Questionpatient’s record found in Module 2:Patient Case Number: ED56-Stauffer, FrankPatient Name: Fr

Questionpatient’s record found in Module 2:Patient Case Number: ED56-Stauffer, FrankPatient Name: Frank StaufferDOB:08-10-62Sex: MDate of Service: 11-01-XXAttending Physician: Paul Morrows, MDReason for Visit: Abdominal/Chest painHistory of Present Illness:Mr. Stauffer is a 52-pack year smoker and presents with a complaint of abdominal/chest pain and SOB. Patient reports onset of symptoms about 2 weeks ago. Initially started as RUQ and right lower chest pain that was pleuritic in nature and associated cough. Patient states that about 3 days ago he had argument with friend and was punched in right upper abdomen. Since then, his pain has gotten significantly worse.Medical History: Alcohol Dependence in remission-attends AA every monthMedications: None Surgical History: None Review of Systems:Constitutional: Negative for fever, chills, activity change and appetite change.HENT: Negative.Eyes: Negative.Respiratory: Positive for cough and SOBCardiovascular: Positive for chest painGastrointestinal: Positive for abdominal pain. Negative for nausea and vomiting.Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative.Allergic/Immunologic: Negative.Hematological: Negative.Vitals:Temperature98.9°FPulse110Respirations18Blood Pressure180/110SpO292% on room airHeight6’0ftWeight178lbsBMI24.1Physical Examination:Constitutional: He appears well-developed and well-nourished. No distress.HENT:Head: Normocephalic.Mouth/Throat: Oropharynx is clear and moist.Eyes: Conjunctivae are normal.Neck: Neck supple.Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no friction rub. No murmur heard. tachycardiaPulmonary/Chest: Effort normal. Rhonchi right lower lobeAbdominal: There is Right upper and lower quadrant abdominal pain Skin: He is not diaphoretic.Nursing note and vitals reviewed.MDM:Number of Diagnoses or Management OptionsCAP (community acquired pneumonia) Chest pain, unspecified chest pain type, Sepsis, due to unspecified organism1) CAP/Sepsis-possible SIRS with 3/4 indicators (WBC 24, RR>20, HR >90)-blood cultures sent; started on ceftriaxone and azithromycin-patient 91 % on room air which improved to >94% on 4L NCCT of Chest and Abdomen IMPRESSION:1. Multilevel degenerative disc disease most significant at L3-L4 and L4-L5 with moderate spinal canal stenosis. Patient with loculated effusion possibly para-pneumonic vs hemothorax vs malignant effusion. Patient with total health and will likely be admitted to XYZ Hospital. Risk of Complications, Morbidity, and/or Mortality1. Possible Sepsis due to unspecified organism. Uncertain etiology and patient will require greater than 2 midnights to establish cause and manage illness.2. CAP.3. Alcoholism in remission.4. SmokerPHYSICIAN QUERY PROCESS:Objectives: At the conclusion of this assignment, design 2 different physician queries, yes/no, open-ended, or multiple choice to request clarification about documentation. After reviewing all of the resources provided, design 2 physician queries to address the conditions identified CT impressions. We will reflect the answers to the queries in our feedback. Utilizing the same patient record found in Module 2, Take the next steps in capturing all pertinent information from a medical record. It is common to encounter information within a document that requires clarification. This is where a physician query comes in. Example:The patient, Frank Stauffer, is diagnosed with possible sepsis and CAP, Alcoholic dependence in remission, and a smoker. The vitals note that the patient has a blood pressure of 180/110. Can the blood pressure be further specified as:Attributed to Sepsis__________________Elevated Blood Pressure reading without a diagnosis of Hypertension____________________Hypertension___________________Undetermined_______________________________Health ScienceScienceNursingCODING AND 1017Share Question

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