Medical Specialty:
Hematology - Oncology
Sample Name: Lymph Node Excisional Biopsy
Description: Left axillary lymph node excisional biopsy. Left axillary adenopathy.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Left axillary adenopathy.
POSTOPERATIVE DIAGNOSIS: Left axillary adenopathy.
PROCEDURE: Left axillary lymph node excisional biopsy.
ANESTHESIA: LMA.
INDICATIONS: Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only. Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast. Patient has been following with Dr. Diener and Dr. Wilmot. I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both. She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion. I recommended that she have this lymph node removed. The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.
Keywords: hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy,