WHAT WOULD THE ICD-10 DIAGNOSES CODES BE FOR THIS PATIENT? PATIENT: ACCOUNT/EHR #: Attending Physici

WHAT WOULD THE ICD-10 DIAGNOSES CODES BE FOR THIS PATIENT? PATIENT: ACCOUNT/EHR #: Attending Physician: HPI:KAHN, SERENA KAHNSE001DATE: 09/16/18Oscar R. Prader, MD  This patient is being admitted to Weston Hospital for wide excision of a level 2 melanoma, right side of the face. She was referred from Dr. Robinson. Patient states she has had the lesion forever. Dr. Robinson found it disturbing and decided to take a biopsy; results, melanoma, level 2. This lesion is located just anterior to the ear on the right zygomatic region; we should get a reasonably good margin. PAST MEDICAL HISTORY: Hypothyroidism and takes thyroid replacement medication. PAST SURGICAL HISTORY: The patient had carcinoma of the breast and underwent a left mastectomy in 2012. She had a hysterectomy for benign ovarian tumors in 2015. ALLERGIES: NKA SOCIAL HISTORY: Nonsmoker. Drinks alcohol socially. FAMILY HISTORY: The patient’s sister is diabetic. ROS: Negative. PHYSICAL EXAMINATION: Ht: 5’6″, Wt: 142, T: 98.6, R: 18, BP 170/70. HEENT: Head is atraumatic, normocephalic; there is a pigmented lesion just anterior to the right ear over the zygomatic region, which is slightly irregular in shape and different shades of brown. Biopsied site is noted and healing within normal limits. NECK: Negative. CHEST: Clear and symmetrical HEART: Regular rhythm, no murmurs ABDOMEN: Soft, nontender, no masses or organomegaly EXTREMITIES: No cyanosis, clubbing, or edema NEUROLOGIC: Grossly intact IMPRESSION: Melanoma of the right cheek, level 2 PLAN: Wide excision with flap advancement closure ORP/pw D: 09/16/18 09:50:16 T: 09/18/18 12:55:01 Health Science Science Nursing HIS 115 Share QuestionEmailCopy link Comments (0)

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