This is a 29-year-old female who presents today with fever and nausea for 3 days. The patient has tried over-the-counter cold and flu medicine with no results. No other family memb
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Get it written →S: This is a 29-year-old female who presents today with fever and nausea for 3 days. The patient has tried over-the-counter cold and flu medicine with no results. No other family members are ill at this time. Temp. has been running between 99 and 102?F. When asked about any other symptoms, the patient states that she “feels like my heart is racing sometimes.” The patient has not voided in 2 days.
O: Respirations: 31; Pulse: 100; BP: 150/90. She is alert, oriented, and in no acute distress.
Lungs: Clear, no rhonchi or wheezing
HEENT: WNL
Skin: Clammy to touch
Heart: RRR with no murmurs
Abdomen: Soft and nontender
Extremities: Ankle edema +12
A: Staphylococcus septicemia
P: The patient is admitted to the hospital and will follow staphylococcus septicemia protocol.
ICD-10-CM Code Assignment: ___________________________________
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