Case -AUDIT REPORT T5.2 OPERATIVE REPORT, MASTECTOMY

Essay

Case
-AUDIT REPORT T5.2 OPERATIVE REPORT, MASTECTOMY
LOCATION: Outpatient, Hospital
PATIENT: Rosemary Ely
SURGEON: Gary Sanchez, MD
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Left segmental mastectomy and axillary node dissection
ANESTHESIA: General
PROCEDURE: The patient was given a general anesthetic. I did an ultrasound, which showed the node in the axilla was 2.16 cm. The cavity itself was 3.22 cm with a depth from skin to the top of the cavity of 0.52 cm. Prints were made and placed on the chart. I then proceeded with free-draping her left arm, and she was prepped and draped in this position. I started with the axilla. I made an incision in the axilla and went down through clavipectoral fascia. I identified this large lymph node, and it looked quite terrible. I sent it for frozen section, and it came back signet cell variation, which concerned the pathologist. He felt that there may be a GI component rather than the breast; however, I had a copy of the pathology report showing that this small cancer had signet cell variation, so it is likely from the breast. The oncologist was in the room, and we felt that we should explore the upper GI tract afterward just to be sure. The oncologist will organize that for us.
I then completed the axillary dissection. I identified the thoracodorsal vessel and nerves, long thoracic nerve, intercostals brachial nerve, and the axillary vein. We made sure there were no palpable nodes left.We stripped right from the axillary vein all the way down. I used clips and ties during this dissection. I then did the segmental mastectomy.
I developed the superior flap and then the inferior flap. I then removed the segmental mastectomy going from lateral to medial. I sent it out for frozen section margins. The pathologist felt that our margins were clear. I then put a Hemovac drain in with one limb in the axilla and one limb on the chest wall. I sutured the drains in and then brought the subcutaneous tissue together with Vicryl. Staples were placed in the skin.
Telfa, Toppers, and gauze were applied. The patient tolerated the procedure well and went to the recovery room in good condition.
PATHOLOGY REPORT LATER INDICATED: Adenocarcinoma, breast; Metastatic adenocarcinoma, lymph node consistent with breast carcinoma.
T5.2:
SERVICE CODE(S): 19301, 38525-51__________________________________
ICD-10-CM DX CODE(S): C50.912____________________________________
INCORRECT/MISSING CODE(S): ____________________________________