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hpi

daniel

True Blue
Messages
596
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0
What Level Of Hpi Does One Get Out Of This.


She Is A 54-year Old Female Recently Found To Have A Left Breast Cyst After An Abnormal Mammogram. This Was Aspirated Recently With Resolution Of The Cyst. She Is Her For Follow-up. She Did Not Find This Herself. It Was Completely Asymptomatic.

She Also Complains Of Feeling Her Heart Pound In Her Neck, Particularly At Night When She Sometimes Awakens From Sleep. She Is On A Combination Of Toprol-xl And Hyzaar For Hypertension. She Doesn't Have Any Blood Pressure Measurements Iwth Her Of Recent.


The Two Ros Are Met. Not Noted Here.


Respectfully
Daniel, Cpc
 

LLovett

Guest
Messages
1,722
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0
I say it is detailed.

Location-breast
Modifying factor-aspirated or this could be used as past history if no other was obtained
Severity-asymptomatic

Location-neck
Timing-night
Severity-awakens from sleep
Modifying factors- medications she is on


Laura, CPC
 

pamtienter

Expert
NAB Member
Messages
349
Location
Mound, MN
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0
Here is what I find:
CC: Cyst
Location: Breast
Severity: Asymptomatic
Modifying Factor: Resolved by aspiration.

CC: Heart pounding sensation
Location: Neck
Timing: particularly at night when she wakes up.

For modifying factor credit, it should state if something is making it better or worse, so I wouldn't count the meds here. So for both complaints, I only come up with a brief HPI.
 
Messages
4,466
Location
Milwaukee WI
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0
Detailed

I come up with detailed (but I assumed that chief complaint is separately recorded, just as ROS is)

Duration - recently
Location - breast
Quality - cyst
Context - after mammogram
Modifying factors - aspirated w/ resolution
Assoc sign/sympt - asymptomatic

I didn't even count the heart pounding paragraph because I already had 4+

F Tessa Bartels, CPC, CPC-E/M
 
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