A patient in the emergency department has a temperature of 1…
A patient in the emergency department has a temperature of 105 F and is in acute respiratory distress. Symptoms include shortness of breath, chest pain, and gasping. The physician documents that he is unable to obtain a history or perform a physical exam because the patient’s condition is critical.
Read DetailsA patient is on observation status in the hospital for influ…
A patient is on observation status in the hospital for influenza symptoms and extreme nausea and vomiting. The decision was made to admit the patient whose condition had worsened and who was not responding to the therapy initiated in the observation unit. The physician performed a detailed H&P to reflect the patient’s current status. The patient’s problem was of low complexity but required ongoing active management.
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