Wiki Need help with this

Create Wiki
Gemini18

Gemini18

Expert
Messages
324
Location
NYMAC, GMAC
Best answers
0
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
 
This is a detailed history. "Otherwise, as noted in HPI" is not the same thing as all others reviewed and negative. I agree with you, 6 is the max and I actually consider the allegeries as more of a past history in this case so I get 5.

2 gallons? Exactly how much blood is even in the human body? Anyway..

Laura, CPC, CEMC
 
lets see that is 2 pints to a quart and 4 quarts to a gallon so that would be 16 pints total.. really?? The average human body holds 8 pints of blood... Just how big is this 80 year old woman!
 
Here's what I get

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 (duration) history of recurrent bloody quality)stools. The patient states she thinks that over the past 24 hrs, she lost two gallons(severity) of blood in her stool. She also complained of left lower quadrant abdominal pain (Assoc Sign)and abdominal cramping(ROS GI) prior to evacuating her bowels. She denies any fever or chills.(ROS constitutional) Appetite has been normal. She is being admitted for further evaluation and workup.

ROS: Patient reports occasional chest painROS CV). She denies shortness of breath or coughROS Resp). She denies dysuriaROS GU). Otherwise, as noted in the HPI above. No nausea or vomiting.

Allergies: Penicillin and Latex ROS allergy)

Still not complete ...
F Tessa Bartels, CPC, CEMC
 
You must log in or register to reply here.
Top