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PIISA 12

The patient has a history of dysphagia and underwent a gastrostomy tube placement due to severe oropharyngeal dysphagia secondary to a stroke. The patient presents with localized erythema, tenderness, and purulent discharge at the gastrostomy site. There are no signs of hemorrhage, colostomy malfunction, or enterostomy complications. Wound culture from the gastrostomy site shows the presence of Staphylococcus aureus, indicating a localized infection. Other complications of gastrostomy (ICD-10-CM code K9429): The patient presents with localized erythema, tenderness, and purulent discharge at the gastrostomy site, consistent with a localized infection. The patient's symptoms are indicative of a localized infection at the gastrostomy site. No signs of hemorrhage, colostomy malfunction, or enterostomy complications are noted. The patient was started on oral antibiotics targeting Staphylococcus aureus, and local wound care was initiated. The gastrostomy tube was not removed as there were no signs of tube dislodgement or malfunction. The patient responded well to treatment, with resolution of symptoms and signs of infection. The patient was discharged with a course of antibiotics and instructions for wound care. 68 Female Caucasian ICD Code: K9429

The patient has no history of gastrointestinal or bariatric procedures, skin abscesses, or other dermatological conditions. The patient presents with a localized skin rash on the face characterized by redness, itching, and honey-colored crusts. Skin swab culture confirmed the presence of Staphylococcus aureus. Impetigo, unspecified. The diagnosis is based on the presence of honey-colored crusts and vesicles on the face, along with a positive skin culture for Staphylococcus aureus. The patient's skin lesions are consistent with impetigo, a superficial bacterial skin infection commonly caused by Staphylococcus aureus or Streptococcus pyogenes. The patient was started on oral antibiotics (e.g., cephalexin) and advised to practice good hygiene to prevent the spread of infection. The patient responded well to treatment and was discharged with a prescription for a full course of antibiotics. Follow-up in one week is recommended to monitor the progress. 38 Female Caucasian ICD Code: L0100

The patient has no history of gastrointestinal surgeries or bariatric procedures. There is no history of abscesses or skin infections. The patient presents with honey-colored crusts on the face and extremities, which are classic signs of impetigo. There are no symptoms suggestive of enterostomy complications or cutaneous abscesses. Skin swab culture confirmed the presence of Staphylococcus aureus, consistent with impetigo. Blood tests show no signs of systemic infection. Other impetigo (L0109): The patient presents with honey-colored crusts on the face and extremities, consistent with the diagnosis of impetigo. The patient's skin lesions are localized, with no signs of deeper tissue involvement. There are no findings to suggest an enterostomy infection or cutaneous abscesses. Prescribed topical mupirocin ointment for application three times a day for ten days. Advised on proper hand hygiene to prevent the spread of infection. The patient responded well to treatment, with the lesions healing appropriately. Discharged with instructions for follow-up in one week if any new lesions develop. 42 Female Caucasian ICD Code: L0109

The patient has a history of mild eczema on the face but no previous history of abscesses. The patient presents with a painful, swollen, and warm lump on the right side of the face. The lump is tender to touch and has been gradually increasing in size over the past week. The patient reports no fever or systemic symptoms. Physical examination reveals a fluctuant, erythematous nodule on the right cheek consistent with an abscess. No imaging studies were performed as the diagnosis was clear clinically. Cutaneous abscess of face (ICD-10-CM code L0201): 'Abscess of face' is assigned to code L0201 in ICD-10-CM. The patient's presentation is consistent with a cutaneous abscess of the face. No signs of cellulitis or deeper tissue involvement were noted. Incision and drainage were performed, and the patient was started on oral antibiotics. Incision and drainage of the abscess were performed under local anesthesia. The patient was prescribed a 7-day course of oral antibiotics and instructed on wound care. The patient responded well to treatment, with decreased swelling and pain at the site of the abscess. The patient was discharged home with oral antibiotics and wound care instructions. 42 Female Caucasian ICD Code: L0201

The patient has a history of occasional skin infections but no chronic skin conditions or recent surgeries. The patient presents with a swollen, tender, warm, and erythematous area on their back. They complain of localized pain and report no systemic symptoms like fever or chills. Physical examination reveals a fluctuant mass on the back consistent with an abscess. No imaging studies are performed as the diagnosis is clear clinically. Cutaneous abscess of back [any part, except buttock]. On examination, a 5 cm fluctuant mass with surrounding erythema and warmth is noted on the patient's upper back. No signs of cellulitis or deeper tissue involvement are present. Incision and drainage of the abscess are performed under local anesthesia. The wound is packed, and the patient is prescribed a course of oral antibiotics. The patient responded well to treatment, with decreased pain and swelling. They are advised to follow up if any signs of infection reoccur. 45 Female Caucasian ICD Code: L02212

The patient has a history of recurrent skin infections but no history of bariatric procedures or gastrostomy. The patient presents with a painful, swollen area in the groin, with redness and warmth upon touch. There is no mention of symptoms related to other body parts. Physical examination shows a fluctuant mass in the groin area consistent with an abscess. No imaging studies are performed as the diagnosis is clear clinically. Cutaneous abscess of groin (ICD-10-CM code L02214) - A localized collection of pus in the groin area, typically caused by a bacterial infection. The patient presents with a painful, swollen area in the groin, consistent with a cutaneous abscess. The patient reports tenderness and warmth in the groin area. On examination, a fluctuant mass is palpated, confirming the presence of an abscess. No signs of impetigo or abscess in other body parts are noted. Incision and drainage of the abscess are performed. The patient is started on a course of antibiotics to treat the infection. Proper wound care instructions are given. The patient responded well to treatment, with decreased pain and swelling. Discharge instructions include completing the antibiotic course and monitoring the wound for signs of infection. 42 Male Caucasian ICD Code: L02214

The patient has a history of type 2 diabetes mellitus and obesity. The patient presents with localized swelling, erythema, and tenderness in the perineal area. There is no associated fever or systemic symptoms. Physical examination reveals a fluctuant mass in the perineal region consistent with an abscess. No imaging studies were performed as the diagnosis was clear clinically. Cutaneous abscess of perineum. Verbatim_EHR_quote_justifying_the_code: 'The patient presents with a localized abscess in the perineal region, characterized by swelling, erythema, and tenderness. Physical examination findings are consistent with a cutaneous abscess.' The abscess was incised and drained under local anesthesia. Pus was evacuated, and the wound was packed. The patient was educated on wound care and signs of infection. Incision and drainage of the abscess, wound packing, and prescription of oral antibiotics. The patient was discharged in stable condition with instructions for wound care and a follow-up appointment in one week. 45 Male Caucasian ICD Code: L02215

The patient has a history of recurrent skin infections and has previously been treated for cellulitis and furuncles. The patient presents with a painful, swollen, and erythematous lesion on the right buttock. The area is warm to touch, and the patient reports tenderness upon palpation. Physical examination reveals a fluctuant mass consistent with an abscess. No systemic signs of infection are noted. Cutaneous abscess of buttock (ICD-10-CM code L0231): A cutaneous abscess is a localized collection of pus within the dermis or subcutaneous tissues. It presents as a tender, erythematous, and fluctuant nodule. The buttock is a common site for abscess formation due to hair follicles and sweat glands, making it prone to bacterial infections. The patient's clinical presentation is consistent with a cutaneous abscess of the buttock. The lesion is likely a result of a localized skin infection. Incision and drainage are recommended to expedite the healing process and alleviate the patient's symptoms. The patient underwent incision and drainage of the abscess under local anesthesia. The wound was irrigated, and appropriate wound care instructions were provided. The patient was prescribed oral antibiotics to prevent secondary infection. The patient was discharged in stable condition with instructions for wound care and antibiotic therapy. Follow-up in the outpatient setting was recommended to monitor the healing process and ensure resolution of the abscess. 45 Female Caucasian ICD Code: L0231

The patient has no history of immunodeficiency disorders or chronic skin conditions predisposing to recurrent skin infections. The patient presented with a painful, erythematous swelling in the right axilla, measuring approximately 5 cm in diameter. The swelling was warm to touch and tender. Ultrasound of the right axilla revealed a well-defined fluid collection consistent with an abscess. Cutaneous abscess of right axilla (L02411): A localized collection of pus in the skin and subcutaneous tissue of the right axilla, typically caused by bacterial infection, presenting with erythema, warmth, and tenderness. Verbatim EHR quote justifying the code: 'The patient has a 5 cm painful, erythematous swelling in the right axilla, consistent with a cutaneous abscess. Ultrasound confirmed the presence of a fluid collection.' On examination, the patient had no signs of systemic infection or lymphadenopathy. There were no other cutaneous lesions or abscesses noted on the body. Incision and drainage of the abscess were performed under local anesthesia. The wound was packed, and the patient was prescribed a course of oral antibiotics. The patient responded well to treatment with resolution of symptoms. Discharge instructions included wound care and completion of the antibiotic course. 42 Female Caucasian ICD Code: L02411

The patient has a history of occasional skin infections but no prior history of abscesses in the upper limbs. The patient presented with a swollen, erythematous, and tender area on the right upper limb. There was also purulent drainage upon examination. Ultrasound imaging confirmed the presence of a localized fluid collection consistent with an abscess. Cutaneous abscess of right upper limb (ICD-10-CM code L02413) - The patient presented with a swollen, erythematous, and tender area on the right upper limb with purulent drainage. Ultrasound imaging confirmed a localized fluid collection consistent with an abscess. The patient reported increasing pain and swelling in the affected area over the past few days. No signs of systemic infection were noted. Incision and drainage of the abscess were performed under local anesthesia. The wound was packed, and the patient was prescribed a course of oral antibiotics. The patient responded well to treatment, with decreased swelling and pain. They were discharged with instructions for wound care and a follow-up appointment in one week. 42 Male Caucasian ICD Code: L02413

The patient has a history of recurrent skin infections and has previously been treated for cellulitis in the lower limbs. The patient presents with a painful, erythematous, warm, and fluctuant swelling on the left lower limb. There is associated tenderness and local warmth. Ultrasound of the left lower limb shows a well-defined fluid collection consistent with an abscess. Cutaneous abscess of the left lower limb (L02416): A localized collection of pus in the skin and subcutaneous tissue of the left lower limb. The patient reports increasing pain and swelling over the past few days. Physical examination reveals a fluctuant mass on the left lower limb consistent with an abscess. No signs of cellulitis or deeper tissue involvement are noted. Incision and drainage of the abscess were performed. The wound was packed, and the patient was started on oral antibiotics. Instructions for wound care and follow-up were provided. The patient responded well to treatment, with decreased pain and swelling. Discharge instructions include wound care, antibiotic course completion, and follow-up with the primary care provider in one week. 45 Female Caucasian ICD Code: L02416

The patient has a history of type 2 diabetes mellitus and hypertension. The patient presents with localized redness, swelling, and tenderness on the dorsum of the right hand. There is also purulent drainage upon palpation. Ultrasound of the right hand confirms the presence of a fluid collection consistent with an abscess. Cutaneous abscess of right hand (ICD-10-CM code L02511): A cutaneous abscess is a localized collection of pus within the dermis or subcutaneous tissues. In this case, the abscess is specifically located on the dorsum of the right hand. The abscess is likely secondary to the patient's history of diabetes, which can predispose individuals to skin infections. Incision and drainage were performed, and the patient was started on oral antibiotics. Incision and drainage of the abscess were performed, and the patient was prescribed a 7-day course of oral antibiotics. The patient's condition improved post-procedure, with decreased swelling and tenderness. The patient was discharged with appropriate wound care instructions. 58 Female Caucasian ICD Code: L02511

The patient has a history of mild eczema on the left hand, but no previous abscesses or infections. The patient presents with localized redness, swelling, and tenderness on the dorsal aspect of the left hand. There is also purulent drainage upon palpation. Ultrasound of the left hand shows a well-defined fluid collection consistent with an abscess. Cutaneous abscess of left hand (L02512): A localized collection of pus in the subcutaneous tissues of the left hand, typically caused by a bacterial infection. Verbatim: 'Patient diagnosed with cutaneous abscess of left hand.' The patient reports pain upon movement of the fingers and is unable to fully flex the left hand due to discomfort. No signs of systemic infection such as fever or chills. Incision and drainage of the abscess performed under local anesthesia. The wound was packed, and the patient was started on oral antibiotics. The patient was discharged in stable condition with oral antibiotics and wound care instructions. Follow-up appointment scheduled in one week for wound reevaluation. 42 Male Caucasian ICD Code: L02512

The patient has a history of recurrent skin infections and has previously been treated for a cutaneous abscess on the right foot. The patient presents with localized pain, redness, and swelling on the right foot. There is also purulent drainage from a small punctum on the plantar surface of the foot. Ultrasound of the right foot shows a well-defined fluid collection consistent with an abscess. Cutaneous abscess of right foot (L02611): A localized collection of pus in the subcutaneous tissues of the right foot, typically caused by a bacterial infection. The patient presents with pain, redness, swelling, and purulent drainage from a punctum on the plantar surface of the foot. The patient reports increasing pain and difficulty walking due to the abscess. There are no signs of systemic infection or cellulitis. Incision and drainage are recommended. Incision and drainage of the abscess performed. The wound was packed, and the patient was started on oral antibiotics. Instructions given for wound care and follow-up. The patient was discharged in stable condition with oral antibiotics and wound care instructions. Follow-up appointment scheduled in one week for wound reevaluation. 45 Male Caucasian ICD Code: L02611

The patient has a history of recurrent cutaneous abscesses in various locations, including the left foot. The patient presents with localized pain, redness, and swelling on the left foot. There is also purulent drainage. Ultrasound of the left foot shows a well-defined fluid collection consistent with an abscess. Cutaneous abscess of left foot (L02612): A localized collection of pus in the subcutaneous tissues of the left foot. The patient reports tenderness upon palpation over the affected area. No signs of systemic infection are noted. The abscess appears to be superficial and is likely to respond well to incision and drainage. Incision and drainage of the abscess performed. The wound was irrigated, and the patient was started on a course of oral antibiotics. The patient was discharged in stable condition with instructions for wound care and a follow-up appointment in one week to monitor healing. 45 Male Caucasian ICD Code: L02612

The patient has a history of recurrent skin infections but no prior abscesses on the head. The patient presents with a painful, swollen area on the scalp, with localized warmth and redness. There is no associated lymphadenopathy or systemic symptoms. Ultrasound imaging shows a well-defined fluid collection consistent with an abscess on the scalp. Cutaneous abscess of head (L02811): A cutaneous abscess is a localized collection of pus within the dermis or subcutaneous tissue. The abscess on the patient's head meets the criteria for L02811 due to the presence of a painful, swollen area on the scalp with localized warmth and redness, confirmed by ultrasound imaging. The patient reports tenderness on palpation over the affected area. No signs of surrounding cellulitis or deeper tissue involvement are noted upon examination. Incision and drainage of the abscess were performed under local anesthesia. The patient was started on a course of oral antibiotics and instructed on wound care. The patient responded well to treatment, with decreased pain and swelling. Discharge instructions include completing the antibiotic course and following up with the primary care provider in one week. 42 Female Caucasian ICD Code: L02811

The patient has a history of occasional fungal infections of the toes but no prior history of cellulitis. The patient presents with erythema, warmth, tenderness, and swelling localized to the right toe. There are no systemic symptoms such as fever or chills. Laboratory tests show elevated white blood cell count and inflammatory markers. A wound culture is obtained, and results are pending. Cellulitis of the right toe. On examination, there is a well-defined area of erythema and warmth on the right toe. The patient reports pain with palpation. No abscess or purulent drainage is noted. The patient is neurovascularly intact distally. The patient was started on oral antibiotics, advised on wound care, and instructed to elevate the right foot. Follow-up in two days is recommended. The patient responded well to treatment with resolving symptoms and decreased erythema. Discharged home with a prescription for a full course of antibiotics. 45 Female Caucasian ICD Code: L03031

The patient has no history of recent trauma or surgery to the periorbital area. The patient presents with swelling, redness, warmth, and tenderness of the upper and lower eyelids. There is no associated trauma or injury. Laboratory findings show leukocytosis. Imaging studies reveal periorbital inflammation without orbital involvement. Periorbital cellulitis (ICD-10-CM code L03213): Periorbital cellulitis is an infection and inflammation of the eyelid and surrounding tissues. The patient reports gradual onset of symptoms over the past few days. No signs of vision changes or proptosis. No fever reported. The patient was started on oral antibiotics (specific antibiotic based on culture results) and advised warm compresses. Close monitoring for any progression of symptoms or vision changes. The patient responded well to treatment with resolution of symptoms. Discharged home with a course of antibiotics and advised to follow up if any worsening of symptoms. 42 Female Caucasian ICD Code: L03213

The patient has a history of occasional skin infections but no prior history of cellulitis. No history of chronic skin conditions or immunodeficiency. The patient presents with localized redness, warmth, and tenderness on the back. There is no swelling or drainage noted. The patient denies any systemic symptoms such as fever or chills. Physical examination reveals erythema and edema localized to the back area. No abscess formation or crepitus noted. No imaging studies performed as the diagnosis was clinical. Cellulitis of back. Verbatim EHR quote justifying the code: 'Localized redness, warmth, and tenderness on the back area without signs of abscess or crepitus.' Clinical assessment indicates a mild case of cellulitis confined to the back region. No signs of spreading infection or deeper tissue involvement observed. The patient is in good overall health with no signs of systemic illness. The patient was started on oral antibiotics (cephalexin) and advised on wound care and monitoring for signs of progression. Follow-up scheduled in one week. The patient responded well to treatment with resolution of symptoms. Discharged home with instructions for completing the antibiotic course and to seek medical attention if symptoms worsen. 42 Male Caucasian ICD Code: L03.312

The patient has a history of diabetes mellitus type 2 with well-controlled blood glucose levels. The patient presents with localized redness, swelling, warmth, and tenderness in the perineal area. There are no signs of involvement of other body parts. Laboratory tests show an elevated white blood cell count and C-reactive protein levels, indicating an inflammatory process. No other abnormalities were noted. Cellulitis of perineum: The skin in the perineal region is inflamed, presenting with erythema, warmth, swelling, and tenderness. There is no involvement of adjacent areas or other body parts. These findings support the diagnosis of Cellulitis of perineum (L03315). On examination, the perineal area shows classic signs of cellulitis with no extension to adjacent regions. The patient is in good general condition with stable vital signs. The patient was started on oral antibiotics (such as cephalexin) and advised on wound care. Pain management was provided as needed. The patient responded well to treatment with a significant reduction in symptoms. Discharge instructions included completing the full course of antibiotics, monitoring for any worsening symptoms, and follow-up with the primary care provider in one week. 56 Male Caucasian ICD Code: L03315

The patient has a history of obesity and type 2 diabetes mellitus. The patient presents with a 2-day history of increasing redness, swelling, and tenderness in the right buttock area. Physical examination reveals erythema, warmth, and induration localized to the right buttock. No systemic signs of infection are noted. Laboratory tests show elevated white blood cell count and C-reactive protein. Cellulitis of buttock (ICD-10-CM code L03317): The patient presents with a 2-day history of increasing redness, swelling, and tenderness in the right buttock area. The patient's symptoms and physical examination findings are consistent with Cellulitis of buttock. No evidence of infection in other body parts. The patient is started on oral antibiotics and advised on wound care. The patient is prescribed a 7-day course of oral antibiotics (e.g., cephalexin) and instructed on proper wound care, including keeping the affected area clean and dry. The patient responded well to treatment, with decreased redness and swelling in the right buttock. The patient is discharged home with a prescription for oral antibiotics and instructions for follow-up care. 55 Female Caucasian ICD Code: L03317

The patient has a history of mild eczema but no history of recurrent skin infections or cellulitis. The patient presents with erythema, warmth, tenderness, and swelling on the trunk. There are no symptoms of cellulitis in other body parts. Laboratory tests show elevated white blood cell count and C-reactive protein levels, supporting the diagnosis of cellulitis. Cellulitis of trunk, unspecified. Verbatim EHR quote justifying the code: 'Patient presents with erythema, warmth, tenderness, and swelling on the trunk, consistent with cellulitis of the trunk.' Upon examination, the patient's trunk shows classic signs of cellulitis with no evidence of infection in other areas. The patient is responsive to treatment. The patient was started on oral antibiotics, instructed on wound care, and advised on signs of worsening infection. The patient responded well to treatment, and the cellulitis on the trunk improved. Discharged with a prescription for a full course of antibiotics and advised to follow up if symptoms worsen. 45 Female Caucasian ICD Code: L03.319

The patient has a history of intermittent sacrococcygeal pain and discomfort. The patient presents with a tender, swollen nodule in the sacrococcygeal area, associated with localized pain and redness. Physical examination reveals a non-fluctuant nodule in the sacrococcygeal region. Ultrasound confirms the presence of a cystic structure without signs of abscess formation. Pilonidal cyst without abscess. Verbatim_EHR_quote_justifying_the_code: 'Patient diagnosed with a Pilonidal cyst without abscess based on physical examination and ultrasound findings.' No signs of cellulitis or abscess noted. Advised warm compresses and pain management. Prescribed oral analgesics for pain management. Instructed on warm compresses to the affected area. 28 Male Caucasian ICD Code: L0591

The patient has a history of recurrent skin lesions characterized by pus-filled vesicles and bullae. The patient presents with multiple pustules, vesicles, and bullae on the skin, some of which have ruptured, leading to crusted erosions. Bacterial culture from the skin lesions grew Staphylococcus aureus. Pyoderma (ICD-10-CM code L080) - The patient presents with multiple pustules, vesicles, and bullae on the skin, consistent with pyoderma. Ruptured lesions have resulted in crusted erosions. Bacterial culture confirmed Staphylococcus aureus as the causative agent. The patient reports intense itching and burning sensation over the affected areas. No signs of systemic infection noted. Started the patient on oral antibiotics and topical antiseptic creams. Prescribed oral antibiotics to target the Staphylococcus aureus infection. Recommended daily wound care with topical antiseptic creams to prevent secondary infections. The patient responded well to treatment with a significant reduction in the number of skin lesions. Discharged with a prescription for a full course of antibiotics and scheduled for a follow-up in two weeks. 42 Female Caucasian ICD Code: L080

The patient has a history of mild eczema managed with emollients. The patient presents with a small, tender, erythematous lesion on the right forearm. Skin culture revealed Staphylococcus aureus. Other specified local infections of the skin and subcutaneous tissue (ICD-10-CM code L0889): A small, tender, erythematous lesion on the right forearm consistent with a localized skin infection caused by Staphylococcus aureus. The lesion appears to be a localized infection rather than a more extensive cellulitis. No systemic symptoms such as fever or malaise are present. The patient was started on a course of oral antibiotics and advised to keep the area clean and dry. The patient responded well to treatment, and the lesion showed signs of improvement. Discharged with a prescription for a full course of antibiotics and advised to follow up if any worsening of symptoms. 42 Female Caucasian ICD Code: L0889

The patient has a history of seasonal allergies and mild eczema. The patient presents with multiple pruritic papules on the trunk, associated with intense itching. Skin biopsy results revealed acantholysis and dyskeratosis without evidence of infection. Transient acantholytic dermatosis [Grover] (ICD-10-CM code L111): The patient presents with pruritic papules predominantly on the trunk, consistent with the histopathological findings of acantholysis and dyskeratosis. The patient denies any recent changes in skincare products or exposure to new allergens. No vesicles, pustules, or bullae were observed during the examination. Prescribed topical corticosteroids for symptomatic relief and advised on proper skincare routine. The patient's symptoms improved with treatment, and they were discharged with instructions for follow-up in two weeks if needed. 45 Male Caucasian ICD Code: L111

The patient has a history of hypertension and osteoarthritis. The patient presents with multiple tense bullae on the extremities and trunk, intense pruritus, and erythema. Direct immunofluorescence of a skin biopsy showing linear IgG and C3 along the basement membrane zone. Bullous pemphigoid (ICD-10-CM code L120): The patient presents with tense bullae, pruritus, and positive direct immunofluorescence showing linear IgG and C3 along the basement membrane zone. The patient's skin lesions are consistent with bullous pemphigoid. No signs of infection or other dermatological conditions are noted. Treatment with oral corticosteroids initiated. Topical emollients prescribed for symptomatic relief. The patient responded well to treatment and was discharged in stable condition. 68 Female Caucasian ICD Code: L120

The patient has a history of recurrent seborrheic dermatitis flare-ups managed with topical treatments. The patient presents with erythematous plaques with greasy scales on the scalp, eyebrows, and central face. Skin scraping microscopy shows Malassezia yeast overgrowth, confirming the diagnosis of seborrheic dermatitis. Seborrheic dermatitis of the face, scalp, and eyebrows. The patient reports a chronic history of similar skin lesions with characteristic distribution and response to antifungal treatments. Prescribed ketoconazole shampoo for scalp, hydrocortisone cream for facial lesions, and education on proper skincare. The patient responded well to treatment, with a plan for outpatient follow-up in three weeks to monitor the condition. 42 Female Caucasian ICD Code: L218

The patient has a history of mild eczema but no other significant dermatological conditions. The patient presents with erythematous patches covered with greasy scales on the scalp, eyebrows, and nasolabial folds. No specific diagnostic tests were performed as the clinical presentation is consistent with seborrheic dermatitis. Seborrheic dermatitis, unspecified (ICD-10-CM code L219): The patient presents with erythematous patches covered with greasy scales on the scalp, eyebrows, and nasolabial folds. Clinical examination reveals typical findings of seborrheic dermatitis with no signs of infection or allergic reaction. Prescribed ketoconazole shampoo for scalp application and hydrocortisone cream for facial areas. Advised on skincare routine and follow-up in 4 weeks. The patient responded well to treatment and was discharged with instructions for continued care at home. 42 Female Caucasian ICD Code: L219

The patient has a history of sensitive skin and has previously experienced rashes and itching when using certain adhesive products. The patient presents with erythematous patches, papules, and vesicles on the skin in areas where adhesive products were in contact. Patch testing revealed a positive reaction to the adhesive components used in medical tapes and bandages. Allergic contact dermatitis due to adhesives. The patient developed erythematous patches, papules, and vesicles on the skin in areas where adhesive products were in contact. Patch testing confirmed a positive reaction to the adhesive components, supporting the diagnosis of Allergic contact dermatitis due to adhesives. The patient reports intense itching and burning sensation on the affected skin areas. Physical examination shows well-defined erythematous patches with papules and vesicles, consistent with allergic contact dermatitis due to adhesives. The patient was advised to avoid adhesive products and prescribed topical corticosteroids to reduce inflammation and itching. Additionally, emollients were recommended to maintain skin hydration. The patient responded well to treatment, with a significant reduction in skin inflammation and itching. Discharged with instructions to continue topical corticosteroids and follow up after two weeks for reevaluation. 42 Female Caucasian ICD Code: L231

The patient has a history of seasonal allergies but no previous history of skin conditions or dermatitis. The patient presents with erythematous, pruritic, and vesicular rash on the forearms and hands after gardening without gloves. Skin patch testing confirmed a positive reaction to common plant allergens like poison ivy and oak. Allergic contact dermatitis due to plants, except food. Verbatim_EHR_quote_justifying_the_code: 'Patient diagnosed with allergic contact dermatitis due to plants, except food, supported by clinical presentation and positive skin patch testing.' The patient reports worsening of symptoms upon exposure to sunlight and improvement with topical corticosteroids. No signs of infection or pyoderma noted. Prescribed topical corticosteroid cream for rash, advised on allergen avoidance, and provided education on proper gardening practices. Patient's condition improved with treatment, symptoms resolved, and patient educated on preventive measures to avoid future flare-ups. 42 Female Caucasian ICD Code: L237

The patient has a history of sensitive skin and has experienced rashes in the past after using certain skincare products. The patient presents with erythematous, edematous, and pruritic plaques on the skin with clear borders. Patch testing revealed a positive reaction to nickel, confirming allergic contact dermatitis. Allergic contact dermatitis, unspecified cause. The patient presents with erythematous, edematous, and pruritic plaques on the skin with clear borders, and patch testing revealed a positive reaction to nickel. The patient reports that the symptoms started after wearing a new nickel-containing watch. Physical examination shows well-defined plaques with signs of inflammation. Prescribed a topical corticosteroid cream to apply twice daily on the affected areas. Advised the patient to avoid nickel-containing items. The patient responded well to treatment, with a significant reduction in skin inflammation and pruritus. Educated the patient on allergen avoidance strategies to prevent future flare-ups. 42 Female Caucasian ICD Code: L239

The patient has a history of sensitive skin and occasional rashes upon contact with certain substances. The patient presents with redness, itching, and skin inflammation on the forearms and hands after exposure to a cleaning agent at work. Physical examination shows erythema and edema on the affected skin areas consistent with irritant contact dermatitis. Irritant contact dermatitis due to other agents (L2489) The patient reports a clear history of skin reactions following exposure to irritant substances. Physical examination reveals typical signs of irritant contact dermatitis without features suggestive of other dermatological conditions. Prescribed topical corticosteroid cream for local application, advised on skin protection measures at work, and provided education on irritant contact dermatitis. The patient responded well to treatment, with a significant reduction in symptoms. Discharged with instructions for follow-up in case of flare-ups. 42 Female Caucasian ICD Code: L2489

The patient has a history of sensitive skin and has previously experienced rashes upon contact with certain substances. The patient presents with redness, itching, and small blisters on the skin at the site of contact with a known irritant. Skin patch testing was performed, confirming irritant contact dermatitis without evidence of allergic reactions. Irritant contact dermatitis, unspecified cause (L249) The patient reports that the symptoms started shortly after exposure to a new cleaning agent. Physical examination reveals erythema, papules, and vesicles localized to the area of contact. The patient was advised to avoid further contact with the irritant. Topical corticosteroids and emollients were prescribed to alleviate symptoms. The patient's symptoms improved with treatment, and he was discharged with instructions to follow up if the condition persists or worsens. 42 Male Caucasian ICD Code: L249

The patient has no known history of skin allergies, atopy, or chronic dermatological conditions. The patient presents with red, inflamed skin patches with itching and burning sensations. No specific triggers or exposures are reported. Patch testing revealed non-specific irritant contact dermatitis with no identifiable allergens. Unspecified contact dermatitis due to other agents (L258): The patient presents with red, inflamed skin patches with itching and burning sensations. Patch testing revealed non-specific irritant contact dermatitis with no identifiable allergens. The patient denies any recent changes in skincare products or exposure to known allergens. The diagnosis of unspecified contact dermatitis is made due to the lack of a specific identifiable cause. Prescribed topical corticosteroid cream for symptom relief and advised the patient to avoid harsh soaps and detergents. The patient's symptoms improved with treatment, and they were discharged with instructions for follow-up if symptoms persist or worsen. 42 Female Caucasian ICD Code: L258

The patient has no known history of skin allergies, atopic dermatitis, or other dermatological conditions. There is no history of recent medication changes or new exposures to potential irritants or allergens. The patient presents with erythematous patches on the arms and legs, accompanied by mild itching. There are no vesicles, bullae, or nodules present. The patient denies any history of similar skin eruptions in the past. Skin scraping tests were negative for fungal infections. Patch testing for common allergens showed no significant reactions. Unspecified contact dermatitis, unspecified cause. The patient presents with erythematous patches on the arms and legs, consistent with contact dermatitis. There are no specific allergens or irritants identified to attribute the condition to a more specific cause. The patient reports the onset of symptoms after using a new brand of laundry detergent. However, given the lack of clear evidence linking the dermatitis to a specific allergen or irritant, the diagnosis of unspecified contact dermatitis is most appropriate. The patient was advised to discontinue the use of the new laundry detergent and switch to a hypoallergenic alternative. Topical corticosteroids and emollients were prescribed for symptom relief. The patient responded well to treatment and reported a significant reduction in itching and redness. Discharge instructions include avoiding known irritants and following up with a dermatologist if symptoms persist or worsen. 42 Female Caucasian ICD Code: L259

The patient has a history of atopic dermatitis and seasonal allergies. The patient presents with severe itching and thickened, leathery skin on the back of the neck. Skin biopsy results indicate hyperkeratosis and acanthosis without evidence of allergic reaction. Lichen simplex chronicus The patient reports a long-standing history of itching in the affected area, exacerbated by stress. Physical examination reveals lichenification and excoriations consistent with Lichen simplex chronicus. Prescribed topical corticosteroid ointment for symptomatic relief and advised on stress management techniques. The patient responded well to treatment and was discharged with instructions to follow up in two weeks for a reevaluation of symptoms. 42 Female Caucasian ICD Code: L280

The patient has a history of chronic, severe pruritus and recurrent skin lesions. The patient presents with multiple hyperkeratotic papules and nodules on the extremities, associated with intense itching that worsens at night. The lesions are excoriated due to scratching. Skin biopsy results show epidermal hyperplasia, hyperkeratosis, and chronic inflammatory infiltrate in the dermis. Prurigo nodularis (L281): The excoriated hyperkeratotic papules and nodules associated with severe pruritus are consistent with the diagnosis of Prurigo nodularis. The patient reports a long-standing history of refractory itching, and the physical examination reveals multiple excoriated nodules with hyperkeratosis. No signs of acute contact dermatitis or psoriatic plaques are observed. Prescribed topical corticosteroids for symptomatic relief and advised on proper skincare to prevent exacerbations. The patient responded well to treatment, with a significant reduction in pruritus and improvement in the appearance of the skin lesions. Discharged with instructions for follow-up in two weeks. 58 Female Caucasian ICD Code: L281

The patient has a history of mild eczema on the arms but no other significant dermatological conditions. The patient complains of persistent itching localized to the external genitalia, specifically the vulvar area. The itching is not associated with any rash, redness, or lesions. Physical examination reveals no signs of inflammation, infection, or other dermatological abnormalities on the external genitalia. No abnormalities were noted in the routine blood tests. Pruritus vulvae The patient reports that the itching has been ongoing for the past two months and is significantly bothersome, affecting daily activities and sleep. There are no visible skin changes or other associated symptoms. Differential diagnoses such as contact dermatitis, psoriasis, or drug-related eruptions are ruled out based on the absence of characteristic findings. Prescribed a mild topical corticosteroid cream for symptomatic relief and advised on gentle genital hygiene practices. The patient's symptoms improved with the prescribed treatment, and she was discharged with instructions for follow-up if needed. 42 Female Caucasian ICD Code: L292

The patient has a history of seasonal allergies but no known history of skin conditions or dermatitis. The patient reports generalized itching without any visible rash or lesions. The itching is not localized to a specific area and has been persistent for the last two weeks. No abnormal findings on skin examination or blood tests. Allergy tests were negative. Pruritus, unspecified: The itching is generalized without any underlying skin condition or specific cause identified. The patient appears otherwise healthy with normal skin appearance. No signs of eczema, psoriasis, or other dermatological conditions noted. Prescribed antihistamines for symptomatic relief. Advised on general skin care practices and to follow up if symptoms persist. The patient's itching improved with antihistamines, and no further concerns were noted upon discharge. 45 Female Caucasian ICD Code: L299

The patient has a history of obesity and diabetes mellitus type 2. The patient presents with erythematous patches with well-defined borders in the skin folds of the groin area. The affected areas are pruritic and exhibit maceration but no signs of lichenification or nodules. Skin scraping for fungal culture was negative. No signs of psoriatic plaques or lichen planus-like lesions were observed. Erythema intertrigo (ICD-10-CM code L304): Erythema intertrigo is an inflammatory condition of the skin involving the skin folds, characterized by erythema, maceration, and pruritus. It typically spares the areas of lichenification and nodules, which helps differentiate it from other dermatological conditions. The patient's presentation of erythematous patches in the skin folds, along with the absence of psoriatic plaques, lichen planus-like lesions, lichenification, or nodules, supports the diagnosis of Erythema intertrigo. The negative fungal culture further rules out fungal infections as the cause of the skin changes. The patient was advised on proper skin hygiene, including keeping the affected areas dry and using barrier creams. Topical corticosteroids and antifungal creams were prescribed for symptomatic relief. The patient responded well to treatment and was discharged with instructions for follow-up in the outpatient clinic. 45 Female Caucasian ICD Code: L304

The patient has a history of occasional skin rashes triggered by exposure to specific allergens. The patient presents with localized erythematous patches on the skin with mild scaling and itching. Skin biopsy results indicate spongiosis, exocytosis of lymphocytes, and parakeratosis. Other specified dermatitis (L308): The skin biopsy findings of spongiosis, lymphocytic exocytosis, and parakeratosis, along with the clinical presentation of localized erythematous patches with itching, are consistent with a diagnosis of Other specified dermatitis. The patient reports that the skin symptoms appeared after contact with a new type of fabric, suggesting a contact dermatitis trigger. No signs of generalized eruption or drug-related eruptions are observed. Prescribed topical corticosteroid cream for symptom relief and advised the patient to avoid contact with the triggering fabric. The patient's symptoms improved with the prescribed treatment, and no adverse reactions were reported upon discharge. 42 Female Caucasian ICD Code: L308

The patient has no history of allergic reactions, psoriasis, lichen planus, or urticaria. There is no history of drug intake or internal medication causing skin eruptions. The patient presents with red, inflamed, and itchy skin patches with no specific pattern of distribution. There are no nodules, plaques, or silvery scales on the skin. The itching is generalized and not localized to specific areas. The patient denies any vaginal itching or specific genital symptoms. Skin scraping tests were negative for fungal infections. Patch testing for common allergens was negative. No signs of lichen planus or psoriasis were observed on skin biopsy. Dermatitis, unspecified The patient's skin shows signs of acute inflammation with erythema and mild edema. No signs of chronic lichenification or nodules are present. The patient reports generalized itching without specific triggers. No signs of psoriasis, lichen planus, or urticaria are noted. Prescribed topical corticosteroid cream for symptomatic relief. Advised on proper skincare and avoidance of known irritants. The patient responded well to treatment and was discharged with instructions for follow-up in two weeks if symptoms persist. 42 Female Caucasian ICD Code: L309

The patient has a history of chronic plaque psoriasis, with recurrent episodes over the past five years. The patient presents with well-defined, erythematous plaques covered with silvery scales on the elbows, knees, and scalp. There is no history of drug intake or allergic reactions. Skin biopsy results show regular acanthosis, elongation of rete ridges, and parakeratosis, consistent with Psoriasis vulgaris. Psoriasis vulgaris (L400): Chronic plaque psoriasis with characteristic erythematous plaques and silvery scales. The skin biopsy findings confirm the diagnosis of Psoriasis vulgaris. The patient reports mild pruritus associated with the plaques. No signs of drug-induced eruptions or allergic reactions are noted. The patient's presentation is consistent with Psoriasis vulgaris. Treatment includes topical corticosteroids for the plaques, along with emollients for moisturizing the skin. The patient is advised on lifestyle modifications and regular follow-ups. The patient responded well to treatment and demonstrated improvement in the plaques. Discharged with instructions for continued topical therapy and follow-up in three months. 42 Male Caucasian ICD Code: L400

The patient has a history of recurrent streptococcal infections. The patient presents with numerous small, red, scaly, teardrop-shaped lesions covering the trunk and limbs. Streptococcal throat swab was positive. Guttate psoriasis (L404) Characteristic small, drop-like lesions observed on examination. The patient reports a recent history of streptococcal infection, which is a common trigger for Guttate psoriasis. Prescribed topical corticosteroids for the skin lesions and antibiotics for the streptococcal infection. The patient's skin lesions showed improvement with treatment, and the streptococcal infection was successfully treated. Discharged with recommendations for follow-up with a dermatologist. 34 Female Caucasian ICD Code: L404

The patient has a history of chronic plaque psoriasis for the last five years. There is no prior history of joint diseases or arthritis. The patient presents with scaly, well-demarcated, erythematous plaques with silvery scales over extensor surfaces of elbows and knees. Additionally, the patient reports intermittent joint pain and swelling in multiple joints, including the fingers and knees. Laboratory tests show elevated C-reactive protein levels and erythrocyte sedimentation rate, indicating an inflammatory process. X-rays of the affected joints reveal signs of erosive changes and bone proliferation. Arthropathic psoriasis, unspecified - The combination of psoriasis and joint involvement is consistent with arthropathic psoriasis. The patient presents with psoriatic skin lesions along with joint pain and swelling, fulfilling the diagnostic criteria for L4050. The patient's joint symptoms correlate temporally with psoriasis flares, suggesting a link between the skin and joint manifestations. Physical examination shows characteristic psoriatic plaques and tenderness on joint palpation. The patient is started on methotrexate for both skin and joint symptoms. Topical corticosteroids are prescribed for psoriatic plaques. Referral to a rheumatologist is made for further management of the arthropathy. The patient responded well to treatment with reduced skin plaques and improved joint symptoms. Discharged with a follow-up appointment with the rheumatologist in two weeks. 42 Female Caucasian ICD Code: L4050

The patient has a history of recurring episodes of scaly, red patches on the skin. The patient presents with thick, inflamed skin with silvery scales, itching, and occasional burning sensations. Skin biopsy results indicate epidermal hyperplasia, elongation of rete ridges, and Munro microabscesses in the epidermis. Psoriasis, unspecified (L409): The skin biopsy findings are consistent with psoriasis, presenting with typical features such as epidermal hyperplasia, elongation of rete ridges, and Munro microabscesses. The patient reports a positive family history of psoriasis. Physical examination reveals well-demarcated, erythematous plaques with silvery scales predominantly on the extensor surfaces of the elbows and knees. Treatment plan includes topical corticosteroids, vitamin D analogs, and phototherapy sessions. The patient responded well to treatment and was discharged with instructions for follow-up appointments. 42 Female Caucasian ICD Code: L409

The patient has a history of seasonal allergies and mild eczema managed with emollients. The patient presents with multiple purple, polygonal papules on the wrists and ankles associated with severe itching. Skin biopsy results show hypergranulosis and saw-tooth appearance of rete ridges consistent with Lichen planus. Lichen planus, unspecified (L439) - The papules present with Wickham striae are characteristic of Lichen planus. Clinical examination reveals classic Wickham striae on the papules, confirming the diagnosis of Lichen planus. No signs of psoriasis or urticaria observed. Prescribed clobetasol ointment for local application twice daily for four weeks and cetirizine for pruritus as needed. The patient responded well to treatment with a significant reduction in itching and regression of the papules. Discharged with advice for follow-up in four weeks. 42 Female Caucasian ICD Code: L439

The patient has a history of seasonal allergies but no previous history of urticaria or other skin conditions. The patient presents with raised, red, itchy welts on the skin that appear suddenly after exposure to an allergen, consistent with allergic urticaria. Skin prick tests revealed positive reactions to common allergens, confirming the allergic nature of the urticaria. Allergic urticaria (L500): Urticaria due to allergic reaction. The patient reports that the skin lesions worsen with scratching and improve with antihistamines, typical of allergic urticaria. Prescribed antihistamines for symptom relief and advised the patient to avoid known allergens. The patient's symptoms improved with treatment, and they were discharged with instructions to follow up with an allergist for further management if needed. 42 Female Caucasian ICD Code: L500

The patient has no history of psoriasis, lichen planus, allergic urticaria, idiopathic urticaria, Stevens-Johnson syndrome, erythema nodosum, or other specified dermatitis. The patient presents with raised, red welts on the skin that are transient and pruritic, without signs of psoriasis, lichen planus, or other specified dermatitis. Skin biopsy results show typical features of urticaria with perivascular inflammation and dermal edema. Other urticaria (L508): Urticaria is characterized by transient, pruritic wheals on the skin that result from localized dermal edema. The patient's symptoms and skin biopsy findings align with the diagnosis of Other urticaria (L508). The patient reports the sudden onset of pruritic welts that come and go within hours, consistent with urticaria. No signs of psoriasis, lichen planus, or other specified dermatitis are observed. The patient was prescribed antihistamines to manage the symptoms of urticaria and advised on trigger avoidance. The patient's urticaria responded well to treatment, and symptoms resolved. The patient was discharged with recommendations for follow-up if symptoms reoccur. 42 Female Caucasian ICD Code: L508

The patient has a history of seasonal allergies and takes loratadine as needed. No history of psoriasis, urticaria, or other skin conditions. The patient presents with a sudden onset of high fever, malaise, and widespread painful blisters on the skin and mucous membranes, including the mouth and eyes. Skin biopsy shows full-thickness epidermal necrosis and detachment, consistent with Stevens-Johnson syndrome. No evidence of psoriasis or urticaria on skin biopsy. Stevens-Johnson syndrome (ICD-10-CM code L51.1) - The patient presents with high fever, malaise, and widespread painful blisters on the skin and mucous membranes. Clinical examination reveals Nikolsky's sign positive. Ophthalmology consult shows conjunctival involvement. No signs of psoriatic plaques or urticarial wheals. Admitted to the burn unit for intensive wound care, fluid resuscitation, and pain management. Ophthalmology consult for eye care. Discontinued loratadine. The patient showed gradual improvement with supportive care and was discharged after 2 weeks with a plan for close outpatient follow-up. 47 Female Caucasian ICD Code: L51.1

The patient has a history of Crohn's disease, which is currently in remission. The patient presents with tender, red, and warm nodules on both shins. The nodules are non-ulcerative and non-scarring. Laboratory tests reveal elevated erythrocyte sedimentation rate (ESR) and normal levels of antinuclear antibodies (ANA). Imaging studies are unremarkable. Erythema nodosum (L52) The patient's presentation of tender, erythematous nodules on the shins, along with the elevated ESR and absence of ulceration, is consistent with a diagnosis of Erythema nodosum. Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management and addressing the underlying cause, Crohn's disease. The patient responded well to treatment and was discharged with instructions for follow-up with their gastroenterologist for Crohn's disease management. 42 Female Caucasian ICD Code: L52

The patient has a history of mild eczema managed with emollients. No history of psoriasis, lichen planus, or other significant dermatological conditions. The patient presents with diffuse erythema of the skin without scaling or plaques. No evidence of silvery scales, typical of psoriasis, or planus-like polygonal purple papules. Skin biopsy results show nonspecific findings of dermal erythema without distinctive features of psoriasis or lichen planus. Erythematous condition, unspecified. Verbatim EHR quote justifying the code: 'Diffuse erythema of the skin without scaling or plaques, skin biopsy showing nonspecific dermal erythema.' Patient denies pruritus commonly seen in psoriasis and lichen planus. No evidence of typical lesions of psoriasis, lichen planus, or erythema nodosum upon examination. Prescribed mild topical corticosteroid for symptomatic relief of erythema. Advised on skincare routine and follow-up in two weeks. Patient's erythema improved with treatment. Advised to continue topical corticosteroid as needed. Follow-up scheduled in two weeks for re-evaluation. 42 Female Caucasian ICD Code: L539

The patient has a history of hypertension and hyperlipidemia, both well-controlled with medications. The patient presents with loose and sagging skin, especially prominent around the face, neck, and extremities. There are no pruritic or inflammatory skin lesions observed. Skin biopsy results indicate a decrease in dermal elastin fibers and fragmentation of elastic fibers, consistent with Cutis laxa senilis. Cutis laxa senilis (L574) Physical examination reveals redundant and wrinkled skin lacking elasticity, typical of Cutis laxa senilis. There are no signs of lichen planus, urticaria, Stevens-Johnson syndrome, or other inflammatory skin conditions. Prescribed topical emollients and advised on sun protection measures to prevent further skin damage. The patient responded well to treatment, and skin elasticity showed slight improvement upon discharge. Advised for regular follow-up to monitor skin condition. 78 Female Caucasian ICD Code: L574

The patient has a history of radiation therapy for the treatment of breast cancer five years ago. The patient presents with erythema, dry desquamation, and pruritus on the irradiated skin area. Skin biopsy shows epidermal atrophy and dermal fibrosis consistent with radiation-induced skin changes. Other specified disorders of the skin and subcutaneous tissue related to radiation (L598): Dermatitis and other skin changes due to radiation The patient reports that the skin changes started a few months after completing the radiation therapy. Physical examination reveals well-demarcated erythema and dry skin with scaling on the previously irradiated area. Prescribed emollients, topical corticosteroids, and antihistamines for symptomatic relief. Advised on skincare and sun protection measures. The patient responded well to the treatment and was discharged with instructions for follow-up care and monitoring of skin changes. 57 Female Caucasian ICD Code: L598

The patient has a history of mild onycholysis and recurrent nail splitting over the past six months. The patient complains of nail brittleness, yellow discoloration of the nails, and pain along the nail edges. Fungal culture of the nails was negative. Nail microscopy showed irregular nail plate thickening and subungual hyperkeratosis. Other nail disorders (ICD-10-CM code L608): The patient presents with nail brittleness, yellow discoloration of the nails, and pain along the nail edges. Nail microscopy revealed irregular nail plate thickening and subungual hyperkeratosis, indicative of a nail disorder. The patient reports no history of trauma to the nails. No signs of onychomycosis were noted upon examination. Differential diagnoses such as ingrowing nail and nail dystrophy were ruled out based on the absence of ingrowing nail features and the presence of nail plate thickening, respectively. Prescribed topical antifungal ointment for symptomatic relief. Advised on proper nail care techniques to prevent further damage. The patient responded well to treatment with a reduction in nail pain and improvement in nail appearance. Discharged with recommendations for follow-up in four weeks. 42 Female Caucasian ICD Code: L608

The patient has a history of hypothyroidism, which is currently well controlled with medication. The patient reports gradual hair thinning and hair loss in a specific pattern on the scalp without any signs of itching, pain, or inflammation. Scalp examination shows hair follicles with no signs of inflammation or scarring. Trichogram reveals hair miniaturization consistent with nonscarring alopecia. Other specified nonscarring hair loss (L658): The patient presents with gradual hair thinning and hair loss in a specific pattern on the scalp without any signs of inflammation or scarring. The patient's hair loss pattern is consistent with Other specified nonscarring hair loss (L658). No evidence of scarring or inflammation noted during the examination. Prescribed minoxidil topical solution for promoting hair growth. Advised on hair care practices and follow-up in 3 months. The patient was discharged in stable condition with a treatment plan for nonscarring hair loss. Follow-up scheduled in 3 months to assess treatment response. 42 Female Caucasian ICD Code: L658

The patient has no history of autoimmune diseases or skin infections. The patient reports gradual hair thinning without any associated pain, itching, or redness on the scalp. Scalp examination showed no signs of inflammation or scarring. Hair pull test was negative. Nonscarring hair loss, unspecified. Verbatim_EHR_quote_justifying_the_code: 'The patient presents with gradual hair thinning without any signs of inflammation or scarring on the scalp, consistent with nonscarring hair loss.' The patient's hair loss pattern is consistent with androgenetic alopecia. No signs of fungal infections or autoimmune conditions were noted. Prescribed minoxidil topical solution once daily. Advised on hair care practices and follow-up in 3 months for reevaluation. The patient was discharged in stable condition with a treatment plan in place for nonscarring hair loss. 42 Female Caucasian ICD Code: L659

The patient has a history of irregular menstrual cycles and obesity. The patient presents with excessive hair growth on the face, chest, and back, with the hair being coarse and pigmented. There are no symptoms of acne, cysts, or inflammatory nodules. Hormone panel results show elevated levels of androgens. Hirsutism Physical examination reveals terminal hair growth in androgen-sensitive areas without signs of inflammation or scarring. The patient denies any history of acne or cystic lesions. Treatment with oral contraceptives and anti-androgen medications was initiated to manage the hirsutism. The patient responded well to treatment and was discharged with a follow-up appointment in three months. 32 Female Caucasian ICD Code: L680

The patient has a history of mild acne during adolescence but did not seek medical treatment at that time. The patient presents with multiple comedones, papules, and a few pustules on the face and upper back. No signs of cysts or nodules are observed. Skin scraping and microscopy do not show fungal elements. No atypical cells are detected on skin biopsy. Acne vulgaris Physical examination reveals typical acne lesions with no signs of scarring or significant inflammation. The patient reports occasional tenderness of the lesions. Prescribed topical benzoyl peroxide for facial lesions and adapalene for the back. Advised on proper skincare routine and follow-up in six weeks. 24 Female Caucasian ICD Code: L700

The patient has no significant past medical history of skin disorders. The patient presents with multiple comedones, papules, and pustules on the face and upper trunk, consistent with acne vulgaris. No additional diagnostic tests were performed as the diagnosis was made clinically. Acne, unspecified: The patient presents with multiple comedones, papules, and pustules on the face and upper trunk, consistent with acne vulgaris. On examination, the patient has typical acne lesions with no signs of actinic damage, cutaneous laxity, or other skin disorders. The diagnosis of acne vulgaris is clear based on the clinical presentation. Prescribed topical benzoyl peroxide and adapalene gel for acne management. Advised on proper skincare routine and follow-up in 6 weeks. The patient was educated on acne management and prescribed topical medications. Follow-up in 6 weeks was scheduled. 24 Female Caucasian ICD Code: L709

The patient has a history of sensitive skin and occasional facial redness. The patient presents with persistent redness on the central face, visible blood vessels, and occasional pimples. No specific diagnostic tests were performed as the diagnosis was made clinically. Rosacea, unspecified. The verbatim ICD-10-CM description states: 'Rosacea is a chronic, inflammatory skin condition that affects adults. It causes redness in your face and produces small, red, pus-filled bumps or pustules.' Clinical examination revealed typical signs of Rosacea including flushing, persistent erythema, and telangiectasia. No signs of comedones or cysts were noted. The patient was prescribed topical metronidazole gel and advised on trigger avoidance. The patient responded well to treatment and was discharged with instructions for follow-up in 3 months. 47 Female Caucasian ICD Code: L719

The patient has no history of skin conditions or surgeries. The patient presents with a painless, slow-growing, mobile, and well-defined subcutaneous nodule on the back. Ultrasound imaging shows a well-circumscribed hypoechoic lesion consistent with a cyst. Epidermal cyst (L720): A cyst in the skin formed by the dilatation of the infundibular portion of the hair follicle. The physical examination revealed a non-tender, smooth, and movable cystic mass, typical of an epidermal cyst. No signs of inflammation or infection were noted. Incision and drainage of the cyst were performed under local anesthesia. The patient was educated on wound care and advised on signs of infection. The patient was discharged in stable condition with instructions for follow-up in case of recurrence or infection. 42 Female Caucasian ICD Code: L720

The patient has a history of recurrent follicular disorders characterized by inflammation and tenderness in the hair follicles. The patient presents with multiple small, tender nodules on the scalp and neck, associated with occasional discharge of pus. Skin biopsy results show inflammation and follicular destruction consistent with a follicular disorder. Other specified follicular disorders (ICD-10-CM code L738) - The patient presents with multiple tender nodules on the scalp and neck with discharge of pus, consistent with a follicular disorder. The patient reports discomfort and tenderness in the affected areas. Physical examination reveals erythematous papules and pustules around hair follicles. Skin biopsy confirms the diagnosis of a follicular disorder. Treatment includes topical antibiotics, warm compresses, and counseling on proper skin hygiene. Follow-up in two weeks to assess response to treatment. The patient responded well to treatment with resolution of nodules and discharge. Advised to continue topical antibiotics and maintain good skin hygiene. 42 Female Caucasian ICD Code: L738

The patient has a history of recurrent follicular papules and pustules on the face and neck. The patient presents with multiple small, red bumps on the skin with occasional whiteheads, primarily concentrated on the facial area. Skin biopsy results indicate inflammation and hyperkeratosis within the hair follicles. Follicular disorder, unspecified. Verbatim EHR quote justifying the code: 'The patient presents with recurrent follicular papules and pustules on the face and neck, consistent with a follicular disorder. Biopsy results show inflammation and hyperkeratosis within the hair follicles.' The dermatologist noted the presence of follicular-based lesions with no signs of scarring or cyst formation. Prescribed topical retinoids and benzoyl peroxide for the management of the follicular disorder. Advised on proper skincare routine. The patient responded well to treatment with a reduction in the number of papules and pustules. Scheduled for a follow-up appointment in six weeks. 32 Female Caucasian ICD Code: L739

The patient has a history of heat exposure due to working in a hot and humid environment. The patient presents with small, clear, fluid-filled bumps on the skin associated with itching and a prickling sensation. Physical examination reveals the presence of papules and vesicles on areas of the skin where sweat accumulates. Miliaria, unspecified. The diagnosis is based on the patient's history of heat exposure, the presence of sweat retention rash, and typical symptoms of Miliaria. The patient reports worsening of symptoms during hot weather and relief with cooling measures. No signs of infection or inflammation are noted. The patient is advised to avoid heat exposure, wear loose clothing, and use calamine lotion for symptomatic relief. The patient's condition improved with the provided recommendations, and there were no signs of complications at discharge. 42 Male Caucasian ICD Code: L743

The patient has a history of hypertension controlled with medication. The patient presents with localized swelling, tenderness, and ecchymosis at the site of a recent surgical procedure. Laboratory tests show stable hemoglobin levels and normal coagulation parameters. Postprocedural hemorrhage of skin and subcutaneous tissue following other procedure. The patient reports the symptoms started a day after the surgery. Physical examination reveals a hematoma at the surgical site without signs of infection. The patient was managed conservatively with ice packs, elevation of the affected limb, and close monitoring of vital signs. The patient was discharged in stable condition with instructions for follow-up with the surgical team if symptoms worsen. 58 Female Caucasian ICD Code: L76.22

The patient has a history of undergoing a recent surgical procedure for a skin lesion removal. The patient presents with localized swelling, tenderness, and ecchymosis at the site of the recent procedure. Physical examination reveals a palpable hematoma in the skin and subcutaneous tissue without signs of infection. Postprocedural hematoma of skin and subcutaneous tissue following other procedure The patient reports increasing pain and swelling at the surgical site post-procedure. Physical examination shows a hematoma consistent with the reported symptoms. The patient was advised on pain management, ice application, and close monitoring for any signs of infection. Follow-up appointment scheduled for wound reassessment. The patient was discharged in stable condition with instructions to monitor the surgical site for any changes and to follow up as scheduled. 54 Female Caucasian ICD Code: L76.32

The patient has a history of undergoing a recent surgical procedure. The patient presents with localized swelling, tenderness, and pain at the surgical site. Imaging studies reveal a fluid collection consistent with a seroma. Postprocedural seroma of skin and subcutaneous tissue following other procedure. The patient has developed a seroma postoperatively, characterized by a painless fluid collection in the surgical area without signs of infection or hematoma. The patient will be monitored closely, and if necessary, the serous fluid may be aspirated for symptomatic relief. The patient is stable post-aspiration, with resolution of symptoms. Discharged with instructions for follow-up if needed. 56 Female Caucasian ICD Code: L7634

The patient has a history of undergoing a recent surgical procedure on the skin and subcutaneous tissue. The patient presents with localized swelling, redness, and tenderness at the surgical site. Ultrasound imaging shows a fluid collection consistent with a hematoma at the surgical site. Other postprocedural complications of skin and subcutaneous tissue (ICD-10-CM code L7682): The patient developed a postprocedural hematoma at the surgical site. The patient reports increasing discomfort and warmth at the site, consistent with an evolving hematoma. No signs of infection are noted. The patient was started on pain management, advised on local wound care, and scheduled for follow-up monitoring of the hematoma. The patient was discharged in stable condition with instructions to monitor the hematoma for any changes or signs of infection. 45 Female Caucasian ICD Code: L7682

The patient has a history of gradually developing white patches on the skin over the past year, with no previous history of similar skin conditions. The patient presents with well-defined depigmented macules and patches on various parts of the body, including the face, hands, and legs. The lesions are asymptomatic and not associated with any itching or pain. Wood's lamp examination reveals characteristic fluorescence in depigmented areas, confirming the absence of melanin. Skin biopsy shows the typical histological features of Vitiligo, including the absence of melanocytes in the affected areas. Vitiligo (L80) - 'Vitiligo is a condition characterized by the presence of depigmented macules and patches due to the loss of melanocytes in the skin.' The patient's clinical presentation, along with the results of Wood's lamp examination and skin biopsy, are consistent with a diagnosis of Vitiligo. No signs of other skin disorders or infections are noted. The treatment plan includes topical corticosteroids to reduce inflammation and repigmentation therapies such as phototherapy to restore skin color in the affected areas. The patient responded well to treatment and was discharged with instructions for follow-up appointments to monitor the progression of Vitiligo. 42 Female Caucasian ICD Code: L80

The patient has a history of mild eczema managed with emollients. The patient presents with dark patches on the skin, particularly on the face and neck, without any associated itching or pain. Skin biopsy results indicate an increased number of melanocytes in the affected areas. Other melanin hyperpigmentation (L814): The patient presents with dark patches on the skin, particularly on the face and neck, without associated symptoms such as itching or pain. Skin biopsy results show an increased number of melanocytes in the affected areas. The patient reports concerns about the cosmetic appearance of the hyperpigmented patches. No signs of inflammation or infection are noted in the affected areas. Treatment includes topical depigmenting agents and sun protection measures. The patient is advised on the chronic nature of the condition and the importance of long-term management. The patient responded well to treatment and is advised to follow up with a dermatologist for ongoing management of the hyperpigmentation. 42 Female Caucasian ICD Code: L814

The patient has a history of mild eczema managed with emollients. No history of skin cancer or melanoma. The patient reports the gradual appearance of multiple areas of skin discoloration without associated pain, itching, or bleeding. Skin biopsy results showed hyperpigmentation of the epidermis without any evidence of malignancy. Disorder of pigmentation, unspecified. Verbatim_EHR_quote_justifying_the_code: 'The patient presents with multiple areas of skin discoloration without associated symptoms. Skin biopsy revealed epidermal hyperpigmentation without signs of malignancy.' The patient's skin lesions are consistent with benign hyperpigmentation rather than other dermatologic conditions. No signs of infection or inflammation noted. Prescribed topical emollients for dry skin. Advised on sun protection measures. The patient was discharged in good condition with recommendations for follow-up with a dermatologist if the pigmented lesions change in size, shape, or color. 45 Female Caucasian ICD Code: L819

The patient has a history of insulin resistance and obesity. The patient presents with dark, thickened, and velvety skin in body folds and creases. Insulin levels are elevated, and no signs of hemorrhage or hematoma are noted. Acanthosis nigricans - Dark, velvety skin in body folds and creases. The patient's skin condition is consistent with acanthosis nigricans, often associated with insulin resistance. Treatment includes addressing the underlying insulin resistance with dietary modifications and possible medications. The patient is stable and discharged with a follow-up appointment for further management of insulin resistance. 45 Female Caucasian ICD Code: L83

The patient has a history of wearing tight-fitting shoes regularly, leading to chronic friction on the dorsal aspects of both feet. The patient complains of painful, raised hardened skin areas on the dorsal aspects of both feet. Physical examination reveals yellowish, well-defined, raised areas of thickened skin with a central core on both feet, consistent with corns. Corns and callosities (ICD-10-CM code L84): "L84 - Corns and callosities - Includes: clavus; cornu cutaneum; tyloma". Upon examination, the patient presented with localized areas of thickened skin with a central core on the dorsal aspects of both feet, characteristic of corns. No signs of hemorrhage, hematoma, or seroma were noted. The patient was advised to wear appropriate footwear, use protective padding, and undergo regular debridement to manage the corns effectively. The patient was discharged in stable condition with instructions to follow up with a podiatrist for ongoing management of the corns on both feet. 58 Female Caucasian ICD Code: L84

The patient has a history of mild eczema but no other significant dermatological conditions. The patient presents with complaints of persistent dry and itchy skin, especially noticeable during the winter months. Physical examination shows diffuse dryness and scaling of the skin without any signs of infection or other dermatological conditions. Xerosis cutis (L853): Xerosis cutis is a common dermatological condition characterized by dry, rough, and scaly skin. The skin appears dehydrated and lacks moisture, leading to itching and discomfort. The patient's skin condition is consistent with Xerosis cutis, showing typical signs of dryness and scaling without any evidence of postprocedural complications, pigmentation disorders, or pressure ulcers. Prescribed emollient creams for daily use, advised on proper skincare routines including avoiding hot showers and using humidifiers. The patient responded well to treatment and was discharged with instructions for long-term skin hydration and management of Xerosis cutis. 45 Female Caucasian ICD Code: L853

The patient has a history of mild eczema managed with topical corticosteroids. The patient reports persistent thickening and hardening of the skin on the lower back over the past six months. Skin biopsy results indicate hyperkeratosis and acanthosis without signs of malignancy. Other specified epidermal thickening - The patient presents with persistent epidermal thickening and hardening of the skin on the lower back, confirmed by skin biopsy showing hyperkeratosis and acanthosis without malignancy. The patient's condition is consistent with other specified epidermal thickening, likely due to chronic irritation. No signs of infection or postprocedural complications are noted. Prescribed emollient creams for daily application to moisturize the affected area and advised on proper skin care routines. The patient responded well to treatment with improved skin texture and reduced thickening. Discharged with recommendations for continued skincare to prevent further exacerbation. 42 Female Caucasian ICD Code: L858

The patient has a history of inflammatory bowel disease (IBD), specifically ulcerative colitis. The patient presents with multiple painful ulcers on the lower extremities with violaceous borders and sterile pustules. Skin biopsy results indicate neutrophilic infiltrate without vasculitis. Pyoderma gangrenosum The patient's skin lesions are consistent with Pyoderma gangrenosum, showing classic features of sterile pustules, necrotic ulcers with violaceous borders, and the absence of pathergy. Initiated treatment with systemic corticosteroids and topical wound care. The patient responded well to treatment and was discharged with a tapering regimen of corticosteroids for outpatient follow-up. 47 Female Caucasian ICD Code: L88

The patient has a history of immobility due to a recent spinal cord injury. The patient reports localized pain and skin discoloration on the back. Physical examination shows a non-blanchable reddened area over the sacral region with intact skin. Pressure ulcer of unspecified part of back, unstageable. Verbatim EHR quote justifying the code: 'Non-blanchable reddened area over the sacral region with intact skin.' Upon examination, a Stage 1 pressure ulcer was suspected, but further assessment revealed the ulcer to be unstageable due to slough obscuring the depth of the wound. The patient was placed on a turning schedule, prescribed topical wound care, and educated on pressure relief techniques. The patient was discharged with instructions for wound care and follow-up appointments to monitor healing progress. 65 Female Caucasian ICD Code: L89100

The patient has a history of chronic immobility due to paraplegia following a spinal cord injury sustained in a motor vehicle accident three years ago. The patient reports localized pain and tenderness over the sacral area. Upon examination, there is a defined area of erythema and a shallow open wound with visible subcutaneous tissue on the sacral region of the back. Laboratory tests show no signs of infection. Imaging studies confirm the absence of any underlying osteomyelitis or deep tissue involvement. Pressure ulcer of unspecified part of back, stage 2. Verbatim_EHR_quote_justifying_the_code: 'Upon examination, there is a defined area of erythema and a shallow open wound with visible subcutaneous tissue on the sacral region of the back, consistent with a stage 2 pressure ulcer.' The patient's pressure ulcer is staged according to the criteria set by the National Pressure Ulcer Advisory Panel (NPUAP), showing partial thickness skin loss involving the epidermis and dermis. The patient was placed on a pressure-relieving mattress, and local wound care with regular dressing changes and offloading of pressure on the affected area was initiated. Pain management was achieved with acetaminophen. The patient responded well to treatment, with signs of healing observed at the site of the pressure ulcer. Discharge instructions include continued offloading of pressure, regular follow-ups for wound assessment, and education on skin care and pressure ulcer prevention strategies. 45 Male Caucasian ICD Code: L89102

The patient has a history of limited mobility due to chronic back pain. The patient reports localized pain and skin discoloration on the back. Physical examination shows an open wound on the back with visible tissue damage. Pressure ulcer of unspecified part of back, unspecified stage. The patient presents with a pressure ulcer on the back, consistent with the description for L89109 in ICD-10-CM: 'Pressure ulcer of unspecified part of back, unspecified stage.' The wound appears to be in the early stages of ulcer formation, requiring close monitoring and appropriate wound care. The patient was advised on wound care, repositioning techniques, and pain management. Topical dressings and regular turning schedules were initiated. The patient was discharged with instructions for home wound care and follow-up with the primary care provider in two weeks. 65 Female Caucasian ICD Code: L89109

The patient has a history of limited mobility due to chronic back pain and has been bedridden for the past six months. The patient presents with a large open wound on the sacral region with visible damage to the subcutaneous tissue and exposed muscle. The wound is showing signs of infection with purulent discharge and surrounding erythema. Wound culture revealed the presence of Staphylococcus aureus, indicating a bacterial infection. Pressure ulcer of sacral region, stage 3. The wound on the sacral region is a stage 3 pressure ulcer with visible damage to the subcutaneous tissue and muscle. The presence of purulent discharge and surrounding erythema indicates an infected stage 3 pressure ulcer. The patient's pressure ulcer on the sacral region is at stage 3 with clear signs of infection. Immediate treatment and wound care are necessary to prevent further complications. The patient was started on a course of intravenous antibiotics to treat the infection. Daily wound debridement and dressing changes were initiated to promote healing. Pressure-relieving devices were also provided to alleviate pressure on the sacral region. After a week of treatment, the patient's wound showed signs of improvement with reduced purulent discharge and less surrounding erythema. The patient was discharged with instructions for wound care and a follow-up appointment in two weeks. 65 Female Caucasian ICD Code: L89153

The patient has a history of immobility due to paraplegia following a spinal cord injury sustained in a motor vehicle accident five years ago. The patient reports severe pain and foul-smelling discharge from the sacral region. The wound appears deep, exposing muscle and bone. Wound culture showed the presence of multidrug-resistant bacteria. X-ray revealed osteomyelitis of the sacrum. Pressure ulcer of sacral region, stage 4. Verbatim EHR quote justifying the code: 'The patient presents with a deep ulcer on the sacral region, exposing muscle and bone, consistent with a stage 4 pressure ulcer.' The wound care team recommends aggressive debridement, intravenous antibiotics, and daily wound dressing changes. Orthopedic consultation for possible surgical intervention is planned. The patient is started on intravenous vancomycin and meropenem for broad-spectrum coverage. Daily wound care with sterile dressing changes and offloading of pressure are initiated. The patient's condition improved with treatment, showing signs of granulation tissue formation. Discharge instructions include wound care management and follow-up with the outpatient wound clinic for ongoing care. 45 Male Caucasian ICD Code: L89154

The patient has a history of limited mobility due to chronic hip arthritis. The patient reports localized pain and tenderness on the right hip area. Physical examination shows a non-blanchable erythema over the right hip. Pressure ulcer of right hip, unstageable. The ulcer on the right hip is unstageable due to eschar obscuring the wound depth. The patient's right hip ulcer is being monitored closely for signs of infection or deterioration. Treatment includes daily wound dressing changes, offloading the pressure on the right hip, and pain management. The patient is stable, and wound care instructions have been provided for home care. 68 Female Caucasian ICD Code: L89210

The patient has a history of immobility due to a spinal cord injury sustained in a motor vehicle accident three years ago. The patient has been wheelchair-bound since the accident. The patient presents with a large, deep ulcer on the right hip, with extensive tissue damage and visible bone involvement. The ulcer is malodorous and exudative. Imaging studies confirm extensive tissue destruction and bone exposure at the site of the ulcer. Pressure ulcer of right hip, stage 4 The ulcer on the right hip is consistent with a stage 4 pressure ulcer, showing full-thickness skin loss with extensive tissue necrosis and visible bone. The patient is at high risk for infection and requires immediate and intensive wound care. The patient is scheduled for surgical debridement to remove necrotic tissue and bone fragments. Wound care with advanced dressings and antibiotic therapy will be initiated post-surgery. The patient will be discharged with detailed wound care instructions and a follow-up appointment in the outpatient clinic for ongoing management of the pressure ulcer. 45 Male Caucasian ICD Code: L89214

The patient has a history of limited mobility due to chronic back pain. The patient reports localized pain and redness on the buttock area. Physical examination shows a shallow ulcer on the right buttock with intact skin and no signs of infection. Pressure ulcer of unspecified buttock, stage 1. Verbatim EHR quote justifying the code: 'Physical examination reveals a shallow ulcer on the right buttock with intact skin, consistent with a stage 1 pressure ulcer.' The physician notes the presence of a stage 1 pressure ulcer on the right buttock and recommends offloading pressure from the area. Treatment includes wound care with a hydrocolloid dressing, repositioning every 2 hours, and pain management with acetaminophen. The patient was discharged in stable condition with instructions for wound care and follow-up with the primary care provider in two weeks. 68 Female Caucasian ICD Code: L89301

The patient has a history of immobility due to a recent hip fracture. The patient reports localized pain and redness on the buttock area. Physical examination shows a shallow ulcer on the buttock measuring 1.5 cm in diameter, with no signs of infection. Pressure ulcer of unspecified buttock, stage 2. The ulcer on the buttock is superficial with partial skin loss involving the epidermis and dermis. The patient is being closely monitored for signs of infection. Daily wound care and repositioning are being implemented. Treatment includes keeping the area clean, applying barrier creams, and relieving pressure by using a specialized cushion. Pain management is also initiated. The patient is stable, and wound healing is progressing well. Discharge instructions include continuing wound care at home and follow-up with the healthcare provider in two weeks. 68 Female Caucasian ICD Code: L89302

The patient has a history of limited mobility due to chronic back pain and obesity. The patient reports localized pain and redness on the buttock area. Physical examination shows a shallow ulcer on the buttock without signs of infection. Pressure ulcer of unspecified buttock, unspecified stage. The patient presents with a shallow ulcer on the buttock without signs of infection. The ulcer appears to be in the early stages, and the patient is being closely monitored for any signs of deterioration. The patient was advised on repositioning techniques, prescribed topical wound care ointment, and educated on the importance of offloading pressure. The patient's ulcer showed signs of healing, and they were discharged with instructions for wound care and follow-up in the outpatient clinic. 65 Female Caucasian ICD Code: L89309

The patient has a history of immobility due to a recent hip fracture and subsequent surgery. The patient complains of localized pain and tenderness on the right buttock. No signs of infection such as fever or purulent discharge reported. Physical examination reveals a deep ulcer on the right buttock with necrotic tissue, eschar, and undermining of adjacent tissue. No signs of exposed muscle or bone. Pressure ulcer of right buttock, unstageable. The ulcer is covered with eschar, making it difficult to determine the depth and stage of the wound. The patient is being closely monitored for signs of infection. Daily wound care with debridement of necrotic tissue is initiated. Nutritional assessment and support are ongoing to promote wound healing. Wound care with regular dressing changes, offloading of pressure, pain management, and nutritional support. The patient is stable, and wound healing is progressing. Discharge instructions include wound care procedures and follow-up appointments for wound assessment. 78 years Female Caucasian ICD Code: L89310

The patient has a history of limited mobility due to chronic back pain. The patient reports localized pain and redness on the right buttock. Physical examination shows a shallow ulcer on the right buttock with intact skin. Pressure ulcer of right buttock, stage 1. Verbatim EHR quote justifying the code: 'Physical examination reveals a shallow ulcer measuring less than 0.1 cm in depth on the right buttock.' The physician notes the presence of a stage 1 pressure ulcer on the right buttock and recommends offloading pressure from the area. Treatment includes wound cleaning, application of barrier cream, and patient education on pressure relief techniques. The patient is discharged with instructions for wound care and follow-up with a wound care specialist in two weeks. 68 Female Caucasian ICD Code: L89311

The patient has a history of immobility due to a recent hip fracture and subsequent surgery. The patient reports localized pain and tenderness on the right buttock. Upon examination, a deep wound with visible fat is noted on the right buttock. Wound culture taken from the ulcer shows no signs of infection. Imaging studies confirm the depth of the wound. Pressure ulcer of right buttock, stage 3. The patient presents with a stage 3 pressure ulcer on the right buttock, characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer on the right buttock is consistent with a stage 3 pressure ulcer. The patient is being closely monitored for signs of infection or deterioration. The patient is receiving daily wound care with appropriate dressing changes. Pain management is provided, and measures to relieve pressure on the affected area are implemented. The patient's pressure ulcer on the right buttock, stage 3, has shown signs of healing. Discharge instructions include wound care procedures to be continued at home. 68 Female Caucasian ICD Code: L89313

The patient has a history of limited mobility due to chronic lower back pain and osteoarthritis. No history of peripheral vascular disease or diabetes. The patient reports localized pain and tenderness on the right buttock. Skin discoloration and a shallow ulcer with minimal drainage noted on examination. No signs of infection on wound culture. Doppler ultrasound shows adequate blood flow to the area. Pressure ulcer of right buttock, unspecified stage. Verbatim: 'Pressure ulcer of right buttock, unspecified stage (ICD-10-CM code L89319) diagnosed based on clinical presentation and examination findings.' The ulcer is shallow, measuring 1.5 cm in diameter, with no exposed muscle or bone. No signs of infection or necrosis. The patient is instructed on wound care and pressure relief techniques. Wound care with saline irrigation, hydrocolloid dressing, and regular repositioning. Pain management with acetaminophen. Patient education on pressure ulcer prevention. The patient's ulcer shows signs of healing, with decreased pain and improved tissue granulation. Discharged with wound care instructions and follow-up appointment in two weeks. 68 Female Caucasian ICD Code: L89319

The patient has a history of immobility due to a recent hip fracture and is bedridden. No history of peripheral vascular disease or diabetes. The patient reports localized pain and tenderness on the left buttock. Upon examination, a non-blanchable erythema and localized warmth are noted on the left buttock. No signs of infection on wound culture. Doppler ultrasound shows adequate blood flow to the area. Pressure ulcer of left buttock, unstageable. The wound bed is covered with yellow slough obscuring the depth of the wound, making it unstageable. The patient's pressure ulcer on the left buttock is unstageable due to the presence of necrotic tissue covering the base of the wound. The ulcer is localized, with no signs of surrounding cellulitis. Daily wound care with debridement of necrotic tissue. Offloading the pressure on the affected area. Pain management with acetaminophen. The patient is stable, and the wound on the left buttock is showing signs of healing. Discharged with instructions for wound care and follow-up in the outpatient clinic in one week. 78 Female Caucasian ICD Code: L89320

The patient has a history of immobility due to a recent hip fracture and is bedridden. No history of peripheral vascular disease or diabetes. The patient reports localized pain and tenderness on the left buttock. Upon examination, a shallow ulcer with visible subcutaneous tissue is noted on the left buttock. No signs of infection on wound culture. Doppler ultrasound shows adequate blood flow to the affected area. Pressure ulcer of left buttock, stage 2. The ulcer is located on the left buttock and is characterized by partial-thickness skin loss involving the epidermis and dermis. The patient's ulcer on the left buttock is consistent with a stage 2 pressure ulcer. No signs of infection or deep tissue involvement are noted. The patient is being closely monitored for healing progress. Wound care with regular dressing changes. Offloading the pressure on the affected area. Pain management with acetaminophen. Nutritional assessment and supplementation. The patient's pressure ulcer on the left buttock, stage 2, has shown signs of healing. Discharge instructions include continuing wound care at home, maintaining a balanced diet, and follow-up with the healthcare provider in two weeks. 78 Female Caucasian ICD Code: L89322

The patient has a history of immobility due to a recent hip fracture. The patient reports localized pain and redness on the left buttock area. Physical examination shows a shallow ulcer on the left buttock without exposed muscle or bone. Pressure ulcer of left buttock, unspecified stage. The ulcer is located on the left buttock without muscle or bone involvement. The patient's pressure ulcer on the left buttock is being closely monitored for any signs of deterioration. The treatment plan includes keeping the area clean, applying a barrier cream, and repositioning the patient every two hours. The patient is stable, and wound care instructions have been provided for follow-up care at home. 68 Female Caucasian ICD Code: L89329

The patient has a history of diabetes and peripheral neuropathy, increasing the risk of pressure ulcers. The patient reports localized pain, redness, and skin breakdown on the left ankle. Physical examination shows a shallow ulcer on the left ankle without signs of infection. Pressure ulcer of left ankle, unspecified stage. The patient presents with a pressure ulcer on the left ankle, which is in an unspecified stage. The ulcer is shallow, and there are no signs of infection. The wound care team recommends offloading the pressure from the left ankle, keeping the area clean and dry, and monitoring for any signs of infection. The patient was started on a treatment plan that includes wound cleaning, application of a hydrocolloid dressing, and regular monitoring of the ulcer's progress. The patient was discharged in stable condition with instructions to follow up with the wound care clinic in two weeks for reassessment. 65 Female Caucasian ICD Code: L89529

The patient has a history of diabetes and peripheral vascular disease. The patient reports localized pain and foul-smelling discharge from the right heel. Wound culture showed presence of Staphylococcus aureus. Pressure ulcer of right heel, stage 3. Verbatim EHR quote justifying the code: 'Assessment reveals a deep crater with visible subcutaneous tissue on the right heel, measuring 2 cm x 3 cm, with signs of infection.' The wound is necrotic at the base with purulent discharge. No signs of osteomyelitis. Debridement performed, wound dressed with silver alginate, and started on oral antibiotics. Patient educated on wound care and scheduled for follow-up in the wound care clinic in two weeks. 65 Female Caucasian ICD Code: L89613

The patient has a history of limited mobility due to chronic hip arthritis, leading to prolonged pressure on the left heel. The patient reports localized pain and tenderness on the left heel. No signs of infection or necrosis noted. Physical examination shows a 2 cm x 2 cm ulcer on the left heel, with necrotic tissue covering the wound bed. Doppler ultrasound reveals adequate blood flow to the affected area. Pressure ulcer of left heel, unstageable. The wound bed is covered with necrotic tissue, making it impossible to determine the depth of the ulcer. The patient requires offloading of the left heel, daily wound care with debridement of necrotic tissue, and monitoring for signs of infection. Referral to a wound care specialist is recommended. Treatment includes offloading with a heel cushion, daily saline irrigation and dressing changes, and pain management with acetaminophen. The patient received education on pressure ulcer prevention. At discharge, the ulcer showed signs of healing with granulation tissue formation. The patient was advised to continue wound care at home and follow up with the wound care clinic in two weeks. 68 Female Caucasian ICD Code: L89620

The patient has a history of immobility due to a recent hip fracture. The patient reports localized pain and redness on the left heel area. Physical examination shows a shallow ulcer on the left heel with no signs of infection. Pressure ulcer of left heel, stage 1. The patient presents with a shallow ulcer on the left heel with no signs of infection. The patient's skin on the left heel is intact except for a small area with mild erythema and non-blanchable erythema. The patient was advised on offloading the pressure from the affected area, keeping the wound clean, and applying a barrier cream. Pain management was initiated. The patient was discharged with instructions on wound care and follow-up in the outpatient clinic. 65 Female Caucasian ICD Code: L89621

The patient has a history of diabetes and peripheral vascular disease, both of which are well-controlled with medications. The patient reports localized pain and tenderness on the left heel. Upon examination, there is noticeable skin discoloration and a shallow ulcer with pink wound bed visible. Wound culture obtained showing no signs of infection. Doppler ultrasound reveals adequate blood flow to the affected area. Pressure ulcer of left heel, stage 2. Verbatim_EHR_quote_justifying_the_code: 'Upon examination, there is noticeable skin discoloration and a shallow ulcer with pink wound bed visible on the left heel, consistent with a stage 2 pressure ulcer.' The patient's pressure ulcer on the left heel is currently at stage 2, involving partial thickness skin loss with exposure of the dermis. No signs of infection or deep tissue damage are noted. Treatment includes offloading the affected heel, keeping the wound clean and moist, and regular monitoring for signs of healing. The patient is prescribed topical dressings and instructed on proper wound care techniques. The patient responded well to treatment and demonstrated signs of healing. Discharge instructions include continued wound care at home and a follow-up appointment in two weeks. 65 Female Caucasian ICD Code: L89622