Obstetrics / Gynecology
Sample Name: Needle Localized Excision - Breast Neoplasm
Description: Nonpalpable neoplasm, right breast. Needle localized wide excision of nonpalpable neoplasm, right breast.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Nonpalpable neoplasm, right breast.
POSTOPERATIVE DIAGNOSIS: Deferred for Pathology.
PROCEDURE PERFORMED: Needle localized wide excision of nonpalpable neoplasm, right breast.
GROSS FINDINGS: This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast. After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity. This too was excised.
The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm. On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen. Hemostasis was obtained with electrocautery. Good hemostasis was obtained. The incision was closed in two layers. The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl. The second layer consisted of Steri-Strips on the epidermis. A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied. The patient tolerated the surgery well.
Keywords: obstetrics / gynecology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast,