Metastatic Brain Tumor

Patient presents with signs and symptoms suggestive of metastatic brain tumor.  Clinical presentation includes [specific symptoms e.g., headaches, seizures, cognitive impairment, focal neurological deficits, nausea, vomiting, balance difficulties].  Onset of symptoms was [timeframe e.g., gradual over several weeks, sudden].  Patient history includes [relevant medical history e.g., primary cancer diagnosis of [type] with stage [stage], previous brain MRI findings, relevant family history].  Neurological examination reveals [specific findings e.g., cranial nerve palsies, hemiparesis, sensory deficits, altered mental status].  Imaging studies, including MRI of the brain with and without contrast, demonstrate [specific findings e.g., multiple enhancing lesions, single lesion with surrounding edema, location of lesions].  Differential diagnosis includes primary brain tumor, abscess, stroke, and demyelinating disease.  Based on the clinical picture, imaging findings, and patient history, the diagnosis of metastatic brain tumor is most likely.  Treatment plan includes consultation with oncology, neurosurgery, radiation oncology, and palliative care as appropriate.  Options for management include corticosteroids for symptom control, surgical resection if feasible, stereotactic radiosurgery, whole-brain radiation therapy, and systemic therapies targeted at the primary cancer.  Patient and family were counseled regarding prognosis and treatment options.  Referral to social work and support services provided.  Follow-up scheduled in [timeframe].  ICD-10 code C79.31 (secondary malignant neoplasm of brain) is assigned.  CPT codes for evaluation and management, imaging studies, and procedures will be documented separately.