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Help with HPI

  1. #1
    Default Help with HPI
    Medical Coding Books
    "A 85-year old male who has been treated as an outpatient for a UTI for the past month. Every time he takes a pill he develops N/V. First he was on amoxicillin and then Cipro and then Levaquin. The patient came to the ER and was still with UTI. He had a temp of 100.2. He is still apparantly having fevers and when he has fevers he throws up. He blames the antibiotics and switches. According to the ER physician, he thinks it is not actually the antibotics but the infection that is not clearing up. He even had a foley catheter in the past, whic he does not have now."

    The above is a HPI of a chart that I am working on -- my question -- how many HPI elements do you see in here? I have 3.

  2. Default
    I see 4 - duration, context, modifying factors, severity

  3. #3
    Milwaukee WI
    Default Four
    I guess it partly depends on the complaint ... is it UTI or Nausea/vomiting(reaction to drug)?
    For UTI:
    Location: Urinary tract (okay to infer location)
    Duration: past month
    Modifying factor: Antibiotics
    Associated sign: fever

    For N/V:
    Location: GI (inferred)
    Context: every time he takes a pill
    Assoc sign: fever
    Duration: past month (I'm inclined to give him this one because the patient is so adamant that his N/V is directly a result of the Antibiotics, which he's been on for a month)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 09-01-2009 at 01:33 PM.

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