History Present Illness Question & Answer Guide (With Explanation)

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What This Question Is About

This question relates to history present illness and requires a structured academic response.

How to Approach This Question

Structure your response with introduction, analysis, and conclusion.

Key Explanation

This topic involves history present illness. A strong answer should include explanation, application, and examples.

Original Question

History of present illness: This 70-year-old female with a past history of endometrial carcinoma was admitted to the medical oncology unit for a blood transfusion. The patient complains of melena on and off for the past 2 months. She has no changes in her bowel movements, no diarrhea or constipation, and no nausea or vomiting. There is mild abdominal pain in the lower part of the abdomen, no radiation, and the patient is relieved by analgesics. Endometrial carcinoma, stage 2, was diagnosed in November of last year. Status post radiation therapy externally and internally in January. CT scan of the abdomen in March showed a decrease in the size of the mass, the patient had a total abdominal hysterectomy and bilateral salpingo-oophorectomy at that time. The patient presented 1 month ago with GI bleeding, which was thought to be secondary to radiation colitis, but proctoscopy revealed a necrotic mass in the anterior wall. Biopsy was negative times two. There is a 6-year history of hypertension, and a 10-year history of type 2 diabetes mellitus. Medication: Nifedipine, 90 XL once a day; Tolbutamide, 500 mg once a day. No alcohol. The patient smokes one pack of cigarettes per day. Physical examination: Alert and oriented in no active distress. Blood pressure 100/60. HEENT: pale conjunctiva. Neck supple, no lymphadenopathy. The lungs were clear to auscultation, resonant to percussion. Heart regular rate and rhythm, no murmurs, no S3. Abdomen soft; there is tenderness in the lower parts; no hepatosplenomegaly. The bowel sounds are positive. Rectal positive for heme. Extremities +2 edema in the left more than the right. Laboratory data: Hemoglobin 6.7, hematocrit 20.8, white blood cells 9.7, neutrophils 81, lymphocytes 14, and monocytes 4; eosinophils 1. Platelet count 448,000. Sodium 142, potassium 4.8, chloride 108, C02 21, BUN 40, calcium 8.2, phosphorus 3, magnesium 1.4 and glucose 123, SGOT 50, alkaline phosphatase 137, SGPT 42, albumin 2.0; total bilirubin 0.3, direct bilirubin 0. PT 11.7, PTT 27.6. Hospital course: Problem #1: Lower GI bleed. The patient presented 2 months ago with lower GI bleed, which was most likely secondary to radiation therapy. At that time, proctoscopy was done and showed necrotic mass in the anterior wall of the rectum. Biopsy was also done and was negative. Proctoscopy was repeated and was negative the second time. For current admission, the patient presented with the same complaint. Hemoglobin level was 6.7; hematocrit level was 20. The patient was transfused with 4 units of packed red blood cells. Hemoglobin level rose to 14.2, hematocrit level to 41.8, and the patient was stabilized. GI staff were contacted regarding repeating proctoscopy. Their suggestion was to discharge and follow her in the GI clinic. Problem #2: Endometrial carcinoma, status post radiation therapy, status post resection. No further therapy now. Problem #3: Anemia, secondary to lower GI bleed Problem #4: Type 2 diabetes mellitus, which is stable on Tolbutamide, 500 mg once a day. This medication was continued during this hospital and patient was also given a diabetic diet during this stay. Problem #5: Hypertension, which is stable on Nifedipine, 90 XL once a day. Her blood pressure was monitored closely every 4 hours during this hospital admission. Problem #6: Increased creatinine and BUN, which was not corrected after the hydration. On discharge, creatinine was 3.2 and BUN was 39. Testing will be repeated as an outpatient. The patient is known to have increased creatinine and BUN, most likely secondary to hypertension. The patient was discharged home in stable condition to be followed up in Oncology. Discharge medications; Nifedipine, 90 XL, once a day; Tolbutamide, 500 mg once a day. Final diagnosis; Lower gastrointestinal bleeding secondary to radiation colitis. Codes Assigned: Principal DX: K92.1 Additional Diagnoses Codes: Z85.42, E11.9, F17.200 Do you agree with the ICD-10-CM codes assigned? If not, what ICD-10-CM codes should be assigned? Per the clinical information, are they any ICD-10-PCS codes that should be assigned? If so, what? Do you have any concerns/issues for a physician query?

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