🔬 DermSpX

note (synthesized)

- **Patient Information:**
  - Name: Brian Zielinski
  - DOB: 03/07/1959
  - MRN: 43198
- **Past Medical History:**
  - ID=48469
  - Reason=scan, wait
  - Location=Entire body
  - BloodThinning=yes
- **Family History:**
  - ID=10003452
  - Diabetes=yes
- *Source: 0 extracted path events; 0 pathology PDFs on file. CSC pipeline data: see surveillance section above.*

rx (synthesized)

- **Active Medications:**
  - Rosovasti  — 10 — Once daily

code (synthesized)

- **Recent ICD/CPT Codes:**
  - **2024-04-24:**
    - ICD: D22.9 Melanocyte is Nevi unspecified, D22.9 Melanocyte is Nevi unspecified
    - CPT: 99203 Office Visit, 96904 Whole Body Photography

note (existing — what Dermatoscan reads now)

**Patient Information:**
- Age: 65 years old
- Gender: Male
- Marital Status: Married
- Occupation: Sales
- Date of Birth: March 7, 1959
- Height: 5'10"
- Weight: 190 lbs
- Hair Color: Brown
- Eye Color: Blue

**Medical History:**
- Current Medication: Rosuvastatin 10 mg once daily for cholesterol
- Allergies: No known drug allergies (NKDA)
- Anticoagulants: Yes (NSAIDs, Vitamin E)
- Family Medical History: Mother has diabetes; no family history of skin cancer
- Personal Medical History: No past medical history reported
- Smoking: Non-smoker
- Sun Exposure: No significant sun exposure reported
- Skin Cancer Risk: Low (Score of 9)
- Personal History of Skin Cancer: None

**Key Visits:**
- Date: April 24, 2024
- Purpose: Baseline total body skin examination

**Doctor's Findings:**
- A comprehensive total body skin examination was performed, including scalp, ears, eyes, nose, face, lips, neck, chest, abdomen, arms, hands, axillae, groin, buttocks, thighs, legs, ankles, feet, and soles.
- The patient has over 100 nevi, none of which show significant atypia such as intermixed colors, border irregularity, or asymmetry, and are not suggestive of melanoma upon dermatoscopy.
- Impression: Nevomelanocytic skin lesions
- Additional Findings: Solar lentigoes on the right forehead and dorsal hands, high-risk nevi, and a potential risk for melanoma due to the spouse's history of multiple melanomas.

**Plan:**
- The patient was educated on performing monthly self-examinations.
- A follow-up appointment is scheduled in 12 months for another comprehensive skin examination.
- Plan to rescan in six months and treat solar lentigoes.

rx (existing)

code (existing)

The record pertains to a patient visit with dermatologist Dr. Drugge, which was documented on April 24, 2024. During this visit, the patient was diagnosed with melanocytic nevi, unspecified, as indicated by the ICD code D22.9. This diagnosis was recorded twice, suggesting that it may have been noted for different locations or instances. No additional ICD codes were provided for this visit.

In terms of procedures, two CPT codes were recorded. The first CPT code, 99203, corresponds to an office visit, which typically involves a detailed examination and evaluation of a new patient. The second CPT code, 96904, indicates that whole body photography was performed. This procedure is often used in dermatology to document the skin's condition, particularly for monitoring changes in moles or other skin lesions over time.

Overall, the visit focused on the evaluation and documentation of melanocytic nevi, with the use of whole body photography to aid in monitoring the patient's skin health.

Provenance