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: Needle-Localized Excisional Biopsy - Breast - 1

Description: Needle-localized excisional biopsy of the left breast. Left breast mass with abnormal mammogram. The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Left breast mass with abnormal mammogram.

POSTOPERATIVE DIAGNOSIS: Left breast mass with abnormal mammogram.

PROCEDURE PERFORMED: Needle-localized excisional biopsy of the left breast.

ANESTHESIA: Local with sedation.

COMPLICATIONS: None.

SPECIMEN: Breast mass.

DISPOSITION: The patient tolerated the procedure well and was transferred to recovery in stable condition.

INTRAOPERATIVE FINDINGS: The patient had a nonpalpable left breast mass, which was excised and sent to Radiology with confirmation that the mass is in the specimen.

BRIEF HISTORY: The patient is a 62-year-old female who presented to Dr. X's office with an abnormal mammogram showing a suspicious area on the left breast with microcalcifications and a nonpalpable mass. So the patient was scheduled for a needle-localized left breast biopsy.

PROCEDURE: After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought to the operating suite. After IV sedation was given, the patient was prepped and draped in normal sterile fashion. Next, a curvilinear incision was made.

After anesthetizing the skin with 0.25% Marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel. The lesion with needle was then grasped with an Allis clamp. Using #10 blade scalpel, the specimen was colonized out and sent to Radiology for confirmation. Next, hemostasis was obtained using electrobovie cautery. The skin was then closed with #4-0 Monocryl suture in running subcuticular fashion. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was sent to Recovery in stable condition.

Keywords: surgery, needle localized excisional biopsy, excisional biopsy, abnormal mammogram, breast mass, breast, radiology, biopsy, mammogram, needle,
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