Single Well Circumscribed Breast Lesion

Benign

• nipple
• skin lesion
• cyst
• inflammatory lymph node
• fibroadenoma
• papilloma
• hamartoma

Malignant

• Phyllodes tumor
• mets
• medulary carcinoma
• mucoid carcinoma
• colloid carcinoma

Multiple Well Circumscribed Breast Lesions

Benign

• Skin lesions
• Inflammatory nodes
• cysts
• fibroadenomas

Malignant

• Mets

Breast Microcalcifications Differential

Benign

• Sclerosing adenosis
• fibrocystic change
• vascular
• skin lesion

Malignant

• DCIS
• Invasive cancer

Edematous Breast Differential

Benign

• breast abscess
• medical – heart failure
• fluid overload, etc.
• radiotherapy
• recent surgery

Malignant

• Inflammatory carcinoma

Ultrasound Core Biopsy Dictation

CLINICAL HISTORY: [x] 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 [x] on [date]. Recent mammogram performed at [x] on [date] [demostrated/failed to demonstrate] the lesion.

Technique: [x] breast ultrasound guided core biopsy dated [x].

PROCEDURE:
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] x [x] cm mass at the [x] o’clock position, approximately [x] cm from the nipple, at a depth of [x] 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. [x] 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 [x] 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. [x] was in attendance during the entire procedure.

IMPRESSION

Ultrasound-guided core biopsy of [right/left] breast mass. Pathology pending.

Screening Bilateral Breast Ultrasound Dictation

Clinical History: [x] year old woman referred for bilateral breast ultrasound. [x]

Comparison: [x]

Technique: Bilateral breast ultrasound dated [x]

Findings: Real time ultrasound of both breasts was performed as per clinical request. There is no sonographic evidence of a discrete cystic or solid lesion in either visualized breast.

Impression:

No sonographic evidence of a lesion in either breast.

Recommendation:

Screening mammogram in [x]

Findings and recommendations were discussed with the patient following this evaluation.