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Prepare the Report of the Patient according to the Following Information: LOCATION: Inpatient, Hospital PATIENT: Madonna Miller PHYSICIAN: Alma Naraquist, M.D. SUBJECTIVE: Continues to have
Prepare the Report of the Patient according to the Following Information:
LOCATION: Inpatient, Hospital PATIENT: Madonna Miller PHYSICIAN: Alma Naraquist, M.D. SUBJECTIVE: Continues to have a great deal of right groin pain. Was quite unbearable this morning, trying to get to the bathroom. Has not been running a fever. Did have some nausea and vomiting from the morphine. No diarrhea. No other areas of bony pain. Blood sugar this morning was 180. OBJECTIVE: Temperature 35.8, blood pressure 106/42, pulse 78, respirations 18, 02 saturations 98%. Generally alert and oriented, appears uncomfortable. Chest clear, no rales, rhonchi or wheezing. Heart fairly regular rate and rhythm. Abdomen protuberant. ASSESSMENT: 1. Severe persistent right groin pain. 2. Nausea and vomiting 3. Diabetes mellitus. 4. Coronary artery disease 5. Peripheral vascular disease PLAN: She has a bone scan scheduled for today. Depending on how that looks, will make decision regarding CT scan. < CPT HCPCS I I II 1 1 1111 I I ICD-10-CM
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