This is a New Patient referred to Cardiologist for cardio clearance. Cardiologist's note does not state status of chronic conditions, so I need to pull elements of HPI from following note:
"Pt is an 86 yr old w/f and fractured her L shoulder after walking down the stairs a few days ago. Pt apparently tripped and had no syncope or near syncope. Pt is less active since November 2012 due to progressive back issues. She has a hx of significant osteoporosis and has had a decrease in her memory according to her family. Pt is taking oxycodone and has chronically low BP with chronically high heart rates according to the patient.":
I give Location for fx of L shoulder, Duration for a few days ago, Context for apparently tripped, Assoc signs & symptoms for had no syncope or near syncope.
Even though visit is for cardiac clearance, the surgery is for repair of fx shoulder- so I can use this for HPI purposes. Let me know your thoughts! Thanks!!!!
"Pt is an 86 yr old w/f and fractured her L shoulder after walking down the stairs a few days ago. Pt apparently tripped and had no syncope or near syncope. Pt is less active since November 2012 due to progressive back issues. She has a hx of significant osteoporosis and has had a decrease in her memory according to her family. Pt is taking oxycodone and has chronically low BP with chronically high heart rates according to the patient.":
I give Location for fx of L shoulder, Duration for a few days ago, Context for apparently tripped, Assoc signs & symptoms for had no syncope or near syncope.
Even though visit is for cardiac clearance, the surgery is for repair of fx shoulder- so I can use this for HPI purposes. Let me know your thoughts! Thanks!!!!