Subjective: Joy is a 42-year-old female here today for her 6-month follow-up for skin evaluation. She has a history of a
Posted: Thu Mar 31, 2022 8:13 am
Subjective: Joy is a 42-year-old female here today for her
6-month follow-up for skin evaluation. She has a history of actinic
keratosis treated with liquid nitrogen 6 months ago and 1 year ago.
Her mother went through menopause at an early age. She believes her
menstrual period is becoming very irregular, long, heavy and
cramping. She is no longer on oral contraceptives. She sees Dr.
Abbey as her gynecologist. She is on Humira which causes worsening
of her menstrual periods and she believes even more bleeding.
She has some tag-like spots along the neckline that get caught
and irritated on clothing and get very itchy at times. She would
like them removed.
Allergies: codeine and iodine
Physical examination: Physical examination reveals dilated
telangiectatic vessels across the malar eminence; an inflammatory
pink papule present on the right chin; some stuck-on appearing waxy
tan papules present on the face, neck, chest and abdomen, back and
upper extremities. The left shoulder has a stuck on appearing waxy
tan papule with slight erythema. There are tag-like pedunculated
skin-colored papules present along the neckline numbering five. The
left check is clear.
Assessment and plan:
CPT: _______________ ______________ _______________
(code listed first should be the evaluation and management
code).
Diagnoses: (ICD-10-CM) __________________ ___________________
__________________
6-month follow-up for skin evaluation. She has a history of actinic
keratosis treated with liquid nitrogen 6 months ago and 1 year ago.
Her mother went through menopause at an early age. She believes her
menstrual period is becoming very irregular, long, heavy and
cramping. She is no longer on oral contraceptives. She sees Dr.
Abbey as her gynecologist. She is on Humira which causes worsening
of her menstrual periods and she believes even more bleeding.
She has some tag-like spots along the neckline that get caught
and irritated on clothing and get very itchy at times. She would
like them removed.
Allergies: codeine and iodine
Physical examination: Physical examination reveals dilated
telangiectatic vessels across the malar eminence; an inflammatory
pink papule present on the right chin; some stuck-on appearing waxy
tan papules present on the face, neck, chest and abdomen, back and
upper extremities. The left shoulder has a stuck on appearing waxy
tan papule with slight erythema. There are tag-like pedunculated
skin-colored papules present along the neckline numbering five. The
left check is clear.
Assessment and plan:
CPT: _______________ ______________ _______________
(code listed first should be the evaluation and management
code).
Diagnoses: (ICD-10-CM) __________________ ___________________
__________________