Good Morning:
I'm having a bit of a infarct this morning, I do believe I have atleast 4 HPI elements in this note but I just want to double check...
86 yr old female presents to the office today for a f/u of her UTI. She had a UTI, we had urine that had a little bit of klebsiella and it was sensitive to just about everything except Amoxicillin. It was indeterminate with Macrobid, but Macrobid concentrates in teh urine. She was asymptomatic. We're going to repeat another UA dipstick just to make sure we wiped it out. She is asymptomatic as far as symptoms now. Otherwise, no SOB, no CP, she feels good, looks good. Blood sugars have been doing well. Renal functions were up just a little bit but there is no protein in the urine. We're going to follow up on this as well as the blood count in the next month and then see her back as scheduled.
I have location= GU
quality= she feels good
modifying factors= amoxicillin
assoc signs and symptoms= no SOB
I hear from time to time that what I am using as quality ( she feels good) is iffy?
Any takers?
TIA
I'm having a bit of a infarct this morning, I do believe I have atleast 4 HPI elements in this note but I just want to double check...
86 yr old female presents to the office today for a f/u of her UTI. She had a UTI, we had urine that had a little bit of klebsiella and it was sensitive to just about everything except Amoxicillin. It was indeterminate with Macrobid, but Macrobid concentrates in teh urine. She was asymptomatic. We're going to repeat another UA dipstick just to make sure we wiped it out. She is asymptomatic as far as symptoms now. Otherwise, no SOB, no CP, she feels good, looks good. Blood sugars have been doing well. Renal functions were up just a little bit but there is no protein in the urine. We're going to follow up on this as well as the blood count in the next month and then see her back as scheduled.
I have location= GU
quality= she feels good
modifying factors= amoxicillin
assoc signs and symptoms= no SOB
I hear from time to time that what I am using as quality ( she feels good) is iffy?
Any takers?
TIA
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