Please identify the level of HPI, the documented HPI elements and ...

[Cooldude101]

Please identify the level of HPI, the documented HPI elements and the respective, supporting findings. How does the documented HPI provide greater information about the CC?
 
  HPI: 68-year-old male presents to the Emergency Department with a four-day history of loose stools. Patient states that over the past several days he has had at least six to 10 loose, watery stools per day. No hematochezia or melena. He denies any fever or abdominal pain. No chest pain, shortness of breath, or peripheral edema. Did see his primary care physician several days ago, who increased his metoprolol to 100 mg daily.
  PMH:
  1. Coronary artery disease, status post CABG 2002
  2. Sternal osteomyelitis, status post CABG
  3. Gout
  4. Chronic renal insufficiency, baseline creatinine 2.0
  5. Ischemic cardiomyopathy, last echocardiogram 5/21/2012, EF 32
  6. Peripheral neuropathy
  7. Diabetes Mellitus, type II (noninsulin dependent)
  8. Hypertension
  9. Appendiceal abscess, hospitalized 3/2010 to 4/2010, treated by conservative medical management only
  10. Mild COPD
  ROS: As per HPI.
  Medications:
  1. Metoprolol ER 100 mg by mouth daily (dose increased three days ago)
  2. Amitriptiline 25 mg by mouth at night
  3. Plavix 75 mg by mouth daily
  4. Aspirin 81 mg by mouth daily
  5. Lisinopril 20 mg by mouth daily
  6. Spirinolactone 25 mg by mouth daily
  7. Lasix 40 mg by mouth daily
  8. Colchicine 0.6 mg by mouth daily
  9. Simvistatin 20 mg by mouth every night
  10. Glipizide 10 mg by mouth daily
 
  What will be an ideal response?

Question 2

Why do you think the requirements for the comprehensive type 1995 physical examination are specific?
 
  What will be an ideal response?

[dajones82]

Answer to Question 1

HPIExtended:
Duration-Four day history
Timing: Six to 10 stools per day
Quality: Watery stools
Assoc s/s: No melena

The documented HPI describes the CC (loose stools) with greater clarity. The patient has not only had loose stools, but multiple loose stools per day that are not only loose, but also watery stools for four days. This indicates the severity of the loose stools, but the fact that the patient has no melena (blood in stool) provides a certain parameter for the severity of the CC.

Answer to Question 2

By distinguishing between the organ systems and body areas, the comprehensive physical examination documents a thoroughly holistic assessment of the patient's physiology. Since there are twelve organ systems, the documentation of eight organ systems represents more than two-thirds of the human anatomy. Likewise, as there are seven body areas, one of which represents four extremities, eight body areas represents almost  of the human anatomy. Also, since the comprehensive physical examination represents a nature of presenting problem with a high severity of risk, this type of physical examination should clearly document a thorough assessment of the patient's physiology.