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April 12, 2024

A 69-year-old male presents to the ER with a complaint of having problems with his balance and walking along

A 69-year-old male presents to the ER with a complaint of having problems with his balance and walking along with headache and vomiting. He has been seen by his family physician without resolution, and he has a history of falling over ten times in the past six months. After a neurological examination, a large volume lumbar puncture was performed. The lumbar puncture drained 35 ml of CSF and a shunt patency study was performed. An MRI indicated dilatation of fluid spaces within the ventricles. The physician documents INPH and schedules the patient to immediately have a percutaneous shunt placed for drainage of the CSF to the thoracic cavity. The H&P indicates that the patient is a type 2 diabetic with peripheral angiopathy. Patient was discharged home on day 6 with follow-up scheduled with his neurologist in three months. icd

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