Wiki Can you pull an HPI out of this?????

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daniel

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Follow-up for HTN

Pt. has had hypertension for about 6 years and reports taking his medications. Pt. had a nose bleed 1 week ago and took his blood pressure. Pt. found that his blood pressure has been running around 180s. No chest pain. No symptoms. Pt. does not have particular symptoms when the blood pressure is up. No blurred vision. No palpitations. Pt. reports not changing his diet recently.


DUR: 1 week ago
Modifying Factors: Taking medication
Assoc. Signs and symptoms: Running nose, chest pain
Context: does not have particular symptom when the blood pressure is up.


I pulled this out 4 HPI for this scenario, but I've been doing Cardiology surgeries for the last month and jump back into the E/M auditing this week.
So I want to see if I'm looking at this right.

Any input will be appreciated.

Thanks
Daniel, CPC
 
I get a different 4

Location: nose
Timing: 1 week ago
Associated S&S: (nose) bleed in the setting of HTN
Duration: for about 6 years (HTN)

I don't see running nose, only a nose bleed, and it says the patient doesn't have chest pain, which you can't use because it's a negative. The patient doesn't have it.

I don't see meds as a modifying factor here because it doesn't say that the meds make anything better or worse. Again, with context, it's supposed to be what the patient is doing when the symptoms appear, not what they're not doing.

That's my take. Anyone agree?

daniel said:
Follow-up for HTN

Pt. has had hypertension for about 6 years and reports taking his medications. Pt. had a nose bleed 1 week ago and took his blood pressure. Pt. found that his blood pressure has been running around 180s. No chest pain. No symptoms. Pt. does not have particular symptoms when the blood pressure is up. No blurred vision. No palpitations. Pt. reports not changing his diet recently.


DUR: 1 week ago
Modifying Factors: Taking medication
Assoc. Signs and symptoms: Running nose, chest pain
Context: does not have particular symptom when the blood pressure is up.


I pulled this out 4 HPI for this scenario, but I've been doing Cardiology surgeries for the last month and jump back into the E/M auditing this week.
So I want to see if I'm looking at this right.

Any input will be appreciated.

Thanks
Daniel, CPC
Click to expand...
 
Here is my thoughts, since the patient was being seen for HTN, most of the HPI should releate to it.

Dur: 6 yrs
MF: taking Meds
A S/S: BP around 180
Loc: nose.

Just my take on the note.
 
I think both of your views could be argued. HPI is so subjective. I could see why Belinda chose the nose bleed as part of her HPI. There are times when an elevation in blood pressure can create nose bleeds; especially with a severe elevation.
 
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