Get Answer: What Four Codes Question Guide

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to what four codes and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves what four codes. A strong answer should include explanation, application, and examples.

Original Question

what are the four ICD 10 codes History 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 month Medications: 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 SOB Cardiovascular: Positive for chest pain Gastrointestinal: Positive for abdominal pain. Negative for nausea and vomiting. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Allergic/Immunologic: Negative. Hematological: Negative. Psychiatric/Behavioral: Negative. Vitals: Temperature: 98.9°F Pulse: 110 Respirations: 18 Blood Pressure: 180/110 SpO2: 92% on room air Height: 6’0ft Weight: 178lbs BMI: 24.1 Physical 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. tachycardia Pulmonary/Chest: Effort normal. Rhonchi right lower lobe Abdominal: 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 Options CAP (community acquired pneumonia) Chest pain, unspecified chest pain type Sepsis, due to unspecified organism Diagnosis management comments: CAP/Sepsis -3/4 SIRS (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 NC CT of Chest and Abdomen IMPRESSION: Loculated right pleural effusion which measures slightly higher attenuation than simple fluid in the dependent portions may represent superimposed infection, hemorrhage, or a malignant effusion. No definite evidence of empyema. Recommend correlation with thoracentesis fluid testing. No acute intra-abdominal or pelvic process. Multilevel degenerative disc disease as described above, 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 will require diagnostic thoracentesis. Patient with total health and will likely be transferred to XYZ Hospital. Given transfer will defer thoracentesis to transfer facility given loculated effusion which may benefit from IR and expected delays in results. Amount and/or Complexity of Data Reviewed Clinical lab tests: reviewed and ordered Radiology tests: ordered and reviewed Decide to obtain previous medical records or to obtain history from someone other than the patient: yes Review and summarize past medical records: yes Independent visualization of images, tracings, or specimens: yes Risk of Complications, Morbidity, and/or Mortality Presenting problems: high Diagnostic procedures: high Management options: high Final Assessment: Sepsis d/t unspecified organism. Uncertain etiology and patient will require greater than 2 midnights to establish cause and manage illness. CAP. Alcoholism in remission. Smoker

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."