Medical Specialty:
Endocrinology
Sample Name: Axillary Dissection & Mass Excision
Description: Left axillary dissection with incision and drainage of left axillary mass. Right axillary mass excision and incision and drainage. Bilateral axillary masses, rule out recurrent Hodgkin's disease.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Bilateral axillary masses, rule out recurrent Hodgkin's disease.
POSTOPERATIVE DIAGNOSIS: Bilateral axillary masses, rule out recurrent Hodgkin's disease.
PROCEDURE PERFORMED:
1. Left axillary dissection with incision and drainage of left axillary mass.
2. Right axillary mass excision and incision and drainage.
ANESTHESIA: LMA.
ESTIMATED BLOOD LOSS: Less than 30 cc.
INDICATION: This 56-year-old male presents to surgical office with history of bilateral axillary masses. Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter. The patient had been continued on antibiotics preoperatively. The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time. Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses. The patient was explained the risks and benefits of the procedure and informed consent was obtained.
GROSS FINDINGS: Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.
No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time. The right axillary mass was excised without difficulty without requiring full axillary dissection.
Keywords: endocrinology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary,