Wiki HPI Element - I was wondering if anyone could give me their opinion

[jmcalhaney]

I was wondering if anyone could give me their opinion on what HPI elements that you can pull from the following:

A 50 year old, referred for nausea, vomiting, diarrhea, and abdominal pain.The patient states, she was in usual health 4 to 6 weeks ago. She had loss of appetite, early satiety, and weight loss. The patient states she has lost 25 pounds over that time. For 3 to 4 weeks, she was having N&V. This seems to be resolving. She has had a change in bowel habits with decreased stool frequency over the last 6 weeks. Over the last 7 to 10 days, she has had some diarrhea. She has also had some black bowel movements. She denies rectal bleeding or history of anemia. When asked about abdominal pain for about a month, she had lower generalized pelvic pain. This seems to be resolving. The patient has been to see Dr. X and his colleagues 4 times over the last month and was diagnosed with UTI and what seems to be H. Pylori. I do not have all those records at this time.

I am only finding 3 elements of the HPI in this history statement (Location, Duration, and Associated Signs and Symptoms). The Dr. coded it as a level 3 new patient consult, but I can't get to a level 3 without having 4 components of the HPI. Does anyone else see anything that can be used?

 

[Naveen Rachagolla]

I hope you can come with Quality aslo as one of the HPI, as the patient says she had lower generalized pelvic pain i think here patiend is describing the type of pain also, so we can take quality.

Lets wait and for others inputs.

 

[ollielooya]

Naveen, thanks for posting your thoughts, I was going to post similar observations and agree. Somewhere buried deep within the bowels of this forum is another posting very similar to the question being asked. A search might bring it up with the accompanying answers.

 

[twizzle]

I was wondering if anyone could give me their opinion on what HPI elements that you can pull from the following:

A 50 year old, referred for nausea, vomiting, diarrhea, and abdominal pain.The patient states, she was in usual health 4 to 6 weeks ago. She had loss of appetite, early satiety, and weight loss. The patient states she has lost 25 pounds over that time. For 3 to 4 weeks, she was having N&V. This seems to be resolving. She has had a change in bowel habits with decreased stool frequency over the last 6 weeks. Over the last 7 to 10 days, she has had some diarrhea. She has also had some black bowel movements. She denies rectal bleeding or history of anemia. When asked about abdominal pain for about a month, she had lower generalized pelvic pain. This seems to be resolving. The patient has been to see Dr. X and his colleagues 4 times over the last month and was diagnosed with UTI and what seems to be H. Pylori. I do not have all those records at this time.

I am only finding 3 elements of the HPI in this history statement (Location, Duration, and Associated Signs and Symptoms). The Dr. coded it as a level 3 new patient consult, but I can't get to a level 3 without having 4 components of the HPI. Does anyone else see anything that can be used?

The degree of wait loss is all part of the HPI and is severity.

 

[MikeEnos]

I see these types of note a lot - where the provider seems to list Associated Signs and symptoms over, and over, and over, and over then they give a modifying factor, then another, then another, then another. It ends up being a pretty lengthy paragraph but there's really only 2 or 3 elements there. In cases like this you have to do some mental gymnastics to tease out the other elements. It may be a little creative, but here's what I can identify:

Location - Abdomen
Duration - 4 to 6 weeks
Associated Signs and Symptoms - Loss of appetite (among other things)
Quality - Black bowel movements
Severity - lost 25 pounds
Possibly Timing - Over the last 7 to 10 days