Wiki Post mastectomy breast biopsy

[neelaprakash]

Is this exam coded as a breast biopsy or a biopsy of neck and thorax? TIA​

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CLINICAL INFORMATION:​

70-year-old female presenting status post left mastectomy with a
suspicious left chest wall mass.

COMPARISON:​

None

FINDINGS:​

Left ultrasound re-identified the target lesion for biopsy. The lesion to be
targeted is a hypoechoic mass in the left chest wall sixth rib measuring 0.8 x 0.6 x 0.8
cm. The lesion was readily visible.

PROCEDURE:​

The procedure and its risks, including bleeding, infection, and failure to
diagnose, and expected benefits of ultrasound-guided core biopsy with percutaneous
placement of a marking clip and post-procedure unilateral mammogram were discussed with
the patient. Questions were answered. Consent was obtained both verbally and in writing.
The time-out form was completed to confirm patient identity and side/type of procedure.

The left breast was cleansed with chlorhexidine over the target area. Transducer was
sterilely sheathed. Local anesthesia was obtained using 2% lidocaine superficially, with
1% lidocaine with 1:100,000 epinephrine at depth. A 3 mm incision was made in the skin
with a #11 scalpel blade. Using aseptic technique, continuous ultrasound guidance and alateromedial approach, three 14-gauge core needle (Marquee) specimens were obtained of the
lesion. Targeting was judged excellent. All specimens sank to the bottom of the
prefilled container of 10% formalin. Specimen quality was judged excellent.

Specimens were sent to Pathology with an accompanying history sheet. Using continuous
ultrasound-guidance a Bard twirl clip was placed into the lesion in the usual manner.
Pressure was held over the biopsy site until all bleeding subsided. The skin incision was
closed with a Steri-Strip.

No evidence of hematoma or other complication.

A pressure dressing was positioned over the biopsy site and an ice pack positioned over
the pressure dressing. Post-procedure instructions were reviewed with the patient both
verbally and in writing. She tolerated the procedure well with no evident complications
and left the Breast Imaging Department in stable condition.

The procedure was performed by Dr. Jandali.

IMPRESSION:​

Successful ultrasound-guided core biopsy of the left chest wall lesion and
clip placement. Pathology is pending at this time.