Ultrasound core biopsy sample dictation
CLINICAL HISTORY: [ ] year old woman referred for ultrasound-guided biopsy of a mass in the [right/left] breast. The lesion was noted on previous ultrasound performed at [ ] on [date]. Recent mammogram performed at [ ] on [date] [demostrated/failed to demonstrate] the lesion.
Technique: [ ] breast ultrasound guided core biopsy dated [ ].
Preliminary ultrasound evaluation of the [right/left] breast with special attention to the area of [sonographic/mammographic/palpable] concern, confirms the presence of a [ ] x [ ] cm mass at the [ ] o'clock position, approximately [ ] cm from the nipple, at a depth of [ ] cm from the skin.
Following universal protocol, patient and site verification was performed with a "time out" prior to the procedure. Informed consent was obtained. The patient was positioned in the supine oblique position, and the lesion was localized with real-time sonography. The skin was cleansed with Chloraprep. [ ] cc's of 1% Lidocaine was used for local anesthesia. A [lateral/medial/oblique] approach to the target was used. An 18-gauge needle, secured to a spring-loaded device, was advanced to the preselected target. A total of [ ] biopsy specimens were obtained, with pre- and post-fire images documenting needle placement for each pass. Specimens were sent for pathologic analysis, results pending.
Following the procedure, the wound was cleansed and compressed. Steri-strips and sterile gauze were applied and the patient was given post-biopsy instructions. The patient tolerated the procedure well and left the department in good condition.
Dr. [ ] was in attendance during the entire procedure.
Ultrasound-guided core biopsy of [right/left] breast mass. Pathology pending.