Physician 1st Quarter 2016 Radiology IRR Case Study #6 – Neuro
25yoF HNCA COMMUNITYCARE HMO
Provider Specialty: Internal Medicine
Request Initiated: 11/12/2015
CPT: 70460 - CT HEAD or Brain; with contrast
ICD10:
R42 - Dizziness and giddiness
Z91.81 - History of falling
Nurse Reviewer Note:
Phone/FP req CT head wo for 24yoF c/o persistent dizziness 1-2 x per week. Had a fall on 08/15/2015: slipped on the floor of restaurant, hit chin/face. Requesting CT head d/t belief of head injury. No other complaints then dizziness. Reason: Ongoing dizziness s/p fall.
FOV: 08/16/2015, 10/17/2015
LOV: 10/22/2015
PE: Anxious appearing, speech fast, no other abnormalities noted. Nystagmus exam not noted, orthostatic BP note noted, gait exam and Dix-Hallpike not noted.
PMH: No hx of related surg, no hx of CA.
TX: Imaging ordered.
Prior Imaging: 08/16/2015 CT facial bones wo – Negative exam.
No ACDS note
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