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Case #3

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Expand Physical Exam

04/04/XX

Right breast: 4 x 3 cm firm, irregular mass at 1:00 position. No skin changes, no dimpling, no nipple discharge. Freely movable mass.
Left breast: No masses palpated. No palpable lymph nodes in right axilla.

Expand Imaging

04/06/XX

Mammograms: Suspected lesion in right breast. Faint calcifications at mirror image position in left breast.

04/15/XX

Chest X-Ray: Within normal limits.

Expand Laboratory

04/15/XX

SMA 12: fasting blood sugar elevated.

04/30/XX

Estrogen/progesterone receptors: ER mildly positive, PR negative.

Expand Surgical Observations

04/17/XX

Bilateral breast biopsies

04/30/XX

Right simple mastectomy, R sentinel LN biopsy, R TRAM flap reconstruction.

Expand Pathological Reports

04/17/XX

Biopsy, R breast: Intraductal carcinoma of the right breast, comedo type, nuclear grade 3, margins positive.
Biopsy, L breast: Fibrocystic calcifications, no evidence of malignancy.

04/30/XX

R simple mastectomy, R SLN biopsy: Extensive intraductal comedocarcinoma with lobular extension; TS = 4.1 x 3.5 x 3.0 cm; two R sentinel LNs without metastases.

Expand Treatment

04/30/XX

Surgery: Right simple mastectomy with right sentinel lymph node biopsy and right TRAM flap reconstruction.