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Brief HPI?

  1. #1
    Default Brief HPI?
    Medical Coding Books
    Pt is a 38-yo gentleman who presented to the ER with a 1-2 week hx of just not feeling well, getting more fatigued, significant increase in thirst and urination. He states his mouth is so dry it is hard for him to even swallow. In the ER, he was found to have a urinalysis w/ greater than 1000mg/dL of sugar in the urine. His glucose was 530, BUN and creatinine 29 and 2.0, sodium 133, potassium 5.2. The pt is being admitted for IV hydration and new-onset diabetes.

    I want to know does anyone get an extended HPI and how?

  2. #2
    Default Brief HPI cont'd
    Sorry about that I hit the post and was not done --


    The ROS:

    Denies chest pain or shortness of breath. No abdominal pain. No swelling in his legs.

    PMH: negative
    FH: Father died with history of diabetes
    SH: works in shipping and receiving. Does not smoke or drink.

  3. #3
    Default
    CC: not feeling well

    1-2 weeks (duration)
    significant increase (severity)
    mouth dry, worsening fatigue (quality)
    difficulty swallowing (a/s)
    seen/treated in ER (modifying factor)

    Denies chest pain, swelling (CV, 1 ROS)
    Denies shortness of breath (Resp, 2 ROS)
    No abdominal pain (Gastro, 3 ROS)
    Could use the diabetes (Endo, 4 ROS)

    PMH: negative (Does he have no history at all? or is it just not pertinent? ... it doesn't matter anyway, you only need 1 pertinent)
    FH: Father died with history of diabetes
    SH: works in shipping and receiving. Does not smoke or drink.

    I see 4+ HPI, 4 ROS, 2/3 PFSH that gives me a detailed history
    6 more ROS & PMH clarified and you would have had a comprehensive history.

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