76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited

Name of the Procedure:

Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited

Summary

This procedure involves using ultrasound technology to create real-time images of one breast and, if needed, the adjacent axilla (underarm area). It is used to examine and document specific areas of concern within the breast tissue.

Purpose

The primary goal is to investigate abnormalities or areas of concern identified in a clinical exam or another imaging study. It helps in diagnosing conditions like cysts, tumors, or other breast-related issues.

• Medical Condition/Problem: Breast lumps, pain, or abnormalities detected in prior exams.
• Goals/Outcomes: Accurate diagnosis and documentation of breast abnormalities; guidance for further treatment or biopsy if necessary.

Indications

• Detection of a palpable lump or mass.
• Follow-up on abnormal mammogram results.
• Breast pain or tenderness.
• Checking for fluid-filled cysts.
• Evaluation of axillary lymph nodes.

Preparation

• No special preparation required.
• Wear comfortable clothing that can be easily removed or adjusted.
• Avoid applying lotions, powders, or deodorants on the day of the procedure.

Procedure Description

1. The patient is positioned lying on their back or slightly turned to one side.
2. A water-based gel is applied to the breast area to ensure good contact for the ultrasound probe.
3. The technologist or radiologist moves the probe over the skin surface to capture images of the breast tissue and axilla if needed.
4. The real-time images are viewed on a screen, and specific areas are documented.
   • Tools/Equipment: Ultrasound machine, handheld transducer/probe, gel.
   • Anesthesia/Sedation: Not required.

Duration

The entire procedure typically takes about 15-30 minutes.

Setting

Performing location varies, including hospitals, outpatient clinics, or specialized imaging centers.

Personnel

• Sonographer or radiologist conducts the ultrasound.
• Radiologist interprets the images.

Risks and Complications

• Common Risks: None, the procedure is non-invasive and generally safe.
• Rare Risks/Complications: Minimal discomfort from pressure of the probe. Unlikely, but possible skin irritation from the gel.

Benefits

• Expected Benefits: Provides clear, real-time images aiding in accurate diagnosis.
• Timing of Benefits: Immediate visualization during the procedure; results are usually available shortly after.

Recovery

• Post-Procedure Care: None; patients can return to normal activities immediately.
• Expected Recovery Time: None required.
• Follow-Up: May involve further imaging studies, biopsy, or consultation with your healthcare provider.

Alternatives

• Other Options: Mammography, MRI, or biopsy.
• Pros and Cons: Ultrasound is non-invasive, safe, and does not use radiation. MRI may provide more detailed images but is more expensive and involves lying still for a longer period. A biopsy provides a definitive diagnosis but is more invasive.

Patient Experience

• During Procedure: Mild pressure from the probe; generally painless.
• After Procedure: Normal activities can be resumed immediately.