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HPI Elements

  1. Default HPI Elements
    Medical Coding Books
    Please assist with identifying the elements.

    CC: Scoliosis, occasional back pain
    HPI: 45 year old RHD female who presents for evaluation of scoliosis. Diagnosed with scoliosis as a child. Never needed bracing. No recent XR of spine. Had noted some issues with "Lung pain" after exercising, which is only noted on right side of chest. Has not undergone CXR, never underwent EKG, last PFT ten years ago. Underwent blood work one month ago which was normal. Has occasional midback pain, but not severe. Exercises by performing Pilates and riding bicycle. No numbness or tingling.
    PMH:Hernia Repair as a child
    FH: Father - Melanoma
    Medications: No current medications.
    PF? Y
    E-Mail? Y
    Tel? Y

    Allergies: SULFA (Mild)
    Pregnant? N
    Pain site: Midback
    # stairs: 10
    Living environment: apartment, elevator, stairs


  2. Default
    Location: Back; Duration: since childhood; Associated S&S: lung pain after exercising; Timing: occasional; Severity: not severe.

  3. Default
    Thanks, appreciated.

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