Question

Audit Report 4.3 Pathology Report

LOCATION: Inpatient Hospital

PATIENT: Martin Glass

SURGEON: Ira Avila, MD

ATTENDING PHYSICIAN: Ira Avila. MD

PATHOLOGIST: Grey Lonewolf, MD

CLINICAL HISTORY: Adenoma, prostate, and nodules and prostate

TISSUES RECEIVED: LT pelvic lymph nodes (FS). A. LT pelvic, lymph nodes (FS). FB. RT pelvic lymph nodes (FS). B. A pelvic lymph nodes (FS) C. Prostate.

GROSS DESCRIPTION Received in a container labeled "left pelvic nodes" and are multiple tan and red lymph nodes up to 25 cm. 

COOPERATIVE FROZEN SECTION DIAGNOSIS: As per Dr. Lonewolf: left pelvic lymph nodes: Negative for tumor

The lymph nodes are submitted as A.

Received in a container labeled "right pelvic lymph nodes" are multiple tan and red lymph nodes up to 2.5 cm. 

COOPERATIVE FROZEN SECTION DIAGNOSIS: As per Dr. Lonewolt: Right pelvic lymph nodes: Negative for tumor 

The lymph nodes are submitted as B.

Received in a container labeled "prostate" is a prostate measuring 5.8 X 5.5 X 4 cm in greatest dimension and weighing 65 g. The surface has a tan to gray purple appearance and diffuse multincidularity. The seminal vesicles are identified and show no abnormalities. The specimen is step sectioned and demonstrates a varied pattern with multiple foci of yellow infiltrative solid areas amongst the gray-tan moist cut surface. The right seminal vesicle is submitted as Cl and CZ. The left seminal vesicle is submitted as C3 and C4. The right portion of the specimen from posterior to anterior is submitted as CS to C13 and C37 to C40. The left portion is submitted as C14 to C24 and the midline is submitted as C25 to C32 The apex is submitted as C33 to C36.

MICROSCOPIC DESCRIPTION: The lymph nodes of the left pelvic region are negative for tumor and show sinus histiocytosis

The lymph nodes of the right pelvic region are negative for tumor and show sinus histiocytosis.

The prostate demonstrates multiple areas of glands that vary in size and configuration and are lined by cells that are slightly enlarged with vesicular nuclei. The cells are relatively uniform and show intragłandular papillations and foci of hyperplasia. The seminal vesicles show normal morphology. Rare small foci demonstrate closely crowded glands that contain enlarged cells with vesicular nuclei showing prominent nuclei. The cytoplasm varies in amounts Large numbers of the glands cystically dilated and lined by Battened epithelium. Foci of squamousm metaplasiaare present in rare glands.

DIAGNOSIS: Lymph nodes, left pelvic: Negative for tumor, sinus histiocytosis 

Lymph nodes, right pelvic: Negative for tumor sinus histiocytosis

Prostate total prostatectomy: Adenocarcinoma, well differentiated, Gleason's grade 2+2 = 4, occasional foci, adenomatous hyperplasia; prostatic, intraepithelial neoplasia, high grade, ertansive.

COMMENT: The surgical margins of resection appear free of a tumor. Case reviewed with Dr. Avila

One of the following codes is reported incorrectly for this case Indicate the incorrect code

PROFESSIONAL SERVICES: Surgical pathology, 88305-26; Surgical pathology, 88305-26; Pathology surgical consultation, first tissue block, 88331; Pathology surgical consultation, additional tissue block, 88332

ICD-10-CM DX: Prostate neoplasm; C61

INCORRECT CODE:

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