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2nd Opinion on HPI

  1. #1
    Location
    Jacksonville Florida
    Posts
    126
    Lightbulb 2nd Opinion on HPI
    Medical Coding Books
    Hi everyone I'm in need of a second opinion on the HPI in the report below. I am only finding it meets an Expanded Problem Focused and was wanting some additional brains to look at this with me. This is a new patient office visit.

    ----------------------------------------------------------------------------------------------------------------------------------------------------
    History - Expanded Problem Focused, Level 2
    HPI=2 - Brief, Documented status of 2 conditions (Mild Mitral Insufficiency, Well controlled HTN)
    ROS=5 - Complete, 10+ documented
    PFSH=5 - Complete, Past Medical, Family and Social Histories documented
    ----------------------------------------------------------------------------------------------------------------------------------------------------


    REASON FOR VISIT:
    This 66 year old female presents for heart murmur.

    HISTORY OF PRESENT ILLNESS:
    1. heart murmur
    The patient recently moved here from Maryland. She was being followed by a cardiologist for a congenital heart murmur and wants to establish with someone here in FL.
    2. general
    She has had no chest discomfort suggestive of ischemia. The patient denies orthopnea, PND, DOE, or edema. Ms. Mahaffey has not had palpitations, syncope or near syncope. She denies claudication. There is no discoloration or ulceration of the lower extremities. She has had no TIA or stroke-like symptoms. The patient has no symptoms attributable to valvular heart disease.

    CARDIAC HISTORY
    VALVULAR:
    1 AR
    2 MR

    RISK FACTORS:
    1 Hypertension
    2 Dyslipidemia [Type: Hyperlipidemia]

    CARDIOVASCULAR PROCEDURES
    ELECTROPHYSIOLOGY:
    EKG (Sinus Rhythm, 52 bpm) - 2/20/2014

    ALLERGIES/INTOLERANCES:
    NO KNOWN ALLERGIES

    PAST MEDICAL/SURGICAL HISTORY (Detailed)
    cosmetic surgery
    Dermatitis
    Diverculitis
    Onychomycosis, Toenail

    FAMILY HISTORY (Detailed)
    Family history of Cancer, unknown
    dn 09/11/2014 - Basal Cell Carcinoma, Skin

    SOCIAL HISTORY (Detailed)
    Preferred language is English.
    MARITAL STATUS/FAMILY/SOCIAL SUPPORT
    Currently single.
    Does not have children.
    CAFFEINE
    The patient uses caffeine.
    LIFESTYLE
    Regularly.

    REVIEW OF SYSTEMS:
    CONST - Negative for weight gain, fever. Positive for weight loss. EYES - Positive for visual changes. ENT - Negative for hearing loss. RESP - Negative for snoring, hemoptysis, dyspnea. CARD - Negative for chest pain, diaphoresis, orthopnea, palpitation, syncope, PND. VASC - Negative for claudication, edema. GI - Negative for nausea, reflux, bleeding. GU - Negative for hematuria, nocturia. REPROD - Positive for Hx of OCP. ENDO - Negative for goiter, tremors. NEURO - Negative for dizziness, memory loss, seizures. PSYCH - Negative for depression, hallucinations. DERM - Negative for rash, skin sores. M/S - Negative for joint pain, myalgia. HEMAT - Negative for acute anemia, thrombocytopenia.

    VITAL SIGNS
    BP mm/Hg 110/72
    Pulse/min 74
    Height (Total in.) 68.00
    Weight (lbs.) 185.00
    BMI 28.13

    PHYSICAL EXAM:
    Const Neg Nourishment - Well Nourished. Appearance - Well Developed.
    Eyes Neg Lids/External - Bilateral Normal. Conjunctiva - Bilateral Normal.
    NMT Neg Oral Mucosa - Moist, No Cyanosis, No Pallor.
    Neck Neg JVP - Less Than 8.
    Resp Neg Respirations - Nonlabored. Breath Sounds - Clear Throughout. Rales - Absent. Wheezes - Absent. Rhonchi - Absent.
    Cardiac Neg Rhythm - Regular. Palpation - PMI Normal. Heart Sounds - S1 Normal, S2 Normal, No S3, No S4.
    Cardiac Pos Murmurs - I/VI systolic ejection murmur heard at the base; II/VI holosystolic murmur heard at the apex.
    Vasc Neg Carotid - Bilateral Normal Pulse. Aorta - Normal Size. Femoral - Bilateral Normal Pulse. Posterior Tibial - Bilateral Normal Pulse.
    Abd Neg Tenderness - None. Hepatomegaly - Absent. Splenomegaly - Absent.
    Skin Neg Venous Stasis Ulcer - Absent.
    M/S Neg Gait - Normal. Able to Exercise - Yes.
    EXT Neg Clubbing - Absent. Lower Extremity Edema - Absent.
    Psych Neg Orientation - Oriented to Time, Person, Place. Mood - Appropriate.

    IMPRESSION AND PLAN
    01. Aortic regurgitation: EKG performed - ordered and reviewed by me today. It shows NSR, LAE
    02. Mitral regurgitation: Tests reviewed with patient. Echocardiography demonstrates mild mitral insufficiency.
    03. Mixed hyperlipidemia: Managed by: PCP.
    04. Hypertension: Well controlled on medical therapy. We will continue the current therapy.


    ORDERS:
    1 Return office visit with XX MD in 1 Year.

    FINAL MEDICATION LIST
    Sig Description
    atorvastatin 20 mg tablet - take 1 tablet by oral route every day
    lisinopril 20 mg tablet - take 1 (20MG) by oral route every day at bedtime
    Jammie Barsamian, CPC, CCC, CEMC, CCS-P, CPMA

  2. #2
    Default
    Quote Originally Posted by jlb102780 View Post
    Hi everyone I'm in need of a second opinion on the HPI in the report below. I am only finding it meets an Expanded Problem Focused and was wanting some additional brains to look at this with me. This is a new patient office visit.

    ----------------------------------------------------------------------------------------------------------------------------------------------------
    History - Expanded Problem Focused, Level 2
    HPI=2 - Brief, Documented status of 2 conditions (Mild Mitral Insufficiency, Well controlled HTN)
    ROS=5 - Complete, 10+ documented
    PFSH=5 - Complete, Past Medical, Family and Social Histories documented
    ----------------------------------------------------------------------------------------------------------------------------------------------------


    REASON FOR VISIT:
    This 66 year old female presents for heart murmur.

    HISTORY OF PRESENT ILLNESS:
    1. heart murmur
    The patient recently moved here from Maryland. She was being followed by a cardiologist for a congenital heart murmur and wants to establish with someone here in FL.
    2. general
    She has had no chest discomfort suggestive of ischemia. The patient denies orthopnea, PND, DOE, or edema. Ms. Mahaffey has not had palpitations, syncope or near syncope. She denies claudication. There is no discoloration or ulceration of the lower extremities. She has had no TIA or stroke-like symptoms. The patient has no symptoms attributable to valvular heart disease.

    CARDIAC HISTORY
    VALVULAR:
    1 AR
    2 MR

    RISK FACTORS:
    1 Hypertension
    2 Dyslipidemia [Type: Hyperlipidemia]

    CARDIOVASCULAR PROCEDURES
    ELECTROPHYSIOLOGY:
    EKG (Sinus Rhythm, 52 bpm) - 2/20/2014

    ALLERGIES/INTOLERANCES:
    NO KNOWN ALLERGIES

    PAST MEDICAL/SURGICAL HISTORY (Detailed)
    cosmetic surgery
    Dermatitis
    Diverculitis
    Onychomycosis, Toenail

    FAMILY HISTORY (Detailed)
    Family history of Cancer, unknown
    dn 09/11/2014 - Basal Cell Carcinoma, Skin

    SOCIAL HISTORY (Detailed)
    Preferred language is English.
    MARITAL STATUS/FAMILY/SOCIAL SUPPORT
    Currently single.
    Does not have children.
    CAFFEINE
    The patient uses caffeine.
    LIFESTYLE
    Regularly.

    REVIEW OF SYSTEMS:
    CONST - Negative for weight gain, fever. Positive for weight loss. EYES - Positive for visual changes. ENT - Negative for hearing loss. RESP - Negative for snoring, hemoptysis, dyspnea. CARD - Negative for chest pain, diaphoresis, orthopnea, palpitation, syncope, PND. VASC - Negative for claudication, edema. GI - Negative for nausea, reflux, bleeding. GU - Negative for hematuria, nocturia. REPROD - Positive for Hx of OCP. ENDO - Negative for goiter, tremors. NEURO - Negative for dizziness, memory loss, seizures. PSYCH - Negative for depression, hallucinations. DERM - Negative for rash, skin sores. M/S - Negative for joint pain, myalgia. HEMAT - Negative for acute anemia, thrombocytopenia.

    VITAL SIGNS
    BP mm/Hg 110/72
    Pulse/min 74
    Height (Total in.) 68.00
    Weight (lbs.) 185.00
    BMI 28.13

    PHYSICAL EXAM:
    Const Neg Nourishment - Well Nourished. Appearance - Well Developed.
    Eyes Neg Lids/External - Bilateral Normal. Conjunctiva - Bilateral Normal.
    NMT Neg Oral Mucosa - Moist, No Cyanosis, No Pallor.
    Neck Neg JVP - Less Than 8.
    Resp Neg Respirations - Nonlabored. Breath Sounds - Clear Throughout. Rales - Absent. Wheezes - Absent. Rhonchi - Absent.
    Cardiac Neg Rhythm - Regular. Palpation - PMI Normal. Heart Sounds - S1 Normal, S2 Normal, No S3, No S4.
    Cardiac Pos Murmurs - I/VI systolic ejection murmur heard at the base; II/VI holosystolic murmur heard at the apex.
    Vasc Neg Carotid - Bilateral Normal Pulse. Aorta - Normal Size. Femoral - Bilateral Normal Pulse. Posterior Tibial - Bilateral Normal Pulse.
    Abd Neg Tenderness - None. Hepatomegaly - Absent. Splenomegaly - Absent.
    Skin Neg Venous Stasis Ulcer - Absent.
    M/S Neg Gait - Normal. Able to Exercise - Yes.
    EXT Neg Clubbing - Absent. Lower Extremity Edema - Absent.
    Psych Neg Orientation - Oriented to Time, Person, Place. Mood - Appropriate.

    IMPRESSION AND PLAN
    01. Aortic regurgitation: EKG performed - ordered and reviewed by me today. It shows NSR, LAE
    02. Mitral regurgitation: Tests reviewed with patient. Echocardiography demonstrates mild mitral insufficiency.
    03. Mixed hyperlipidemia: Managed by: PCP.
    04. Hypertension: Well controlled on medical therapy. We will continue the current therapy.


    ORDERS:
    1 Return office visit with XX MD in 1 Year.

    FINAL MEDICATION LIST
    Sig Description
    atorvastatin 20 mg tablet - take 1 tablet by oral route every day
    lisinopril 20 mg tablet - take 1 (20MG) by oral route every day at bedtime
    I only see 3 (Brief) in the HPI; Location (heart); Duration (congenital); Associated S/S (none)
    HPI=EPF

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