and temperature is 98.7. O2 saturation is 99% on room air. His Emergency Room evaluation included a urinalysis, which was unremarkable. A drug screen is positive for opiates, otherwise within normal limits. CBC was essentially normal. Serum chemistry shows a potassium of 3.4, ALT is mildly elevated at 68. The remainder of his serum chemistry was within normal limits. A blood alcohol was less than 5; however, because of his syncopal episode, it was elected to admit him to Acute Care for observation. PAST MEDICAL HISTORY: This gentleman's past medical history is essentially negative. PAST SURGICAL HISTORY: Negative. MEDICATIONS: He takes no routine medications. ALLERGIES: He is allergic to penicillin. FAMILY HISTORY: Essentially negative. REVIEW OF SYSTEMS: Essentially negative as well. PHYSICAL EXAMINATION: GENERAL: At the time of my exam, he is awake, alert, oriented and cooperative with his exam. HEENT: Head is normocephalic without masses, scars or lesions. Hair distribution is normal for age and sex. Ears, external auditory canals are patent without erythema or exudate. Tympanic membranes are pearly gray in color and exhibited normal cone of light. Eyes, ocular adnexa are unremarkable. There is no scleral icterus or hyperemia noted. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Funduscopic exam is unremarkable. Nose, nares are patent bilaterally. Mouth, oral mucosa is moist. There are no oral lesions noted. Posterior pharynx is free of erythema or exudate. NECK: Supple. No anterior or posterior cervical lymphadenopathy. Trachea is midline and freely movable. Thyroid is nonpalpable. Carotid pulses 2/4+, equal bilaterally, exhibited good upstroke and no bruits to auscultation. CHEST: Symmetrical. Exhibits good excursion on deep inspiration. Breath sounds are vesicular and bronchovesicular in all lung fields. HEART: Regular rate and rhythm without murmurs, clicks, rubs or gallops. There is no precordial heave or thrill noted. PMI is approximately at fifth intercostal space at the midclavicular line. ABDOMEN: Mildly obese and soft. Bowel sounds are active in all 4 quadrants on auscultation. There are no unexpected areas of tympani or dullness to percussion. No masses or organomegaly are appreciated by palpation. The abdomen is nontender. EXTREMITIES: There is no cyanosis, clubbing or edema noted. Pulses; brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis pulses are all 2/4+ and equal in all 4 extremities. Deep tendon reflexes are 2/4+ and equal in all 4 extremities. VITAL SIGNS: Height on admission is 6 feet 1 inch. Weight is 223. His vital signs have remained stable. He is afebrile. He has had no further syncopal episodes and is felt that he can be discharged at this time and managed on an outpatient basis. He will be given a prescription for hydroxyzine 25 mg 1 every 6 hours p.r.n. for anxiety. He is encouraged to eat a healthy diet and increase his fluids over the next few days and I have asked him to follow up with me in the office on an as needed basis.

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Answer #1

1.He may be having stress induced hypertension and bcz of alteration in ALT he might be having liver disease

2.F40-F48 stress related disorders

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