Get Answer: History Present Illness Question Guide
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Original Question
History of Present Illness: This patient is a 53-year-old Caucasian female with a past medical history significant for autoimmune disorder including systemic lupus erythematosus, Sjogren’s syndrome, autoimmune hepatitis, Hashimoto’s thyroiditis, and Factor V Leiden Mutation, who presents with a concern of worsening low back pain and difficulty in ambulation. The patient had multiple back problems before. She follows up with neurosurgeon and has been following up for quite some time. The patient, because of her difficulty ambulation and difficulty in climbing upstairs, was electively scheduled for laminectomy and fusion of her lumbar spine. The patient did undergo the procedure today. Currently, the patient is back in her room. However, the patient is quite uncomfortable in the chair, complaining of significant amount of pain, having her pain medications and not really taking care of it. She denies that she is having any chest pain or shortness of breath. No lightheadedness or dizziness. However, she is complaining of severe excruciating back pain. The patient did not have any bowel movements yet at this point. We were asked to see this patient in consultation for medical management. Past Medical History: Asthma, Factor V Leiden Deficiency, previous DVTs and PEs, on Coumadin that was held for the procedure, endometriosis, rheumatoid arthritis, coronary artery disease, SLE, Sjogren’s syndrome, autoimmune hepatitis, and Hashimoto’s thyroiditis. Past Surgical History: Past surgical history is significant for cholecystectomy, total abdominal hysterectomy, gastric bypass surgery, thyroidectomy, and ventral hernia repair. Medications: Synthroid 100 mcg daily, Neurontin 600 mg three times daily, methadone 10 mg every 6 hours, prenatal vitamins one capsule daily, Proventil two puffs inhalation every 4 to 6 hours, ferrous sulfate 325 mg twice daily, aspirin 325 mg daily, lisinopril 2.5 mg daily, metoprolol 25 mg twice daily, and Coumadin 5 mg daily, Lotemax eye drops, Remicade infusion. Allergies: Penicillin, Levaquin, erythromycin, and Zofran. Family History: Noncontributory. Social History: The patient denies alcohol, tobacco or illicit drug use Review of Systems: A 14-point review of systems was done. negative findings are as per History of Present Illness. Vital Signs: Temperature: 97°F Pulse: 80 Respirations: 20 Blood pressure: 120/69 Oxygen saturation: 95% on room air Physical Examination: HEENT: Normocephalic and atraumatic. Extraocular muscles are intact. NECK: Supple. LUNGS: Bilateral air entry. No wheezes or rhonchi heard. HEART: Normal S1 and S2 with no murmur, rubs or gallops. ABDOMEN: Soft and nontender with hypoactive bowel sounds. BACK: Back examination reveals a surgical dressing over her lumbar spine. EXTREMITIES: No cyanosis or clubbing. NEUROLOGICAL: The patient does not show any focal deficits. neurological examination has been limited. Laboratory Data: There is no laboratory values as of yet. Assessment Low back pain, status post lumbar laminectomy and fusion.* History of deep vein thromboses and pulmonary emboli, on Coumadin, currently was held. Last INR over a week ago was 1.** Autoimmune disease including systemic lupus erythematosus, RA, Sjogren’s, autoimmune hepatitis and Hashimoto’s thyroiditis.***** Asthma.* CAD.* Plan: Continue postsurgical care management and pain control which is going to be per primary team. We will resume the patient’s home medications. We will check her TSH and will resume her Synthroid at this point. We will hold on any anticoagulants and antiplatelet therapy at this point until cleared by Surgery. We will recommend the patient to be seen by a pain specialist in regard to her high tolerance and potential for toxicity because the patient has been on methadone 10 mg every 6 hours. what is the correct evaluation and management codes
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