Wiki Help with HPI

[Gemini18]

"A 85-year old male who has been treated as an outpatient for a UTI for the past month. Every time he takes a pill he develops N/V. First he was on amoxicillin and then Cipro and then Levaquin. The patient came to the ER and was still with UTI. He had a temp of 100.2. He is still apparantly having fevers and when he has fevers he throws up. He blames the antibiotics and switches. According to the ER physician, he thinks it is not actually the antibotics but the infection that is not clearing up. He even had a foley catheter in the past, whic he does not have now."

The above is a HPI of a chart that I am working on -- my question -- how many HPI elements do you see in here? I have 3.

 

[Carsil864]

I see 4 - duration, context, modifying factors, severity

 

[FTessaBartels]

Four

I guess it partly depends on the complaint ... is it UTI or Nausea/vomiting(reaction to drug)?
For UTI:
Location: Urinary tract (okay to infer location)
Duration: past month
Modifying factor: Antibiotics
Associated sign: fever

For N/V:
Location: GI (inferred)
Context: every time he takes a pill
Assoc sign: fever
Duration: past month (I'm inclined to give him this one because the patient is so adamant that his N/V is directly a result of the Antibiotics, which he's been on for a month)

Hope that helps.

F Tessa Bartels, CPC, CEMC