BFAITHFUL
Expert
I'm not sure which code to use for the following im thinking 19301-LT not sure what to use for the ultrasound part?
DX: Papilloma of breat and need for lumpectomy
The patient is a 70 year old female who had an ultrasound directed biopsy of a nodule, which was in the subareolar left breast in the upper outer quadrant of the subareolar portion closer to the 12 o'clock position. The biopsy results revealed a papilloma. For this reason, the patient is having a mammographic directed lumpectomy of this area to make sure there is no missed carcinoma. The patient before coming to the surgical center was seen at _____Imaging by Dr. D and a mammographic and ultrasound directed placement of wire is performed and the patient comes to the surgical center with wire taped in place. The patient was found to be hypertensive with a systolic blood pressure over 200, but because she already had the wire in place, because she was on medication, and because she came down nicely with just sedation, we elected to proceed.
DESCRIPTION OF PROCEDURE:
The patient is placed on the table in supine position. IV sedation is given. Antibiotic is given. Venodyne boots are in place. The left arm is abducted. The tape was removed from the breast. The breast is prepared with Betadine and draped out sterilely and time out is had.
Now using the SonoSite ultrasound with transducer draped out sterilely, we examine the breast with the transducer held longitudinally just to the lateral side of the nipple and transversely just above the nipple. We find the area of concern on both these views and mark it out so that the intersection is the area, which we will use to make the center of our lumpectomy. We now design a periareolar incision just outside the areolar complex from the 12 o'clock to the 3 o'clock position with a sterile marking pen. Now, we infiltrate the skin all around the area of intended surgery with 1% lidocaine and deeply with Marcaine. The incision is made. We come down through skin and subcutaneous tissue. The area of concern is easily 1.5 to 2 cm deep into the skin so we make our subcutaneous margin about three-quarters of a centimeter below the skin and then develop flaps to encompass the area of concern. After making the flaps, we then develop the incision through the breast tissue straight down through breast tissue to the underlying pectoralis fascia and then bring the incision through the pectoralis fascia and lift up on the lumpectomy specimen. We bring the guidewire, or the previously placed wire, out of its skin puncture site into the main incision and elevate the entire lumpectomy specimen out of the wound. With the lumpectomy specimen held out of the wound with wire in place, we mark the lateral aspect with a long silk suture and the short border or margin with a short silk suture. It is labeled lumpectomy subareolar left breast upper outer quadrant. We examine the specimen with the ultrasound on the table and see the area of concern on two views with the wire going through it with the clip within the nodule right in the center of the lumpectomy specimen. I therefore feel very confident that the area of concern has been removed and that there is adequate tissue all the way around it should it be malignant. With this done, we hand the specimen off. We irrigate the wound and dry it with sterile gauze. The gauze is held first medially and then laterally until we stop all oozing and irrigate again and dry making sure there is no further oozing. The breast wound is now closed in layers using interrupted inverted 3 0 Vicryl sutures and a deep to more superficial fashion until the skin is well approximated. At that time we use a 4 0 Monocryl subcuticular to finish the skin closure. Benzoin and Steri-Strips are placed followed by Telfa, Bioclusive and then we place 4x4s combine over the Bioclusive and use Medipore tape. The patient tolerated the procedure well and goes to the recovery room in stable condition. In the recovery room and before the patient left the surgery center, her blood pressure was re-measured a number of times and was in the 140 to 70 range. Vital signs were otherwise stable. The patient and her husband were notified of the blood pressure problem.
DX: Papilloma of breat and need for lumpectomy
The patient is a 70 year old female who had an ultrasound directed biopsy of a nodule, which was in the subareolar left breast in the upper outer quadrant of the subareolar portion closer to the 12 o'clock position. The biopsy results revealed a papilloma. For this reason, the patient is having a mammographic directed lumpectomy of this area to make sure there is no missed carcinoma. The patient before coming to the surgical center was seen at _____Imaging by Dr. D and a mammographic and ultrasound directed placement of wire is performed and the patient comes to the surgical center with wire taped in place. The patient was found to be hypertensive with a systolic blood pressure over 200, but because she already had the wire in place, because she was on medication, and because she came down nicely with just sedation, we elected to proceed.
DESCRIPTION OF PROCEDURE:
The patient is placed on the table in supine position. IV sedation is given. Antibiotic is given. Venodyne boots are in place. The left arm is abducted. The tape was removed from the breast. The breast is prepared with Betadine and draped out sterilely and time out is had.
Now using the SonoSite ultrasound with transducer draped out sterilely, we examine the breast with the transducer held longitudinally just to the lateral side of the nipple and transversely just above the nipple. We find the area of concern on both these views and mark it out so that the intersection is the area, which we will use to make the center of our lumpectomy. We now design a periareolar incision just outside the areolar complex from the 12 o'clock to the 3 o'clock position with a sterile marking pen. Now, we infiltrate the skin all around the area of intended surgery with 1% lidocaine and deeply with Marcaine. The incision is made. We come down through skin and subcutaneous tissue. The area of concern is easily 1.5 to 2 cm deep into the skin so we make our subcutaneous margin about three-quarters of a centimeter below the skin and then develop flaps to encompass the area of concern. After making the flaps, we then develop the incision through the breast tissue straight down through breast tissue to the underlying pectoralis fascia and then bring the incision through the pectoralis fascia and lift up on the lumpectomy specimen. We bring the guidewire, or the previously placed wire, out of its skin puncture site into the main incision and elevate the entire lumpectomy specimen out of the wound. With the lumpectomy specimen held out of the wound with wire in place, we mark the lateral aspect with a long silk suture and the short border or margin with a short silk suture. It is labeled lumpectomy subareolar left breast upper outer quadrant. We examine the specimen with the ultrasound on the table and see the area of concern on two views with the wire going through it with the clip within the nodule right in the center of the lumpectomy specimen. I therefore feel very confident that the area of concern has been removed and that there is adequate tissue all the way around it should it be malignant. With this done, we hand the specimen off. We irrigate the wound and dry it with sterile gauze. The gauze is held first medially and then laterally until we stop all oozing and irrigate again and dry making sure there is no further oozing. The breast wound is now closed in layers using interrupted inverted 3 0 Vicryl sutures and a deep to more superficial fashion until the skin is well approximated. At that time we use a 4 0 Monocryl subcuticular to finish the skin closure. Benzoin and Steri-Strips are placed followed by Telfa, Bioclusive and then we place 4x4s combine over the Bioclusive and use Medipore tape. The patient tolerated the procedure well and goes to the recovery room in stable condition. In the recovery room and before the patient left the surgery center, her blood pressure was re-measured a number of times and was in the 140 to 70 range. Vital signs were otherwise stable. The patient and her husband were notified of the blood pressure problem.