Medical Specialty:
Obstetrics / Gynecology
Sample Name: Breast Mass Excision - 1
Description: Left breast mass and hypertrophic scar of the left breast. Excision of left breast mass and revision of scar. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Left breast mass.
2. Hypertrophic scar of the left breast.
POSTOPERATIVE DIAGNOSES:
1. Left breast mass.
2. Hypertrophic scar of the left breast.
PROCEDURE PERFORMED: Excision of left breast mass and revision of scar.
SPECIMEN: Scar with left breast mass.
DISPOSITION: The patient tolerated the procedure well and transferred to the recover room in stable condition.
BRIEF HISTORY: The patient is an 18-year-old female who presented to Dr. X's office. The patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site. The patient also has a hypertrophic scar. Thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.
INTRAOPERATIVE FINDINGS: A hypertrophic scar was found and removed. The cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.
Keywords: obstetrics / gynecology, hypertrophic scar, palpable mass, fibrocystic, scar, fibrocystic disease, breast mass, breast, cicatrix, excision, biopsy, hypertrophic, palpable,