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Nancy Posted Tue 12th of April, 2011 12:52:38 PM

Could someone tell me what elements you see in this HPI. We are having alittle disagreement and I need help.
HPI: Rreview of labs in detail with the patient. Cholesterol is clearly elevated, blood sugar mildly elevated. Thyroid levels are stable.
Due for GYN yearly physical. Has not scheduled yet.
Allergic rhinitis is stable however worse during spring and fall.
Thanks for the help.

Nikhil Answered Tue 12th of April, 2011 17:39:11 PM

Seems to me Counting by elements of HPI, "stable however worse during spring and fall" is modifying factors making it BRIEF. But, you have told Review of Labs in detail with the patient... in the HPI section starting. So, I would like to analyze in a different way.

That this is an establised pt, who is constantly monitoring and following up his/her "cholesterol is elevated: Hypercholesterolemia, Blood sugar mildly elevated: Diabetic condition monitoring, and Thyroid levels .

Status of three chrnic conditions received from past medical history would contribute to HPI: DETAILED.

Plz share your thought.

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