Wiki HPI level

[solocoder]

I'd like to get some opinions on this HPI. This is for a new patient.
HISTORY OF PRESENT ILLNESS: This 72-year-old male is still active with farm work, several hundred head of cattle, and wonders if he should have new orthotics made or if he should have the current orthotics refurbished. He had a second pair which he somehow lost and is down to one pair remaining. He has noticed a gradual increase in width of his feet develop over time. He continues to wear either a lace-up work boot or a casual shoe with the orthotics.

 

[btadlock1]

I'd like to get some opinions on this HPI. This is for a new patient.
HISTORY OF PRESENT ILLNESS: This 72-year-old male is still active with farm work, several hundred head of cattle, and wonders if he should have new orthotics made or if he should have the current orthotics refurbished. He had a second pair which he somehow lost and is down to one pair remaining. He has noticed a gradual increase in width of his feet develop over time. He continues to wear either a lace-up work boot or a casual shoe with the orthotics.

This 72-year-old male is still active with farm work: Social History (or HPI Context)
several hundred head of cattle: HPI Context
and wonders if he should have new orthotics made or if he should have the current orthotics refurbished: Past History
gradual, over time: HPI Timing
increase in width: HPI Quality
of his feet: HPI Location
He continues to wear either a lace-up work boot or a casual shoe with the orthotics: HPI Modifying Factors

It was kind of tricky to place these with the usual elements, just because they don't fit quite as neatly as most problems. This is excellent documentation of HPI, though. You've got an Extended HPI and 2/3 PFSH in this portion of the note alone. Remember, though, that for new patients, you have to have 3/3 PFSH to consider it 'Complete'
If you've got at least 2 ROS documented, then your overall history should be Detailed. Hope that helps!

 

[solocoder]

Thanks

Thanks for the great reply. I will save that one for future reference!