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Pathology report confirms a malignant melanoma of the skin


Assignment Task:

Patient:  Harris, Everett

Date: 02/09/20XX

Attending Physician: Wyatt Williams, MD

Referring Physician: Jacob Lloyd, MD

S: Patient is a 48-year-old male, referred by Dr. Lloyd for a consultation regarding a sore on his right cheek. Patient states he spends a lot of time outside and rarely applies sunscreen.  Patient has not had any dermatologic concerns prior to this. Patient states his skin is occasionally dry and that he has adult onset acne

O: H: 5'11", Wt: 185lb., R:18, T:98.6.  After an examination of the skin along the face as well as along the hairline, a culture is taken of the lesion. The pathology report confirms a malignant melanoma of the skin of the cheek.

A: Malignant melanoma, cheek

P:

1. Discuss surgical and pharmaceutical options for treatment

2. Consultation report sent to Dr. Lloyd

Medical Decision Making is high.

Time: 45 minutes

CPT-4 code(s) and if applicable modifier(s):

Patient: Jones, Herald

Account:  JONHE001

Admit Date: 01/18/20XX

Date of Service: 01/18/20XX

Attending Physician: Jessica Elementary, M.D.

Location:  Onsee Community Hospital, PICU

This 3 year old male is admitted to the pediatric critical care. This is my initial evaluation and management of this critically ill patient. Mother claims onset of symptoms was sudden. She states that she rushed the child to the ED immediately.

Child is unresponsive. Respiration is shallow.  B/P 85/60 mmHg, T 102.

CPT-4 code(s) and if applicable modifier(s): Looking for Online Tutoring?

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Other Subject: Pathology report confirms a malignant melanoma of the skin
Reference No:- TGS03450748

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