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ollielooya

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CC: URI: pain in inguinal hernia site

54 YO new patient male brought in by his son with URI symptoms cough for past week. this has made his inguinal hernia area bulge more and painful. it is still reducible. Duration: 1 week, runny nose: yes, Congestion: yes, mucopurulent nasal discharge: yes, Fever; no, Sneezing, yes, chest congestion: yes.

I see location, duration, assoc signs and conditions, but not sure about how to assign the :Hernia area bulge more". Would this be applicable for severity OR quality. Is there a 4th element to be assigned here? What about context?
 
Before looking at your last sentence I saw: location, duration, assoc signs and sx, context
Severity is going to be something such as "5 on a scale of 10" or "worst he has ever felt", etc. Quality is things like "sharp" "dull" "throbbing", etc. Context is what makes it happen so I'd put the cough makes the area painful as context.

Karen Hill, CPC, CPMA, ICD-10-CM
 
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