Question

INPATIENT HOSPITAL Gender: F Age: 48

Preprocedure diagnosis: Mass in left breast

Procedure description: Needle biopsy. Using a needle, took out a tissue sample from the left breast that was previously marked with a wire.

Postprocedure diagnosis: Benign neoplasm, breast per pathology report

1. What is the stated procedure?

  

2. What organ or body part is involved?

  

3. Is the procedure description what you would expect based on the name of the procedure?

  

4. Was more than one procedure, or a combined procedure, performed?

  

5. Review the Key Criteria for Abstracting Root Operations. To which question did you answer yes?

  

6. Review the definitions of the root operations that answer this question. Which root operation correctly describes this procedure?

  

7. Review the Key Criteria for Abstracting the Approach. What surgical approach is used?

  

8. Review the Key Criteria for Abstracting the Qualifier. Was the procedure diagnostic or therapeutic?

Answer 1

Ans :

1. Stated procedure:  

Needle biopsy. Using a needle, took out a tissue sample from the left breast that was previously marked with a wire.

2. Part of the organ involved: Breast

3. Procedure description:

When other tests show that you might have breast cancer, you will probably need to have a biopsy. Needing a breast biopsy doesn’t necessarily mean you have cancer. Most biopsy results are not cancer, but a biopsy is the only way to find out for sure. During a biopsy, a doctor will remove small pieces from the suspicious area so they can be looked at in the lab to see if they contain cancer cells.

4. Types of breast biopsies

There are different kinds of breast biopsies. Some are done using a hollow needle, and some use an incision (cut in the skin). Each has pros and cons. The type you have depends on a number of things, like:

How suspicious the breast change looks

How big it is

Where it is in the breast

If there is more than one

Any other medical problems you might have

Your personal preferences

5. Yes

6. Root operations:

Root operations used in the breast cancer

Mastectomy of the left breast (the entire breast is removed and not just a quadrant or mass)

7. Surgical approaches:  Breast-conserving surgery (also called a lumpectomy, quadrantectomy, partial mastectomy, or segmental mastectomy) is a surgery in which only the part of the breast containing the cancer is removed. The goal is to remove the cancer as well as some surrounding normal tissue.

8.Diagnostic