HPI Help

tosborne

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Big Stone Gap
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Can someone please take a look at the HPI from a Palliative Care Initial Consult note? Please help me determine the HPI elements.

History of Present Illness:
Patient is a 72-year old female with past medical history of COPD on home oxygen, hypertension, and diabetes type 2, who was transferred to ___________ from ___________________ on March 30,2016. The patient was admitted there on March 29, 2016 with possible pneumonia, and COPD exacerbation. Upon, transfer, the patient was intubated at the transferring facility, and upon arrival to __________ the patient was partially sedated, but mostly awake and she was connected to the monitor and her SATS were low in the 60s and continued to drop and got as low as 30%. At that point, the patient's ET tube from the prior facility was noted to be in the posterior oropharynx and coursing down to the esophagus at the 25th cm mark and she was extubated and then reintubated to the 20th cm mark after her SATS came up by Ambu bag. Patient was brought and then monitored in the ICU until April 12, 2016 when she was transferred to the floor and at that point, the patient was doing fairly well, eating and drinking without difficulty and was alert, and oriented to person and place. Upon arrival to the floor patient's condition continued to deteriorate. The palliative care team was consulted to determine goals of care and transitional care for the patient. We did speak to her son and he preferred for her to be transferred back to _________ if possible and we did also speak to him about comfort measures here and possible inpatient hospice, if she was not able to go back to __________, he said he would think about this and let us know.
 

trarut

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I would give duration (admission date), associated signs (possible pneumonia, exacerbated COPD) and severity (sat levels/%s). That appears to be what ultimately led them to the palliative care service.

Tracy
 
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