Hello
I am auditing consultations done by a cardiologist. Patient was referred by her orthopedic surgeon.
I am having trouble with some of the HPI. Here is an example:
Patient is an 80-year old pleasant female with a longstanding history of hypertension. She complains of disabling pain in the left knee. It is also affecting her left hip joint. She also complains of generalized myalgia. She denies any chest pain, shortness of breath, palpitation or dizziness. She underwent left partial knee replacement about six years ago and is now schedule for a total replacement.
I didn't want to use the "status of chronic conditions" because he didn't state the status. What elements of HPI can I count when it is hypertension? I can count Associated signs/symptoms for the pain and myalgia. What else?
Thank you for your help
Debby
I am auditing consultations done by a cardiologist. Patient was referred by her orthopedic surgeon.
I am having trouble with some of the HPI. Here is an example:
Patient is an 80-year old pleasant female with a longstanding history of hypertension. She complains of disabling pain in the left knee. It is also affecting her left hip joint. She also complains of generalized myalgia. She denies any chest pain, shortness of breath, palpitation or dizziness. She underwent left partial knee replacement about six years ago and is now schedule for a total replacement.
I didn't want to use the "status of chronic conditions" because he didn't state the status. What elements of HPI can I count when it is hypertension? I can count Associated signs/symptoms for the pain and myalgia. What else?
Thank you for your help
Debby