breasts appear normal and symmetrical w/o dimpling or nipple/areolar erosion or discharge. On palpation breasts are nontender, and no nipple blood or discharge evoked by exam. Right breast shows a 2.5cm mass palpable in the upper-inner quadrant at 2o-clock position, no skin fixation or inflammation Right breast also shows a second 2.0cm lesion palpable at 12o-clock position, no skin fixation or inflammation Left Breast: WNL Lymphatic: 1.0cm Right axillary lymph node is firm, but mobile. Remaining lymph node assessment is negative. Abdomen: Abdomen mildly obese; nondistended ASSESSMENT/PLAN Test Results: Diagnostic Mammography: Highly suspicious of breast cancer. o Right breast: 3cm mass in upper inner quadrant @ 2-o-clock position o Right breast: 1cm mass in the 12-o-clock position o Right breast: 1cm deeper mass in the 12-o-clock position o No left breast abnormality seen Breast and Lymph node biopsy: o Breast mass: Invasive ductal carcinoma: ER-positive, PR-positive, HER2/neu-negative o Right-axillary lymph node: metastatic breast adenocarcinoma
Management Plan Refer to surgical/radiation for mastectomy / lumpectomy Refer to oncology for best approach. Refer to psychologist / support group.
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- Fall '19
- breast disease, right breast lumps