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Case #1

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Expand Physical Exam

06/02/XX

Right breast: 5 x 3 cm mass noted on physical exam by family physician. No pain or tenderness; no nipple discharge; no skin changes. Slight nipple retraction; freely movable mass.
Left breast: No masses palpated
No enlarged lymph nodes bilaterally

Expand Imaging

06/13/XX

Chest X-Ray: Within normal limits

07/01/XX

Bone Scan: No evidence of skeletal mets; questionable early stage osteophytosis

6/20/XX

Thoracic and lumbar spine: Negative for metastases

Expand Laboratory

06/13/XX

SMA 12: Within normal limits

06/15/XX

Estrogen receptor assay: Positive for estrogen receptors

Expand Surgical Observations

06/06/XX

Biopsy right breast mass

06/15/XX

Right modified radical mastectomy

Expand Pathological Reports

06/06/XX

Biopsy right breast mass: Adenocarcinoma of right breast, margins involved.

06/15/XX

R MRM: Infiltrating duct carcinoma of right breast with dermal invasion; no evidence of tumor in 32 regional lymph nodes; tumor is attached to fat; tumor size is 5.5 x 4.0 x 4.0 cm; lesion is located at 12:00; differentiation is grade 2.

Expand Treatment

06/15/XX

Surgery: Right modified radical mastectomy with axillary lymph node dissection.

08/01/XX

Hormone: Arimidex started.