Coding ICD HPI: The patient is a 65-year-old male, established…
Question Answered step-by-step Coding ICD HPI: The patient is a 65-year-old male, established… Coding ICDHPI: The patient is a 65-year-old male, established patient, here today with his daughter for depression and forgetfulness. History if obtained from both daughter and patient. He has had depression for several years and has been compliantly taking his medication regimen. Daughter reports increasing forgetfulness over the past few months. She states he has been repeatedly losing his keys, forgetting to pay bills, and not dressing appropriately for weather). The patient reports he has noticed some of these symptoms but thought “I was just getting older.” He denies any recent stressors or changes in his routine. He reports sleeping well at night. He does state he has not been paying as much attention to his wood working hobby as he would like. Past Family/Social History: Widowed, wife died 4 years ago, current lives alone with his daughter within driving distance. He does not have a current driver’s license. Mother – history of Alzheimer’s age 66, died age 73 Father – history of heart disease, fatal MI age 50 ROS: denies any sleeping problems. Denies any anger or aggression, headaches, dizziness, recent falls, weakness, blurred vision, seizures, SOB, CP, or fever/chills/sweats Physical Examination: Appearance: appropriate dress, appears stated age, good eye contact Muscle strength and tone: normal. Normal gait. Speech: Normal rate and tone; though process: logical with some mild pauses; Associations: intact; Thought content: no SI/HI or psychotic symptoms; Alert and oriented x3; attention and concentration: unable to focus on serial 7s; Mood and affect: euthymic and appropriate; recent and remote memory: mild struggle with telling history and remember 1/3 objects – MINI MENSTAL STATUS EXAM 24/30 Assessment: _____ Depression, stable _____ Mild cognitive impairment, new Health Science Science Nursing NURS 605 Share QuestionEmailCopy link Comments (0)
