Results 1 to 5 of 5

Can you pull an HPI out of this?????

  1. #1
    Default Can you pull an HPI out of this?????
    Exam Training Packages
    Follow-up for HTN

    Pt. has had hypertension for about 6 years and reports taking his medications. Pt. had a nose bleed 1 week ago and took his blood pressure. Pt. found that his blood pressure has been running around 180s. No chest pain. No symptoms. Pt. does not have particular symptoms when the blood pressure is up. No blurred vision. No palpitations. Pt. reports not changing his diet recently.


    DUR: 1 week ago
    Modifying Factors: Taking medication
    Assoc. Signs and symptoms: Running nose, chest pain
    Context: does not have particular symptom when the blood pressure is up.


    I pulled this out 4 HPI for this scenario, but I've been doing Cardiology surgeries for the last month and jump back into the E/M auditing this week.
    So I want to see if I'm looking at this right.

    Any input will be appreciated.

    Thanks
    Daniel, CPC

  2. #2
    Default I get a different 4
    Location: nose
    Timing: 1 week ago
    Associated S&S: (nose) bleed in the setting of HTN
    Duration: for about 6 years (HTN)

    I don't see running nose, only a nose bleed, and it says the patient doesn't have chest pain, which you can't use because it's a negative. The patient doesn't have it.

    I don't see meds as a modifying factor here because it doesn't say that the meds make anything better or worse. Again, with context, it's supposed to be what the patient is doing when the symptoms appear, not what they're not doing.

    That's my take. Anyone agree?

    Quote Originally Posted by daniel View Post
    Follow-up for HTN

    Pt. has had hypertension for about 6 years and reports taking his medications. Pt. had a nose bleed 1 week ago and took his blood pressure. Pt. found that his blood pressure has been running around 180s. No chest pain. No symptoms. Pt. does not have particular symptoms when the blood pressure is up. No blurred vision. No palpitations. Pt. reports not changing his diet recently.


    DUR: 1 week ago
    Modifying Factors: Taking medication
    Assoc. Signs and symptoms: Running nose, chest pain
    Context: does not have particular symptom when the blood pressure is up.


    I pulled this out 4 HPI for this scenario, but I've been doing Cardiology surgeries for the last month and jump back into the E/M auditing this week.
    So I want to see if I'm looking at this right.

    Any input will be appreciated.

    Thanks
    Daniel, CPC

  3. #3
    Location
    Lincoln, NE
    Posts
    44
    Default
    Here is my thoughts, since the patient was being seen for HTN, most of the HPI should releate to it.

    Dur: 6 yrs
    MF: taking Meds
    A S/S: BP around 180
    Loc: nose.

    Just my take on the note.

  4. #4
    Location
    North Carolina
    Posts
    3,126
    Default
    I think both of your views could be argued. HPI is so subjective. I could see why Belinda chose the nose bleed as part of her HPI. There are times when an elevation in blood pressure can create nose bleeds; especially with a severe elevation.

  5. #5
    Default Thank you
    Thank you for taking the time to give your input.

    Daniel, CPC.

Similar Threads

  1. pull info from previous days or no?
    By AmandaW in forum E/M
    Replies: 0
    Last Post: 12-09-2011, 11:07 AM
  2. Dx self pull intubation
    By millortsui in forum Anesthesia
    Replies: 0
    Last Post: 11-02-2011, 08:19 AM
  3. Pull diagnosis from the exam
    By Love Coding! in forum E/M
    Replies: 5
    Last Post: 07-11-2011, 01:38 PM
  4. Pull Back Pressures
    By mgord in forum Interventional Radiology
    Replies: 1
    Last Post: 01-30-2009, 12:01 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.