HPI Assistance

kgodda1

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I would like someone to look at the note below and let me know what elements of HPI that you are able to pull out. There is currently some disagreement on the level of HPI.

Thank you for referring XXXX for cardiac consultation. As you know, he is an XX year old gentleman with hypertension and dyslipidemia who is referred for the evaluation of an abnormal EKG. An EKG was performed in your office, the computer reading of which reads atrial fibrillation with T waves in the inferior leads. In fact, I believe this EKG likely represents sinus bradycardia with first-degree A-V block and PACs, corrupted by significant artifact.

XXXX has no specific complaints. He denies chest discomfort or exertional dyspnea. He does note occasional palpitations. He denies any lightheadedness, dizziness, syncope or near syncope. He is quite active and denies any limiting dyspnea or chest discomfort. He has no known history of coronary artery disease. He denies any previous admission for congestive heart failure. He sleeps on one pillow. He denies any PND, orthopnea, or lower extremity edema. He overall feels well and has no specific complaints.


I scored this a follows:

CC: Abnormal EKG
Location: Inferior leads
Quality: Atrial fibrillation w/ T waves
Associated Signs and Symptoms: No chest discomfort

Any assistance is appreciated.
 
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Additional HPI elements

To what you already identified, I would add
Severity - first-degree A-V block
Possibly Context - performed in your office

HOWEVER a lot would depend on the rest of the note and whether I needed some of the elements in the history you've provided to count for ROS or PFSH.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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