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Chief Complaint - I presented this as an invalid

  1. Default Chief Complaint - I presented this as an invalid
    Medical Coding Books
    I presented this as an invalid chief complaint, due to the first sentence and was told by other employees that there were plenty of complaints to pull out of the HPI. Can I get some opinions, so I can look at other peoples view on this?

    HPI The patient is here today with her husband for followup. She said she has had kind a recurrence of things at this time. The pain in her legs is somewhat better. She had been seen in Pain Clinic, received a caudal block and that has helped her some. She said it wsn?t bad pain there. She said the Dilaudid really stopped helping with her abdominal pain. She had some Norco as well and that actually worked better. She was also on some 5-FU topically that she got from a different office to help treat some precancerous skin spots. She said in the morning, when she gets up, she feels little bit nausea, when she brushes her teeth, it will make her gag and throw up. She has been drinking a couple of supplements, her Carnation Instant Breakfast every day and getting some food down. She is keeping things down after that initial morning gagging and vomiting, but just does not feel well and still has chronic nausea. Since she has some onychomycosis in her fingernails and has been working with Dr. Ryan on natural hormones, but neither of those physicians want to make any changes in her medications to treat her for anything right now until this nausea she gets sorted out. She did bring a stool sample in today to get her elastase measured which was ordered when she was in the hospital, but had not been obtained because she did not have a stool sample. She just keeps having this recurrent nausea and is kind of frustrated by it and was wondering if she needed to be considered to go to Mayo Clinic or somewhere else to get seen. Reviewed her medication list with her at this time.

    Thanks for any input
    DE

  2. #2
    Default
    Chief Complaint: Nausia unknown Etiology.
    Just a Guess.

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