HPI help please

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Shoshana
Posts: 85
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Wed May 30, 2018 11:41 am

"Patient is a 339 yo lady with a history of multiple prior miscarriages less than 10 weeks who presents in clinic to establish care for futher evaluation and management of elevated anticardiolipin antibody. She is recently had a miscarriage. Her primary gynecologist performed an extensive workup including hypercoagulable panel rheumatologic panel and antiphospholipid antibody panel results of the antiphospholipid antibody panel were negative for lupus anticoagulant. Results of the beta-2 glycoprotein IgG and IgM were within normal limits. Results of the anticardiolipin antibody IgG was normal. Results of the anticardiolipin antibody IgM was elevated at 17. This places this value in the indeterminate range." (typed as written on note).

I am seeing recently (timing), miscarriage (context) and elevated anticardiolipin antibody IgM (associated signs and symptoms).

Am I missing anything that would give them a 4th element?
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admin
Site Admin
Posts: 448
Joined: Mon Apr 09, 2012 1:54 pm

Thu May 31, 2018 10:53 am

We don’t have much to work with here. I would suggest educating the provider that results are best placed elsewhere to keep the focus of the history on HPI/ROS/PFSH. Let’s break it down- the patient is here for multiple prior miscarriages as our chief complaint. So our HPI should define “symptoms” that have impacted that so to say.

Multiple- I think this demonstrates quality. It defines the “worsening” tone of the problem.
<10 weeks- typically I would only give duration for the how long the patient has had their problem, but in this case knowing that the typical pregnancy only has a duration of 10 weeks is HUGE in treating this patient. So I would give duration.
Elevated Antibodies- I would prefer that the documentation better indicate that the elevated antibodies are the perceived root of the problem, hence the consult, but I think we can loosely identify that. Therefore if this is what is causing the problem I would surmise it to be considered context.
Recently- I would, again, typically categorize this word more with duration, but we identified that she has had multiple miscarriages and now a recent one- I do think that demonstrates timing.

This is a tough one, and at first I was thinking there's not much to work with, but I think it is due to how it is being documented- so choppy and less telling a story about the patient and more about hitting the bullets.

Your question has been answered by Shannon O. DeConda, CPC, CEMC, CEMA, CPMA, CRTT
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