A thrombosis

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					                Nonpalpable Breast                                   Name: ________________________
                Lump Localisation                                    DOB: ____________ Sex: M F
A. CONDITION AND PROCEDURE                                  (f) The scar may be thickened and red coloured, and it
The doctor has explained that the patient has the           may be painful.
following condition:                                        (g) Increased risk in obese people of wound infection,
___________________________________________                 chest infection, heart and lung complications and
                                                            thrombosis.
___________________________________________                 (h) Increased risk in smokers of wound and chest
___________________________________________                 infections, heart and lung complications and thrombosis.

The following procedure will be performed to the
RIGHT           LEFT             BOTH breast(s):            E. SIGNIFICANT RISKS AND RELEVANT
                                                            TREATMENT OPTIONS
A lump has been detected in the breast which is not         The doctor has explained any significant risks and
palpable. This lump needs to be found by localisation       problems specific to me, and the likely outcomes if
with a needle under x-ray control. The surgeon will then    complications occur. The doctor has also explained
remove the lump following the needle pathway. The           relevant treatment options as well as the risks of not
tissue removed will usually be x-rayed to make sure the     having the procedure.
lump is present and then the Pathologist will test the
lump.
                                                            F. PATIENT CONSENT
B. ANESTHESIOLOGY                                           I acknowledge that:
If you have any concerns, you will have the opportunity     The doctor has explained my medical condition and the
to talk these over with your doctor prior to surgery.       proposed procedure. I understand the risks of the
                                                            procedure, including the risks that are specific to me,
C. GENERAL RISKS OF A PROCEDURE                             and the likely outcomes.
They include:
(a) Small areas of the lungs may collapse, increasing the
                                                            The doctor has explained other relevant treatment
risk of chest infection. This may need antibiotics and
                                                            options and their associated risks. The doctor has
physiotherapy.
                                                            explained my prognosis and the risks of not having the
(b) Clots in the legs (deep vein thrombosis or DVT) with
                                                            procedure.
pain and swelling. Rarely part of this clot may break off
and go to the lungs which can be fatal.
(c) A heart attack because of strain of the heart or a      I have been given a Patient Information Sheet
stroke.                                                     about the procedure and its risks.
(d) Death is possible due to the procedure.
(e) Increased risk in obese people of wound
                                                            I was able to ask questions and raise concerns with the
infection, chest infection, heart and lung complications,
                                                            doctor about my condition, the procedure and its risks,
and thrombosis.
                                                            and my treatment options. My questions and concerns
(f) Increased risk in smokers of wound and chest
                                                            have been discussed and answered to my satisfaction.
infections, heart and lung complications and thrombosis

D. RISKS OF THIS PROCEDURE                                  I understand that the procedure could include a blood
There are some risks, which include:                        transfusion, in the event of an emergency.

(a) Sometimes the lump is missed at the operation and
                                                            I understand that samples of tissue may be removed
further surgery may be necessary.
                                                            during the procedure, for testing and then disposed of
(b) The pathology report may indicate further treatment
                                                            sensitively by the hospital.
is necessary.
(c) Bruising may occur around the operation site.
(d) There may be a depression in the breast at the site     The doctor has explained to me that if immediate life-
of the excised lump.                                        threatening events happen during the procedure, they
(e) Scarring may pull the nipple out of shape.              will be treated accordingly.
I understand that no guarantee has been made that the
procedure will improve the condition, and that the
procedure may make my condition worse.


On the basis of the previous statements,
I REQUEST TO HAVE THE PROCEDURE.
(Nonpalpable Breast Lump Localization)
Date: ________________
Name of Patient/Substitute decision maker and
relationship:
____________________________________
Signature:
____________________________________

G. DOCTOR’S STATEMENT
I have explained:
     The patient’s condition
     Need for treatment
     The procedure and the risks
     Relevant treatment options and their risks
     Likely consequences if those risks occur
     The significant risks and problems specific to
        this patient

I have given the patient/substitute decision-maker an
opportunity to:
     Ask questions about any of the above matters
     Raise any other concerns which I have
       answered as fully as possible.

I am of the opinion that the patient/substitute decision-
maker understood the above information.

Marcus L Wever M.D., F.A.C.S.

Signature:_____________________________
Date:_________________________________

				
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