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SO much going on here Is this detailed? thanks

This is a 20-year-old female patient with history of depression, diabetes
mellitus, who was brought in for weakness. History was obtained from the
patient's husband, patient, as well as the sister. The sister found her
lying on the floor this evening. The patient was unable to get up. She
was not confused. She was just feeling weak. The patient denies any
focal weakness, tingling or numbness. No headache, blurred vision, or
double vision. There was no report of any facial droop or any slurred
speech. As per the sister, the patient appeared very pale and weak. The
patient could not get up from the floor. Her sister and her sister
in-law helped her to get up and she was brought here for further
evaluation. Also she had urinated all over the sofa. The patient has
had episodes like this where she is incontinence of urine. She also has
increased urine frequency. The patient denies any fall or any
light-headedness or syncopal episode. No chest pain. No shortness of
breath. She denies any hip pain or any back pain. She just feels weak.
The patient is a very poor historian. She has history of depression as
per the family. The patient sleeps almost all day. She does not complain
much. There was no report of any seizures. She does not appear to be
confused. The patient states she was lying on the floor for about 1 hour,
but she clearly denies any syncopal episode or any focal weakness. She
just says she does not know why she was on the floor. She denies any
fever, chills or cough. No abdominal pain, nausea, vomiting or diarrhea.
No blood in the stools. No pain with urination or any burning sensation
with urination. No rash.
 
Yes, I would say this is detailed.

This is a 20-year-old female patient with history of depression, diabetes
mellitus, who was brought in for weakness. Chief Complaint.
History was obtained from the
patient's husband, patient, as well as the sister. The sister found her
lying on the floor this evening. The patient was unable to get up. She
was not confused. She was just feeling weak. Location (general)The patient denies any
focal weakness, tingling or numbness. No headache, blurred vision, or
double vision. Associated Signs and Symptoms
There was no report of any facial droop or any slurred
speech. As per the sister, the patient appeared very pale Quality and weak. The
patient could not get up from the floor Severity
. Her sister and her sister
in-law helped her to get up and she was brought here for further
evaluation. Also she had urinated all over the sofa. The patient has
had episodes like this where she is incontinence of urine. She also has
increased urine frequency. The patient denies any fall or any
light-headedness or syncopal episode Context (pertinent negative)
. No chest pain. No shortness of
breath. She denies any hip pain or any back pain. She just feels weak.
The patient is a very poor historian. She has history of depression as
per the family. The patient sleeps almost all day. She does not complain
much. There was no report of any seizures. She does not appear to be
confused. The patient states she was lying on the floor for about 1 hour, Timing or Duration
but she clearly denies any syncopal episode or any focal weakness. She
just says she does not know why she was on the floor. She denies any
fever, chills or cough. No abdominal pain, nausea, vomiting or diarrhea.
No blood in the stools. No pain with urination or any burning sensation
with urination. No rash.

There are actually probably more, maybe even better than what I picked out, but there are certainly enough to qualify for detailed. You have personal history of depression, etc, social history in that she is married, family history since her sister is alive and with her plus at least 2 ROS.

Detailed history is covered.

Laura, CPC, CPMA, CEMC
 
Detailed

I do get 4 elements of HPI out of this. I also get 10 ROS, a Past Med Hx and a Social hx. If you had a family medical history you'd have a comprehensive history. I would not count family history just because sister is alive and with her. Doesn't tell me anything about the sister's medical history that may pertain to this patient. If there was mention of family history (positive OR negative) of depression, DM, stroke or MS THAT would count.

To try to keep things straight, I'll color code
Chief Complaint
HPI - duration, context, assoc symptoms, severity
ROS - Neuro, Eyes, Constitutional, GU, CV, Respiratory, MS, Psych, GI, skin
Past Medical and Social history

This is a 20-year-old female patient with history of depression, diabetes
mellitus, who was brought in for weakness (chief complaint). History was obtained from the
patient's husband, patient, as well as the sister. The sister found her
lying on the floor(context) this evening(duration). The patient was unable to get up. She
was not confused(Assoc sign). She was just feeling weak. The patient denies any focal weakness, tingling or numbness. No headache (neuro), blurred vision(eyes), or
double vision. There was no report of any facial droop or any slurred
speech. As per the sister, the patient appeared very (severity) pale and weak. The
patient could not get up from the floor. Her sister and her sister
in-law helped her to get up and she was brought here for further
evaluation. Also she had urinated all over the sofa The patient has
had episodes like this where she is incontinence of urine. She also has
increased urine frequency(GU). The patient denies any fall or any
light-headedness or syncopal episode. No chest pain(CV). No shortness of
breath(Resp). She denies any hip pain or any back pain(MS). She just feels weak. The patient is a very poor historian. She has history of depression(Psych) as per the family. The patient sleeps almost all day. She does not complain much. There was no report of any seizures. She does not appear to be
confused. The patient states she was lying on the floor for about 1 hour,
but she clearly denies any syncopal episode or any focal weakness. She
just says she does not know why she was on the floor. She denies any
fever(Constitutional), chills or cough. No abdominal pain, nausea, vomiting or diarrhea(GI).
No blood in the stools. No pain with urination or any burning sensation
with urination. No rash (skin).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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