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
