QC4 TRANSCRIPTION
PATHOLOGY REPORT
Patient Name: Ursula Emma Wagner
Patient ID: 004654
DOB: 6/4/----
Age: 65
Sex: Female
Pathology Report No.: s-10-30178
Date of Surgery: 12/14/----
Admitting Physcian: Bernard Kester, MD, General Surgery.
Preoperative Diagnoses: Right Breast Mass.
Postoperative Diagnoses: Right Breast Mass.
Specimen Submitted: Needle biopsy right breast mass.
GROSS DESCRIPTION: Received fresh spec board with acompany radiograph with a fibrofatty piece of tissue with wire localization in the area in question is circle under radiograph in the 2-7/O-H area. This area is inked blue with the remaining tissue inked black. On sectioning through the tissue it is compraise primarly of soft yellow adipose tissue with scant intervining fiborus tissue. Well distinct mass is seen. The area and question is entirly submitted into cassates A1 through A8.
MICROSCOPIC DESCRIPTION: 8 plus slides label A1 through A8 are examined. Sections displayed occasional cystics spaces lined by a single layer of flattened two cuboidal shape mucinous cells showing no significant cytologic atypia. Rare foci of mild ductal epithelial hyperplasia are also present. A few microcalcifications deposits are seen association with the B-9 memory glands. No atypical hyperplasia carcinoma in situ or invasive melignancy is identified.
FINAL PATHOLOGICAL DIAGNOSIS: Right breast biopsy with needle localization
No evidence of melignancy.
B-9 mucinous cycts.
Focal ductal epithelial hyperplasia. No atypia.
Microcalcifications.
Pathology Report
Patient Name: Ursula Emma Wagner
Patient ID: 004654
Page 2
The CPT code is 88305.
Comment: This case went interdepartmental consantation and accurcanse interpretation was achieved.
______________________________
Georgia Tamayo, MD
GT:JKI
D: 12/14/----
T: 12/14/----
C: Bernard Kester, MD
Patient Name: Ursula Emma Wagner
Patient ID: 004654
DOB: 6/4/----
Age: 65
Sex: Female
Pathology Report No.: s-10-30178
Date of Surgery: 12/14/----
Admitting Physcian: Bernard Kester, MD, General Surgery.
Preoperative Diagnoses: Right Breast Mass.
Postoperative Diagnoses: Right Breast Mass.
Specimen Submitted: Needle biopsy right breast mass.
GROSS DESCRIPTION: Received fresh spec board with acompany radiograph with a fibrofatty piece of tissue with wire localization in the area in question is circle under radiograph in the 2-7/O-H area. This area is inked blue with the remaining tissue inked black. On sectioning through the tissue it is compraise primarly of soft yellow adipose tissue with scant intervining fiborus tissue. Well distinct mass is seen. The area and question is entirly submitted into cassates A1 through A8.
MICROSCOPIC DESCRIPTION: 8 plus slides label A1 through A8 are examined. Sections displayed occasional cystics spaces lined by a single layer of flattened two cuboidal shape mucinous cells showing no significant cytologic atypia. Rare foci of mild ductal epithelial hyperplasia are also present. A few microcalcifications deposits are seen association with the B-9 memory glands. No atypical hyperplasia carcinoma in situ or invasive melignancy is identified.
FINAL PATHOLOGICAL DIAGNOSIS: Right breast biopsy with needle localization
No evidence of melignancy.
B-9 mucinous cycts.
Focal ductal epithelial hyperplasia. No atypia.
Microcalcifications.
Pathology Report
Patient Name: Ursula Emma Wagner
Patient ID: 004654
Page 2
The CPT code is 88305.
Comment: This case went interdepartmental consantation and accurcanse interpretation was achieved.
______________________________
Georgia Tamayo, MD
GT:JKI
D: 12/14/----
T: 12/14/----
C: Bernard Kester, MD