Diagnostico Preoperatorio Anormal Explained for Students (Easy Guide)

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DIAGNOSTICO PREOPERATORIO: MMG anormal o masa palpable en la mama izquierda; otros trastornos de la mama PROCEDIMIENTO: Biopsia estereotactica automatizada de la mama izquierda RESULTADOS: La lesion se encuentro en la region lateral, justo al nivel del pezon o por debajo de el en la vista lateral de 90 grados. Hay un implante subglandular colocado. Hoy hable del procedimiento con la paciente, incluidos los riesgos, los beneficios y las alternativas. Se hablo especificamente del hecho de que el implante se desplazaria durante este procedimiento de biopsia. Se hablo con la paciente sobre la posibilidad de lesionar el implante. La paciente firmo el formulario de consentimiento y desea continuar con la biopsia. Se coloco a la paciente boca abajo sobre la mesa estereotactica; luego se tomaron imagenes de la mama izquierda desde el abordaje inferior. La lesion de interes esta en la porcion anterior de la mama, lejos del implante, que se desplazo hacia la pared toracica. Despues de obtener las imagenes y utilizar la guia estereotactica para determinar las coordenadas para la biopsia, se preparo la mama izquierda con Betadine. Se inyecto lidocaine al 1% por via subcutaneousnestesia local. Luego se inyecto lidocaine adicional con epinefrina a traves de la aguja permanente. Luego se coloco la aguja SenoRx en el area de interes. Bajo guia estereotactica, obtuvimos 9 muestras de biopsia central utilizando la tecnica de vacio y corte. La radiografia de la muestra confirmo que se habia extraido una muestra representative de calcification. El clip marcador de tejido se desplego en la cavidad de la biopsia con exito. Esto se confirmo mediante la imagen digital estereotactica final y mediante la mamografia posterior a la biopsia central de la mama izquierda. Se visualiza el clip proyectondo sobre la mama izquierda anterior lateral en una posicion satisfactoria. No se observa calcio obvious la imagen final posterior a la biopsia central en el area de interes. La paciente tolero bien el procedimiento. No hubo complicaciones aparentes. El sitio de la biopsia se cubrio con Steri-Strips, vendaje y bolsa de hielo de la manera habitual. La paciente recibio instrucciones escritas y verbales posteriores a la biopsia. La paciente dejo nuestro departamento en buenas condiciones. IMPRESION: 1. BIOPSIA ESTEREOTACTICA EXITOSA DE CALCIFICATIONES DE LA MAMA IZQUIERDA 2. COLOCACION EXITOSA DEL CLIP MARCADOR DE TEJIDO EN LA CAVIDAD DE LA BIOPSIA. 3. LA PACIENTE DEJO NUESTRO DEPARTAMENTO EN BUEN ESTADO HOY CON INSTRUCCIONES POST-BIOPSIA. 4. EL INFORME PATOLOGICO ESTA PENDIENTE; SE EMITIRA UN ANEXO DESPUES DE QUE RECIBAMOS EL INFORME PATOLOGICO. Cual es el codigo CPT? (PRE OP DIAGNOSIS: Left Breast Abnormal MMG or Palpable Mass, Other Disorders of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic. Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy samples using vacuum and cutting technique. The specimen radiograph confirmed representative sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive written and verbal post-biopsy instructions. The patient left our department in good condition. IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2. SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT. What is (are) the CPT code(s)?) A. 19681 O B. 19283 O C 19081, 19283 O D. 19100, 19283

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