Needle localization (mammogram) sample dictation

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CLINICAL HISTORY: [ ] year old woman referred for needle-wire localization of a [mass/cluster of calcifications] in the [right/left] breast [ ] noted on previous mammogram performed at [ ] on [ ].


PROCEDURE: Following a universal protocol, patient and site verification was performed with a "time out" prior to the procedure. Preliminary mammographic views of the [right/left] breast confirm the presence of a [ ] cm [mass/cluster of calcifications] in the [ ], approximately [ ] cm from the nipple.


Informed consent was obtained. A localizing grid film was obtained. The skin was cleansed with ChloraPrep. [ ] cc of 1% Lidocaine was used for local anesthesia. Using a [lateral/medial/superior/inferior] approach, a [ ] needle/wire assembly was used to localize the target. Post-localization mammographic views disclosed the target to be[ant/post/med/lat] to the [reinforced segment of the wire/distal portion of the needle]. Labeled films were 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 [mass/calcifications] to be within the specimen. The [ ] wire is intact. Dr. [ ] was notified of these findings at the time of surgery.


IMPRESSION:

Needle/wire localization and documented surgical excision of [left/right] breast [ ] [mass/microcalcifications].