70. 2/5/XX JACOB BOND, MD Patient is seen today in the clinic at the request of Dr. Adams for evaluation of suspicious l

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70 2 5 Xx Jacob Bond Md Patient Is Seen Today In The Clinic At The Request Of Dr Adams For Evaluation Of Suspicious L 1 (74.84 KiB) Viewed 48 times

70 2 5 Xx Jacob Bond Md Patient Is Seen Today In The Clinic At The Request Of Dr Adams For Evaluation Of Suspicious L 2 (30.29 KiB) Viewed 48 times

70. 2/5/XX JACOB BOND, MD Patient is seen today in the clinic at the request of Dr. Adams for evaluation of suspicious lump in the left breast. Patient states that she does not practice self-breast examination and therefore was unaware of the existing lump. She does state, however, on reflection, that the left breast at times was painful. No nipple discharge or puckering has been noted. Patient states that she has a sister who died of breast cancer in her mid-thirties. No other family history for cancer was noted. EXAMINATION: Both breasts seem to be symmetrical. No abnormal findings on first view, right breast examination benign. Left breast identifies small lump where calcifications were noted on mammography. ASSESSMENT: Left breast mass. PLAN: Although it is difficult to say that this is not a single cyst, I would recommend a breast biopsy at patient's earliest convenience to rule out any possible malignancy. Options to include conservative measures of waiting for further signs, repeat mammography, 6-month breast checks were discussed with patient as well as risks and benefits of biopsy and possible mastectomy if findings are positive. Patient wishes to discuss with her husband and will let me know what she decides. Thank you for asking me to consult on the care of Mrs. Smith. My recommendations are as above. I will await her further decision if she wishes further care from a surgical standpoint.
2. Explain why you chose the ICD-9/ ICD-10 and CPT code for each answer. 3. Focus on why you chose the answer and the function of each body system or body part. 4. The purpose of this discussion is to think about the case and add a meaningful, useful response.