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This is a 67-year-old female with history of metastatic breast cancer since 2001 with severe bone pain that has worsened over the past several weeks. The patient presents now for further evaluation. PMH: Polycystic kidney disease. Long history of multiple chemotherapeutic regimens Left modified radical mastectomy 2001 SH: Nonsmoker, nondrinker EXAM: BP 120/80, respirations 18, pulse 72, afebrile HEENT: Normal Lungs: Clear Heart: Regular rate and rhythm Chest: S/P Mastectomy scar GI: Soft, nontender Extrem: Minimal edema Neuro: Normal Lab Studies within normal limits. CT and PET scan indicate bone mets. Patient underwent tunneled central venous catheter placement in chest with port without any complications. Chemotherapy was held to be performed on an outpatient basis. She was discharged on Day 3 stable for subsequent chemotherapy with diagnosis of metastatic bone from breast. Assign the principal diagnosis, additional diagnosis(es), and inpatient procedure(s) as appropriate. Principal ICD-10-CM code: Additional ICD-10-CM code(s): ICD-10-PCS Procedure:
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Earthquake Databases
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