Question

Buck’s The Next Step, 2019-2020                                                                                                                                               13

INTEGUMENTARY SYSTEM

LOCATION: Inpatient, Hospital PATIENT: Lucy Bates

ATTENDING PHYSICIAN: Gary Sanchez, MD

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Right breast cancer. POSTOPERATIVE DIAGNOSIS: Right breast cancer. PROCEDURE PERFORMED: Right modified radical mastectomy. ANESTHESIA: General.

PROCEDURE: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped sterilely. An elliptical incision was made around the right nipple to include the biopsy site, and flaps were created superiorly, inferiorly, medially, and laterally down to the pectoralis superiorly to the rectus fascia inferiorly, sternum medially, and latissimus laterally. We then took the breast off the pectoralis fascia and entered the axillary space.

Perforating vessels were either cauterized or ligated with 3–0 Vicryl suture ligatures. We entered the axillary space. We could feel several lymph nodes. We took the lymph nodes. We could see the thoracodorsal nerve easily and kept this free from our dissection. We were unable to identify the long thoracic nerve. Once we had stripped the lymph nodes free, we irrigated with saline. We could easily see the axillary vein superiorly, the latissimus dorsi laterally, and the pectoralis medially and had cleaned all the lymph nodes out of this space. We then irrigated with sterile water and placed two Jackson-Pratt drains, a lateral drain going into the axilla and a medial drain going underneath the skin flaps. We then closed in two layers with a deep layer of 3–0 Vicryl.

Steri-Strips and sterile Band-Aids were applied.

All sponge and needle counts were correct. The patient tolerated the procedure well and was taken to recovery in stable condition.

CPT Code(s):                                  

ICD-10-CM Code(s): _                               

Abstracting Questions:

1. Was this a radical mastectomy?                                  
2. Is lymph node dissection reported separately?                                  
3. Was skin grafting performed?                                  

Answer 1

1. Yes this was a radical mastectomy as adviced in the name of the procedure: right modified radical mastectomy

2. No lymph node dissection is not reported separately but is included in the intra operative notes itself.

3. No skin grafting procedure was not performed in the patient as it is not mentioned in the note.

CPT code: 19307

ICD 10 code: Z90.11