Description

Renata Chapman 42-year-old female, presenting for complaint of 2 right breast lumps. She 1st noticed the lumps about 6 months ago while taking a shower. Positive for 11 lb weight loss over last 3 months. Negative for nausea, vomiting, abdominal or breast pain, breast discharge, scaly nipples, pain, swelling, or redness. Physical exam reveals 1st a 2.5 cm mass palpable in upper- inner quadrant at 2 o’clock position, 2nd a 2.0 cm, lesion to right breast is palpable at 12 o’clock position. A right axillary lymph node noted that is firm and mobile. The lesions are negative for skin fixation, inflammation, or erythema. Negative for abdominal distention or tenderness. She had and abnormal screening mammogram 3 years ago of right breast. Stereotactic breast biopsy results revealed Atypical ductal hyperplasia. Recommended Genetic testing, follow-up and repeat mammo in 6 months, no record of completion.