One of our surgeons consulted on a patient and didn't do a review of systems. The patient is medicare. Here below is what the dr. documented:
56 year old women seen with c/c abd distention, n/v and aspiration with resp failure and INER.
CT lap amt stool and pas in colon. No free air or ascites.
Pt instubated, no hx available
exam alert intubated
HEENT perla, awake, ng tube, endo trash tube
Chest HRRR with Lungs Bilat coarse BS with Fremitis low BS rt and lt bases
Abd distended no guarding rigidity no BS
foley lt femoral central line scd's
imp:
Acute Apsiration, resp failur, copd
obstipation no obstruct color
non surg abd
recL decompression colon
GI consult will reeval if needed.
What level do you think I can give?
Thanks, any help appreciated
56 year old women seen with c/c abd distention, n/v and aspiration with resp failure and INER.
CT lap amt stool and pas in colon. No free air or ascites.
Pt instubated, no hx available
exam alert intubated
HEENT perla, awake, ng tube, endo trash tube
Chest HRRR with Lungs Bilat coarse BS with Fremitis low BS rt and lt bases
Abd distended no guarding rigidity no BS
foley lt femoral central line scd's
imp:
Acute Apsiration, resp failur, copd
obstipation no obstruct color
non surg abd
recL decompression colon
GI consult will reeval if needed.
What level do you think I can give?
Thanks, any help appreciated