Medical Specialty:
Surgery

Sample Name: Breast Mass Excision


Description: Excision of right breast mass. Right breast mass with atypical proliferative cells on fine-needle aspiration.
(Medical Transcription Sample Report)


PREOPERATIVE DIAGNOSIS: Right breast mass with atypical proliferative cells on fine-needle aspiration.

POSTOPERATIVE DIAGNOSIS: Benign breast mass.

ANESTHESIA: General

NAME OF OPERATION: Excision of right breast mass.

PROCEDURE: With the patient in the supine position, the right breast was prepped and draped in a sterile fashion. A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast. Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue. Hemostasis was obtained using electrocautery. Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign. The breast tissues were approximated using 4-0 Vicryl. The skin was closed using 5-0 Vicryl running subcuticular stitches. A sterile bandage was applied. The patient tolerated the procedure well.



Keywords: surgery, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass,