Heidi bub 2019

PREOPERATIVE DIAGNOSIS: Obstructive jaundice.

POSTOPERATIVE DIAGNOSIS: Pancreatic head mass.

SURGICAL PROCEDURES: EUS with FNA.

After informed consent was obtained, the patient received sedation with IV 10 mg Versed and IV 200 mcg of fentanyl for adequate sedation. The linear echoendoscope was first passed through the mouth down the esophagus to the extent of the duodenal bulb. The scope could not pass beyond the duodenal bulb into the descending duodenum due to the nature of her anatomy. The celiac axis was first scanned from the stomach and was grossly normal with no lymphadenopathy seen. The body and tail of the pancreas were scanned from the stomach at which point that the pancreatic duct was seen to be very irregular in nature and also dilated to approximately 5-6 mm. The parenchyma appeared very atrophic as well of the pancreas in the body and tail. No lymphadenopathy seen near. The scope was then advanced to the duodenal bulb through the pylorus into the duodenal bulb at which point a pancreatic head mass was seen. This mass appeared was very vague to differentiate from the normal pancreatic parenchyma, but appeared to be roughly 3 x 2 cm when scanned from the duodenal bulb. There appeared to be no invasion of the superior mesenteric artery and no invasion of the portal vein. There was seen a clean plane between these 2 structures. The percutaneous drain appeared to be extending into this mass. From the duodenal bulb, 3 biopsies were taken with the 22-gauge FNA needle. Three passes made through the duodenal wall of the pancreatic head lesion and sent for cytology, and cell block. There was maybe one 2 mm lymph nodes seen at this level, but again no definite vascular invasion was seen. The scope was then removed and the procedure complete.

ANESTHESIA TYPE: Conscious sedation.

ESTIMATED BLOOD LOSS: Minimal.

SPECIMENS REMOVED: FNA of the pancreatic head mass x3 with a 22 gauge needle through the duodenal wall.

FINDINGS: Pancreatic head mass measuring roughly 3 x 2 cm. Local collaterals seen, but no apparent invasion of the confluence, the portal vein or the superior mesenteric artery. Unable to pass the scope into duodenum for a full evaluation of this lesion.

COMPLICATIONS: None.

RECOMMEND: Await cytology results.

ICD-10-PCS Code: Click here to enter text.

3. Case Study #3

Code only the biopsy for this procedure.

PROCEDURE: Right heart cardiac catheterization and endomyocardial biopsy

procedure.

REASON FOR PROCEDURE: The patient is status post orthotopic cardiac

transplantation and is undergoing hemodynamic evaluation and surveillance

allograft biopsy for rejection.

The patient was admitted to the catheterization lab. His right neck was prepped

and draped in the usual sterile fashion. Using 2% lidocaine the skin was

anesthetized. Using the Seldinger technique, the right internal jugular vein

was easily entered. Good blood flow was obtained. A short sheath was placed

over a wire. The wire was removed. Through the sheath, the Swan was floated to

the right atrium, right ventricle, pulmonary artery, pulmonary capillary wedge

positions. Pressure was measured. PA saturation and thermodilution cardiac

output was measured. The Swan was withdrawn using a wire for guidance. The

short sheath was exchanged for a long biopsy sheath with its tip in the right

ventricle. The wire was removed through the biopsy sheath. A bioptome was

placed and endomyocardial biopsy specimens from the right ventricle were obtained. The biopsy sheath and bioptome were removed and good hemostasis was obtained using manual compression. The patient tolerated the procedure well. There were no complications. He was discharged from the catheterization lab in good condition.