Needle localization (ultrasound) sample dictation

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CLINICAL HISTORY: [ ] year old woman referred for needle localization of a mass in the [right/left] breast. The lesion was noted on previous ultrasound performed at [ ] on [ ]. Recent mammogram performed at [ ] on [ ] revealed [ ].

Technique: Needle localization under ultrasound guidance, specimen radiography

PROCEDURE: Following universal protocol, patient and site verification was performed with a "time out" prior to the procedure. Preliminary ultrasound of the [right/left] breast with special attention to the area of sonographic concern, confirms the presence of a [ ] x [ ] cm mass at the [ ] o'clock axis, [ ] cm from the nipple.

Informed consent was obtained. The patient was positioned in the supine oblique position. The skin was cleansed. 0.2 cc 1% Lidocaine was used for local anesthesia. Using a [lateral/medial/superior/inferior] approach, a [ ] needle/wire assembly was used to localize the target under real-time sonographic guidance. A post-localization mammographic view was obtained, and sent with the patient to the OR.

The patient tolerated the procedure well and left the department in good condition.

A surgical specimen submitted for radiography demonstrates the targeted lesion to be within the specimen. The [ ] wire is intact. Dr. [ ] was notified of these findings at the time of surgery.

IMPRESSION: Ultrasound-guided needle localization and documented excision [left/right] breast mass.