Er hpi elements

nabernhardt

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just needing some other opinions on how HPI elements out of this one please
72 years old male presents to the ER with Dyspnea and moderate SOB. Pt was in at the end of January with LLL Pneumonia, has had home health coming out upto 2 weeks ago and was improving. Pt feels he has never returned to baseline with his breathing, the past few days has began running a temperature and increased cough and productive cough. Pt uses oxygen at home but has a sat at 83% on RA upon arrival at ED. Speaks in 2-3 word phrases.
cc SOB
severity Moderate
associated s/s temperature cough
modifying factors- home health?
duration-past few days
 

ollielooya

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You seem to already have enough to get to the extended or comprehensive HPI elements. In addition to what you've already listed--- what about location? And consider Context for the "Pt. was in at the end of January with LLL Pneumonia." I'm not sure about modifiying factors as being due to the home health treatment or the fact that pt. uses oxgen at home, but either way...definitely enough to assign to Modifiying Factors. Just my opinion as I'm no EM expert, but do love the subject.

---Suzanne E. Byrum CPC
 
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