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James Okonkwo

MRN DERM-2024-0089 · DOB 1961-11-04 · 62 Male · Medicare Advantage

EPIC EHRPatient ChartLab ResultsImaging StudiesVisit HistoryProblem List

Referral Orderorder_3

PROCEDURE

Wide Excisional Biopsy (Urgent) — Complete with Sentinel Lymph Node Mapping

ORDERING PROVIDER

Dr. Rachel Torres, MD — Primary Care

REQUESTED WINDOW

Within 5 days — URGENT (regional lymphadenopathy + elevated LDH + worsening systemic symptoms)

INDICATION

Urgent wide excisional biopsy with sentinel lymph node mapping for: (1) 6-week history of a rapidly enlarging, irregular pigmented lesion on the back with color variation, now 14mm (ABCDE-positive: Asymmetry, Border irregularity, Color variation, Diameter, Evolving); (2) 12 lb unintentional weight loss over 10 weeks; (3) new ulceration and intermittent bleeding from the lesion (2 weeks); (4) new palpable satellite nodule adjacent to the primary lesion; (5) regional ultrasound showing a 1.8 cm left axillary lymph node with loss of normal fatty hilum — radiologist recommends histopathological correlation; (6) LDH elevated at 285 U/L; (7) Strong family history — father melanoma age 55, maternal uncle melanoma age 62. Prior incomplete shave biopsy (community clinic, 2022) — insufficient depth, Breslow staging not possible. Tertiary dermatologic oncology center required for wide excision with sentinel lymph node biopsy given anatomical/staging complexity.

DIAGNOSES (ICD-10)

L98.9 — Disorder of the skin and subcutaneous tissue, unspecified (evolving pigmented lesion); R59.0 — Localized enlarged lymph nodes; R63.4 — Abnormal weight loss; Z80.8 — Family history of malignant neoplasm of other organs (melanoma); D48.5 — Neoplasm of uncertain behavior, skin (rule out — biopsy pending); R79.89 — Other specified abnormal findings of blood chemistry (elevated LDH); N18.3 — Chronic kidney disease, Stage 3a (eGFR 58); E11.9 — Type 2 diabetes mellitus without complications (newly diagnosed).