A 33-year-old male went to his primary care physician (PCP) with heartburn-like symptoms including reflux, disturbed sleep, and elevated blood pressure. Upon questioning, the PCP asked about alcohol consumption. At first, he denied any, then admitted to drinking half to 1 bottle of scotch per night roughly 4 times a week. He stated that he usually drinks 3 bottles a week and commented that consumption occurs late at night and does not interfere with his work responsibilities.
Do you need to query the physician?
a. Yes, there needs to be a diagnostic statement.
b. Yes, there needs to be information about a follow-up appointment.
c. No. All the needed information is here.
d. Yes, there needs to be a treatment plan.