POA , ICD-10-CM CODE Case #1 The

POA , ICD-10-CM CODE Case #1 The following documentation is from the health record of a 71-year-old female patient. Discharge Summary: History of Present Illness: This patient is a 71-year-old woman with carcinoma of the right breast. She was admitted for re-excision of the right breast mass and right axillary dissection with mirror image biopsy of the left breast. The patient has a history of hypertension, COPD, and heavy smoking. She was in her usual state of health until December, when she noted a lump in her right breast that was painless, without discharge, and without retraction. Mammography was reportedly within normal limits. The patient was followed closely. During recheck in July, a repeat mammography revealed a mass in the right breast with calcifications. The patient underwent an excisional biopsy of the right breast mass, which was positive for in situ intraductal and lobular carcinoma. The initial biopsy specimen showed a positive margin. The patient is therefore admitted at this time for extended excision of the right breast. Mirror image biopsy of the left breast and a right axillary lymph node resection are also to be done. The patient had menarche at age 12 and has given birth to a single child. The patient has no family history of breast carcinoma. Past medical history: positive for hypertension and chronic obstructive bronchitis. Medications include: Aldomet, 250 mg p.o. bid; Dyazide, one p.o. bid; Theo-Dur, Premarin, and Provera. Physical Examination: Examination revealed a well-developed, well-nourished female in no apparent distress. The vital signs are stable, afebrile. The HEENT examination is within normal limits. The neck is supple, the trachea is midline. There are no masses or adenopathy present. The lungs are clear to auscultation and percussion. The cardiovascular examination is within normal limits. The right breast shows a contusion with overlying skin incision and surrounding erythema. The left breast is within normal limits. The left axilla is normal without adenopathy. The right axilla reveals small (less than 1 cm), nonfixed, not matted lymph nodes. The abdominal examination is within normal limits. The rectal examination is normal, with guaiac negative stool present in the vault. Hospital Course: After adequate preoperative preparation, the patient was taken to the operating room. The right breast excision was performed with right axillary lymph node excision. A left breast local excision was performed for the indication of lobular carcinoma in situ of the right breast. The patient’s postoperative course was complicated by a postoperative infection of the wound due to Staphylococcus aureus which was methicillin suspectible. This was treated with IV antibiotics, and she improved. The patient was also noted to have developed a urinary tract infection secondary to E. Coli during the hospitalization. This was also treated with IV antibiotics. The UTI was improved prior to discharge. The patient is discharged with a large Jackson-Pratt in place, continuing to drain from the right axilla. She is on a regular diet. The patient will be followed up in the general surgery clinic. Pathology: small residual of intraductal lobular carcinoma, right breast. Negative nodes in right breast. She will also continue completing the course of antibiotics. Final Diagnoses: Carcinoma right breast Chronic bronchitis Hypertension UTI

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."