Gemini18
Expert
I got 6 elements for the ROS, yet its coded for a complete. I have Constitutional, GI, GU, Card/Vasc, Resp, Immun.
CC: Bloody Stools
HPI: Patient is an 80-year old femal with PMH of ischemic colits and multiple bouts of intermittent hematochezia who presents to the ED today with a 24-hour history of recurrent bloody stools. The patient states she thinks that over the past 24 hrs, she lost two gallons of blood in her stool. She also complained of left lower quadrant abdominal pain and abdominal cramping prior to evacuating her bowels. She denies any fever or chills. Appetite has been normal. She is being admitted for further evaluation and workup.
ROS: Patient reports occasional chest pain. She denies shortness of breath or cough. She denies dysuria. Otherwise, as noted in the HPI above. No nausea or vomiting.
Allergies: Penicillin and Latex
CC: Bloody Stools
HPI: Patient is an 80-year old femal with PMH of ischemic colits and multiple bouts of intermittent hematochezia who presents to the ED today with a 24-hour history of recurrent bloody stools. The patient states she thinks that over the past 24 hrs, she lost two gallons of blood in her stool. She also complained of left lower quadrant abdominal pain and abdominal cramping prior to evacuating her bowels. She denies any fever or chills. Appetite has been normal. She is being admitted for further evaluation and workup.
ROS: Patient reports occasional chest pain. She denies shortness of breath or cough. She denies dysuria. Otherwise, as noted in the HPI above. No nausea or vomiting.
Allergies: Penicillin and Latex