Stereotactic biopsy sample dictation
CLINICAL HISTORY: [ ] year old woman referred for stereotactic core biopsy of a cluster of indeterminate microcalcifications in the [left or right] breast noted on recent mammography at [place and date].
Technique: [ ] breast stereotactic core biopsy. Unilateral [digital] mammography. Specimen radiography. Dated [ ].
PROCEDURE: Preliminary grid localizing film confirms a [ ] cm cluster of microcalcifications in the [location within the breast].
Following universal protocol, patient and site verification was performed with a "time out" prior to the procedure. After obtaining informed consent, the patient was positioned prone on the stereotactic table and the target was localized with digital images. A [ ] approach was used. The skin was cleansed with Chloraprep. Cutaneous and deeper subcutaneous anesthesia was achieved using [ ] cc of 1% Lidocaine and [ ] cc's of 1% Lidocaine containing epinephrine respectively. A small scalpel incision was made. A 9 gauge ATEC probe was inserted and its accurate position confirmed with pre and post fire images on the first pass. A total of [ ] core biopsy specimens were obtained.
[#of radiographs] specimen radiographs revealed calcification in [ ] cores. Cores containing radiographically evident calcium were sent in one container of formalin and cores not containing radiographically evident calcium were sent in another container of formalin for pathologic analysis, results pending. A [ ] clip was [ ] deployed to mark the biopsy site.
Post procedure cranial caudal and medial lateral projections disclose the clip to be at the target site. There [ are or are no ] residual microcalcifications noted at the biopsy site.
Following the procedure, the wound was cleansed and compressed. Steri strips and sterile gauze were applied and the patient was given post biopsy instructions. She left the department in good condition.
Dr. [ ] was in attendance during the entire procedure.
CONCLUSION: Status post stereotactic core biopsy of [right/left]