College

**HISTORY**

**CHIEF COMPLAINT**
- Headache, vomiting, and blurred vision.

**HISTORY OF PRESENT ILLNESS**
- This is a 63-year-old Hispanic female who is an insulin-dependent diabetic.
- She experienced the onset of headache, blurred vision, vomiting, and hypotension this morning after not taking her morning insulin.
- Initially seen in the emergency department with a blood pressure of 130/60 and a Dextrostix of greater than 250.
- Long-standing history of hypertension, felt well until this morning when she developed the above complaints.
- Denies chest pain or diaphoresis.

**PAST HISTORY**
- **Habits**: Does not smoke, drink, or use recreational drugs.
- **Medications**: Regular insulin and nadolol (Corgard).
- **Illnesses**: No prior history of hepatitis, anemia, pulmonary, renal, or gastrointestinal disease.
- Gravida 11, para 7. LNMP 10 years ago.
- **Operations**: None.
- **ALLERGIES**: None.

**PHYSICAL EXAMINATION**
- **GENERAL**: Obese Hispanic female in no acute distress; alert, oriented, and cooperative.
- **VITAL SIGNS**: Pulse: 46. Respiratory rate: 16. Temperature: 97.6 degrees F.
- **NECK**: No JVD. Supple without masses.
- **CHEST**: Clear to auscultation bilaterally. Heart: Bradycardia, regular rhythm, S1 and S2 present without abnormal heart sounds or murmurs. PMI difficult to assess.
- **ABDOMEN**: Bowel sounds normal, no organomegaly, abdomen protuberant.
- **EXTREMITIES**: No edema, cyanosis, or clubbing.
- **NEUROLOGIC**: Grossly intact.

**IMPRESSION**
1. First-degree heart block, possibly secondary to nadolol (Corgard).
2. Diabetes mellitus type 2 requiring insulin adjustment.
3. Hypertension.

**PLAN**
- Monitor fasting and 2-hour postprandial blood sugars.
- Administer regular insulin p.r.n. until blood sugar is adjusted.
- Discontinue nadolol (Corgard). Begin clonidine 0.1 mg t.i.d.
- Stress thallium test, Holter monitoring.

**E/M**: _____

Answer :

The E/M level for this encounter is 99214, indicating a Level 4 visit for an established patient.

  • History: A comprehensive history was taken, including the chief complaint, history of present illness, past medical history, medications, allergies, and a review of systems.
  • Examination: A detailed physical examination was performed, including vital signs and examination of multiple systems (general, neck, chest, abdomen, extremities, neurologic).
  • Medical Decision Making: The complexity of medical decision-making is moderate. This includes the management of diabetes, hypertension, and first-degree heart block. Diagnostic tests (fasting and postprandial blood sugars, stress thallium test, Holter monitoring) were ordered, and medication changes were made (discontinuing nadolol, starting clonidine).

A patient presented with symptoms of headache, vomiting, and blurred vision, leading to a diagnosis of first-degree heart block, diabetes mellitus, and hypertension.

  • Chief Complaint: The patient presented with a headache, vomiting, and blurred vision.
  • History of Present Illness: A 63-year-old diabetic female with longstanding hypertension developed symptoms after missing insulin, leading to hypotension and elevated blood sugar levels.
  • Impression & Plan: The patient was diagnosed with first-degree heart block possibly due to medication, requiring insulin adjustment and hypertension management.

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