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February 10, 2023

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

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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