Wiki Opinions on History elements

[LLovett]

We had a meeting with several physicians this morning to audit some of their notes. One in particular stood out because we had a split decision in the room. I would like to get other opinions on this history.

DM-BS in AM 98-138. Fasting 110. 170's with meals.
Having lows before lunch 50-68
6/09 optho appt +ASA -Urine mirco
HgbA1c 7.2 Filament exam -3/10 LDL 129

There are 2 other chronic conditions and one clear ROS. The question is in the DM info would you give credit for ROS of endocrine based on the above info.

Thanks

Laura, CPC, CPMA, CEMC

 

[Belinda Frisch]

I would.

We had a meeting with several physicians this morning to audit some of their notes. One in particular stood out because we had a split decision in the room. I would like to get other opinions on this history.

DM-BS in AM 98-138. Fasting 110. 170's with meals.
Having lows before lunch 50-68
6/09 optho appt +ASA -Urine mirco
HgbA1c 7.2 Filament exam -3/10 LDL 129

There are 2 other chronic conditions and one clear ROS. The question is in the DM info would you give credit for ROS of endocrine based on the above info.

Thanks

Laura, CPC, CPMA, CEMC

I would. A review of the patient's blood sugars as they relate to meals and time of day seems an appropriate review of the endocrine system to me.