Wiki help with HPI

Gemini18

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What do you make of this HPI:

"35-year old male, who says the last thing he remembers was being at a bus station, where he was visiting his family, when he was mugged by 2 people. Now he remembers walking up in the hospital. He says he never normally go the a hospital. He says this was not his destination. He denies any alcohol, but did say he smoked marijuana yesterday, and has taken Percocet for kidney stones, but other than that he was brought in via police, confused. He says he is having a bad headache. He denies any shortness of breath, nausea, vomiting and diarrhea. He says when he sits up he gets lightheaded, but that has since been resolved."

ROS: Reviewed in the history and physical, otherwise reviewed and are negative.

I'm not getting a comprehensive history.
 
What do you make of this HPI:

"35-year old male, who says the last thing he remembers was being at a bus station, where he was visiting his family, when he was mugged by 2 people. Now he remembers walking up in the hospital. He says he never normally go the a hospital. He says this was not his destination. He denies any alcohol, but did say he smoked marijuana yesterday, and has taken Percocet for kidney stones, but other than that he was brought in via police, confused. He says he is having a bad headache. He denies any shortness of breath, nausea, vomiting and diarrhea. He says when he sits up he gets lightheaded, but that has since been resolved."

ROS: Reviewed in the history and physical, otherwise reviewed and are negative.

I'm not getting a comprehensive history.

this is what i see...
context: was mugged and does not remember events
location: head for headache
modifying factors: took percocet
associated signs and symptoms: denies sob, n/v and diarrhea.
 
4 elements

Location = head (headache)
Severity = "bad"
Context = mugged
Assoc Symptoms = confused, lightheaded

Could almost give duration ... as I'm presuming police brought him in today, but physician should really specify the time line.

F Tessa Bartels, CPC, CEMC
 
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