Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Breast Biopsy - 2

Description: Needle localization and left breast biopsy for left breast mass.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS
Left breast mass.

POSTOPERATIVE DIAGNOSIS
Left breast mass.

PROCEDURE PERFORMED
Needle localization and left breast biopsy.

ANESTHESIA
General.

FLUIDS
1000 cc.

ESTIMATED BLOOD LOSS
Minimal.

DRAINS
None.

COMPLICATIONS
None.

SPECIMEN
Breast biopsy specimen with localizing needle.

FINDINGS
Breast tissue surrounding needle localization while no palpable mass.

HISTORY
The patient is a very pleasant 51-year-old African-American female who presented to the office with a mass in the left breast. She was seen and evaluated. On routine mammography, revealed a density in the left breast approximately at 4 o'clock position several centimeters lateral to the nipple complex. She was readmitted for excisional biopsy.

Due to the nonpalpable nature of this lesion, the patient underwent first needle localization of the breast at the Hospital and was taken to the operating room.

PROCEDURE IN DETAIL
After informed consent was obtained from the patient, the patient taken to the operating room and placed in the supine position on the operating table. After appropriate general endotracheal anesthesia has been administered to the patient, the left breast was prepped and draped in a standard surgical fashion using Betadine solution.

The localization wire was cut at skin. The patient had previously had a reduction mammoplasty in the lateral aspect of the transverse where an incision was re-incised to distance of about 4 cm. The wire was entering the skin about 2 cm above the incision. Superior skin flap was raised using electrocautery, and the needle localization wire was brought into the incision. At this point, a core breast tissue of approximately 2 cm surrounding the needle was excised superiorly, inferiorly, medially, and laterally until the tissue specimen was well below the hook of the needle localization wire.

The breast specimen was then removed from breast, and silk sutures were used to mark the superior and lateral margins. This specimen was then sent for mammography. Pathologist called in the room to verify that the entire needle localization wire and hook were intact in the specimen. At this point, the breast cavity was palpated and no other abnormalities were noted.

The wound was irrigated. Bleeding points were easily controlled using electrocautery. The wound was closed in two layers using 3-0 Vicryl and 4-0 Monocryl suture in a subcuticular fashion. Benzoin, Steri-Strips, 2 x 2's, Tegaderm were placed. The patient was aroused from anesthesia and transported to the recovery room in stable condition. There were no complications. All instrument, needle, and sponge counts were correct x2 at the end of the case.

Keywords: surgery, breast mass, needle localization, steri-strips, tegaderm, biopsy, breast biopsy, breast cavity, excisional biopsy, localization wire, room in stable condition, skin flap, specimen, needle localization wire, needle, breast, mammography, localization,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples