HPI elements

[solocoder]

Hi. Can someone help me pick out some elements of HPI in this "HPI"? Other than location, the rest sounds like past medical history to me.


Reason for Consult: Gangrene of right 2nd toe and 1st metatarsal stump.

Patient is a 74 y.o. Caucasian male who is seen for podiatric consultation as requested by **, MD. He is questioned, examined, and the chart is reviewed. He is well familiar to me as he had disarticular amputation of the left 1st metatarso-phalangeal joint due to dry gangrene on 3/31/17. Pre-operatively, U.S. Duplex arterial studies performed on 3/22/17 showed mild arterial insufficiency of bilateral lower extremities, and triphase bone scan performed on 3/13/17 was negative for osteomyelitis of the right foot.
Of note, he has a history of diabetes mellitus with diabetic neuropathy diagnosed in 2000 and deep vein thrombosis of the right leg in 2012. He has a pacemaker and is on anti-coagulation therapy with Coumadin. He is retired.



Thanks!

 

[jhynek]

Hpi

I agree with you the rest sounds like past medical history. It does not seem like anything was asked of the patient such as current signs/symptoms, how long has it been going on, what makes it better/worse, or severity.

Thanks!