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Biopsy, soft tissue of shoulder area; superficial

CPT4 code

Name of the Procedure:

Biopsy, soft tissue of shoulder area; superficial (Common name: Soft tissue biopsy of the shoulder, Superficial shoulder biopsy)

Summary

A soft tissue biopsy of the shoulder involves taking a small sample of tissue from just below the skin in the shoulder area. This helps doctors diagnose any abnormalities or diseases in the tissue.

Purpose

The procedure is done to:

  • Diagnose unexplained growths or lumps.
  • Determine the nature of a soft tissue mass (benign or malignant).
  • Help in diagnosing infections or inflammatory conditions.

The goal is to provide a clear diagnosis to guide further treatment.

Indications

  • Unexplained masses or lumps in the shoulder area.
  • Persistent pain or swelling without a clear cause.
  • Abnormal imaging results from X-rays, MRIs, or CT scans.
  • Persistent infections or inflammatory symptoms.

Preparation

  • Patients may need to stop certain medications like blood thinners before the procedure.
  • Fasting is typically not required.
  • A physical exam and imaging studies might be done to pinpoint the biopsy site.

Procedure Description

  1. The patient is positioned comfortably, and the shoulder area is sterilized.
  2. Local anesthesia is administered to numb the skin and tissue.
  3. A small incision is made over the targeted area.
  4. A needle or biopsy tool is inserted to collect a tissue sample.
  5. The sample is collected and sent to a lab for analysis.
  6. The incision site is closed with a bandage or a few stitches.

Duration

The procedure typically takes about 15 to 30 minutes.

Setting

The biopsy is usually performed in an outpatient clinic, hospital, or surgical center.

Personnel

  • A physician or surgeon specializing in biopsies.
  • A nurse to assist with the procedure and provide post-procedure care.
  • A pathologist who will examine and interpret the biopsy sample.

Risks and Complications

  • Mild pain or bruising at the biopsy site.
  • Infection at the incision site.
  • Bleeding or hematoma formation.
  • Rarely, damage to surrounding tissues.

Benefits

  • Precise diagnosis of the condition affecting the shoulder.
  • Guidance for appropriate treatment plans.
  • Early detection of serious conditions, leading to better outcomes.

Recovery

  • Keep the biopsy site clean and covered as instructed.
  • Over-the-counter pain relievers can manage minor pain.
  • Most patients can return to normal activities within a day or two.
  • Follow-up appointments may be needed to discuss biopsy results and further steps.

Alternatives

  • Watchful waiting with regular monitoring.
  • Imaging studies such as MRI or ultrasound.
  • Fine-needle aspiration, which is less invasive but may provide less diagnostic information.

Patient Experience

During the procedure, patients typically feel pressure but not pain due to local anesthesia. Post-procedure, there may be minor discomfort, swelling, or bruising at the biopsy site. Pain management includes over-the-counter pain relief, and basic care instructions will ensure a smooth recovery.

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