A patient of yours was admitted with pneumonia. The admitting H&P examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 degrees; heart rate of 120
Physician Query Scenario #3 Doctor Johnson, A patient of yours was admitted with pneumonia. The admitting H&P examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 degrees; heart rate of 120; hypotension; and altered mental status. The patient was administered an IV antibiotic and IV fluid resuscitation. Leading: The patient had elevated WBCs, tachycardia, and was given an IV antibiotic for Pseudomonas cultured from the blood. Were you treating for sepsis? N onleading: Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical indicators? In this patient admitted with pneumonia, the admitting history and physical examination reveals the following: WBC 14,000 Respiratory rate 24 Temperature 102° F Heart rate 120 Hypotension Altered mental status IV antibiotic administration IV fluid resuscitation Please document the condition and the causative organism in the medical record. Thank you, Tabitha Zenzen
Based on adequate research on compliant queries, develop a compliant physician query for the case study below to resolve data and coding discrepancies. The issue for this case study being a lack of documentation for the causative organism of the patient’s pneumonia. Hence, your query to the physician to specify this. Case Study A patient is admitted with pneumonia. The admitting H&P examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 degrees; heart rate of 120; hypotension; and altered mental status. The patient is administered an IV antibiotic and IV fluid resuscitation.
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