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Coding Corner: Real-Life Rheumatology Note
Real-Life Rheumatology Note
Chief Complaint: Diffuse arthralgias.
History of Present Illness (HPI): This is a 46-year-old white female who comes in for consultation on her arthritis pain. She tells me that all of her joints are sore. Her hands are tingling and numb. She has been wearing carpal tunnel braces all of the time, which helps some of the numbness. They get numb very quickly and she tries to shake them out. They get numb at night. She has pain in her elbows, shoulders, knees, hips, and ankles. Her MCPs [metacarpophalangeals] and PIPs [proximal interphalangeals] hurt worse than her DIPs [distal interphalangeals]. She has a lot of right hip pain, particularly at night and with walking on the lateral aspect. This has been going on for at least a year. She also tells me that her knuckles have been swelling up at times. Tramadol has been helping with her pain, but has not been alleviating it completely. She has about an hour of stiffness in the morning prior to reaching baseline, but she remains stiff and in pain all day long. She feels very fatigued and weak. She has some trouble swallowing. No rashes, dry eyes, or dry mouth.
- Past Medical History: She has been told she has angina but no coronary artery disease. She had a nervous breakdown, bad headaches, hypothyroidism, anemia, stomach ulcers two months ago, and asthma.
- Past Surgical History: Hernia repair x2 and ankle fracture repair. She has also broken her left elbow.
- Social History: She quit smoking in January 2008. She has a 20-pack-year history. She does not drink alcohol or use any illicit drugs. She works in a warehouse, lifting a lot of boxes for 40 or more hours per week.
- Family History: Father is alive at age 68 and in fair health. Her mother passed away at age 61 from lung cancer and was a smoker. Her uncle has rheumatoid arthritis with deformities. No other known autoimmunity in her family.
- Current Medications: HCTZ 25 mg daily, metoprolol 12.5 mg daily, fluoxetine 20 mg daily, levothyroxine 50 meg daily, omeprazole 20 mg daily, albuterol inhaler, and tramadol.
- Allergies: Medication allergies—erythromycin, penicillin, and ampicillin all cause rash and throat closing.
- Review of Systems: Her review of systems also includes headaches, muscle spasms, frequent sore throats, easy bruising, chest pain, swollen lower extremities, wheezing, blood in her stools, heartburn, nausea, and stomach pain relieved by food or milk. She tells me she has a history of gastric ulcers. She has nocturia and anemia. The rest of her review of systems is otherwise negative.
Answer these questions about the history in this real-life rheumatology note:
- How many elements are listed in the history of present illness?
- What type of review of system is this?
- Problem focused
- Expanded problem focused
- This example shows the past medical, family, and social history; how often does this need to be updated?
- Once a year
- Whenever there is new information, otherwise the note can refer back to original documentation
- Never, once taken that is sufficient
- This must be documented each time the patient sees the physician
- Only the physician can take the HPI, review of systems (ROS), and past family and social history (PFSH) from the patient.
- There must be a chief complaint on every history.
- Can a chief complaint be recorded as a “follow-up”?