Wiki what hpi elements do you get

[trose45116]

what hpi elements do you see in this besides the location?? per the medical history he has no pain on a scale of 1-10, using it too much makes the pain worst, he has none on the description of the pain but none of this is documented on the note but is in the medical record. can we count these as well??? any help thanks


New patient - Self referred Patient is an 18-year-old male who comes in with chief complaint of right knee pain. He does describe having knee surgery in 2013. He describes having an MRI in Tucson. He is here today with his father. He describes previous patellar tendon surgery. He does have significant patellar tracking issues. He comes in today for evaluation. He describes patellar instability. He has not worn orthotics. He did have an MRI. He does not have the CT scan. He denies any other specific complaints.

 

[JEYCPC]

I could squeeze context out of "using it too much makes the pain worse".

 

[CatchTheWind]

"Using it too much makes the pain worse" is actually a modifying factor. (Modifying factors are what makes it worse or better.)

I could get context from his history of knee surgery and associated signs and symptoms possibly from "no other specific complaints," and definitely from the patellar tracking disorder.