History Patient Year Question & Answer Guide (With Explanation)
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Original Question
History: patient is 50 year old female who noted a swelling in the neck. Outpatient workup was done. Thyroid scan and thyroid sonogram revealed moderate enlargement of the left lobe of the thyroid gland measuring 1.1 x 2.2 cm, a solid nodule at the anterior aspect of the mid of the left lobe of thyroid measuring approximately 1 x 1.9 cm, a small cyst in the middle of the left lobe of the thyroid measuring 2.4 cm, normal right lobe measuring 2.3 mm. thyroid scan showed hot nodule, which is usually negative for malignancy. The fine needle aspiration was strongly suspicious for papillary carcinoma. IMPRESSION: Papillary carcinoma of the thyroid REPORT OF OPERATION Preoperative Diagnosis: Steroid nodule left lobe, rule out papillary carcinoma Postoperative Diagnosis: Papillary carcinoma of thyroid Procedure: Left thyroid lobectomy with isthmectomy and frozen section. Subsequently, patient underwent total thyroid lobectomy. Anesthesia: general endotracheal Estimated blood loss: 50 cc. replacement; IV fluids, sponge count, needle count times two correct. Technique: after a patient was well anesthetized with general endotracheal anesthesia, a sand bag was placed underneath the shoulder blades. The neck was extended and stabilized and placed on a foam head pillow. Entire neck and anterior chest was prepped and draped in the usual manner. The skin incision site was marked with 2-0 VICRYL suture with pressure. Preempt analgesia was obtained with infiltration of .25 percent Marcaine. Transverse skin incision was made in the anterior part of the neck, which was deepened through the subcutaneous tissue and the platysma. Upper and lower flaps were raised, upper flap up to the thyroid cartilage, lower flap up to the sternal notch. Hemostasis obtained with cautery as well as 3-0NvicryL sutures. Midline fascia was incised. Strap muscles on the left side were separated from the underlying thyroid gland. Strap muscles were retracted laterally with a green retractor. Middle thyroid veins were identified, divided between the clamps, ligated with 3-0 VICRYL suture. Patientwas noted to have palpable thyroid nodule on the left lower part of the thyroid gland. Superior thyroid vessels were identified. External of the superior laryngeal nerve was identified and protected. Superior thyroid vessels were divided close to the thyroid clamp between the mixter clamps and ligated with 2-0 VICRYL suture. Recurrent laryngeal nerve was identified and protected throughout the procedure. Superior and inferior parathyroids were identified, protected with their vasculature. Inferior thyroid vessels were divided close to the thyroid capsule after it branching to preserve the blood supply to the parathyroid gland. Isthmus was divided between the clamps and the entire thyroid lobe was removed and sent for frozen section, which was reported to be a papillary carcinoma. After the pathology report, the decision was made to proceed with the total thyroidectomy, which was carried out in the following manner: strap muscles on the right side were separated from the right thyroid gland. Middle thyroid vessels were divided between the clamps, ligated with 3-0 VICRYL suture. Superior and inferior thyroid poles were identified. Superior thyroid vessels were divided close to the upper pole. During the procedure, the external branch of the superior laryngeal nerve was identified and protected. The divided vessel was ligated with 2-0 VICRYL suture. Recurrent laryngeal nerve was identified and protected. Inferior and superior parathyroid glands were identified and protected with vasculature. Inferior thyroid vessel branches were divided between the clamps; thereby the blood supply to the parathyroid was preserved. Care was taken to protect the recurrent laryngeal nerve throughout the procedure. The right lobe of the thyroid was completely removed after satisfactory hemostasis. No drains were placed. The strap muscle was approximated with interrupted 3-0 VICRYL suture. Platysma and subcutaneous tissue was approximated with interrupted 4-0 VICRYL suture. Skin approximated with subcuticular 4- Dexon. Sterile dressing was applied. At the end of the procedure the vocal cords were inspected. They were moving equally well. The patient tolerated the entire procedure well and was discharged in stable condition to the recovery room. Discharge information: patient discharged after 2 days, with no complication. Diagnosis: Papillary carcinoma of the thyroid, left and right lobes, with follicular pattern. Papillary carcinoma positive in one cervical lymph node ICD-10CM Code with POA Indicator and MS-DRG: ICD-10-PCS Code:
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