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Physician Query Assignment

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11 views

Physician Query Assignment

Uploaded by

zara mohammad
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PHYSICIAN QUERY

Attending Physician: Kenneth Green MD Coder: Amina Shaik


Patient name: Anne Romain Contact of coder: 718-7911588
Patient DOB: 09/12/1993
Admission date: 1/17/2024
Discharge date: 1/21/2024
Date of service: 1/18/2024 Today’s date 1/22/2024
Medical record number: MR99088
Account number: 8883218

Dear Dr. Kenneth Green


The following information is recorded in your Admission History and Physical on
January 17, 2024, in the admission diagnosis list indicate “Acute recurrent Maxillary
Sinusitis, Acute recurrent streptococcal tonsillitis and Chronic laryngitis.” Also in your
progress notes on 1/18/2024 documentation states “Acute recurrent Maxillary Sinusitis,
Acute recurrent streptococcal tonsillitis and Chronic laryngitis.”
Clinical indicators for the second problem are:
The progress notes on January 18, 2024, from the Physician assistant Mira
Baker in the notes tab says the patient was saturating at 99%, heart rate was 89,
Blood pressure was 120/80 and patient was resting comfortably on 3L of nasal
cannula oxygen and patient was given azithromycin. There are 7 different lab
results from last year. They are dated as follows January12, 2023, Feb 12, 2023,
March 29, 2023, June 25, 2023, August 26, 2023, October 20, 2023, November
22, 2023, 2023, 2023 in the lab section. They all state that the patient was
positive for streptococcal infection. Also, the History and physical from the
Physician Assistant notes on 1/17/2024 says that the patient has had 7 culture
proven acute recurrent streptococcal tonsillitis episodes last year.
Clinical indicator for the last problem is
The findings and impressions from the Imaging studies report on 1/18/2024 state
inflamed vocal folds from rad tech Rice Matty.
The ENT consultant Dr. Harold Hardcastle on 1/18/2024 in the consultation notes states
that “the patient has Acute recurrent Maxillary sinusitis.”
After considering, could you determine if Acute recurrent streptococcal tonsillitis and
chronic laryngitis were ruled out or in?

Acute recurrent streptococcal tonsillitis:


ruled in_______ ruled out__________ unable to determine__________
Chronic laryngitis:
ruled in_________ rule out ________ unable to determine__________

Provider Signature:
Date:

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