Assessment and Treatment of Movement Disorder in a University Professor - DDA

Medical Diagnoses with ICD-10 codes

Jim is 70 years old and still working as a university professor. A few years ago, he started to notice an uncontrollable hand and arm shaking after taking a new antihypertensive drug called Serpalan®. His previous health care provider put him on another regimen to control his hypertension, but he continued to have subtle movement problems. While his hands and arms no longer shook, he did notice an odd twitch in his shoulder, which eventually progressed to a noticeable tremor in his right arm and leg.

Jim’s previous health care provider diagnosed this as being due to the stress of his job and advised that he take a vacation. Luckily, it was the end of spring term and Jim had no commitments for the summer.  Jim took a long, relaxing summer off, but after returning to work both he and his students noticed that his handwriting had become nearly illegible. He also began having problems cutting his food at dinner and getting his morning cup of coffee to his lips was difficult.  He really feels his signs and symptoms are due to stress and he tells you that “shakiness has always run in my family.”

On exam you find a normal gait, mild voice tremor and mild bradykinesia.  You note a mild intention tremor of the arm R>L.  There is some rigidity of his lower limbs.  He appears to have no difficulty getting up out of a chair.  

No allergies; meds include Lisinopril 5 mg daily; no surgeries; no other pertinent medical history; no alcohol, tobacco or illicit drug use.  

VS today—98-80-16 140/82  72 inches tall and 220 pounds

Use the required texts, slides and Epocrates to complete the DDAs 

_______40% Medical Diagnoses with ICD-10 codes [List all current diagnoses—this includes new and chronic medical problems and chief complaint; signs or symptoms are considered diagnoses until the cause is known; be sure and include an ICD-10 code for each diagnosis]: 

Differential Diagnoses with ICD-10 codes [List the most likely differentials for a the chief complaint; limit your differentials [diagnoses that you are trying to rule in our rule out] to 6; and be sure and include ICD-10 codes or each differential]

Rule out #1

Rule out #2

Rule out #3

Rule out #4

Nursing Diagnosis/Health Maintenance or Social issue [List one nursing, health maintenance or social issue here with an ICD-10 code; looking for a diagnosis—not an intervention—education/intervention should be listed below, not here in the diagnosis section]:

________20% Diagnostics/Laboratories [List any additional diagnostics or lab tests you believe are needed]

________20% Rxs [Identify initial prescriptions, referrals, nonpharmacological medical treatments needed; there may be situations when you do not need to order something]

________20% Nursing Interventions / Education [cite follow-up and specific health promotion and education needs]