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Case #4

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Expand Physical Exam

01/10/XX

Right breast: 4 x 5 x 3 cm hard mass near 6:00. Normal nipple without discharge. Lesion not attached to fascia or muscle.
Left breast: Normal. No enlarged lymph nodes bilaterally and no abdominal masses palpated.

Expand Imaging

01/15/XX

Chest X-Ray: Normal

02/01/XX

Bone scan: Abnormality in left knee, consistent with known arthritis; otherwise normal.

02/08/XX

L-S scan: WNL

Expand Laboratory

01/15/XX

SMA 20: Within normal limits

Expand Surgical Observations

01/10/XX

R breast aspiration biopsy

01/16/XX

R partial mastectomy/axillary lymph node dissection: Lesion located in the lower inner quadrant.

Expand Pathological Reports

01/10/XX

Aspiration bx: Right breast: Cells compatible with adenocarcinoma.

01/16/XX

R partial mastectomy/ALN dissection: Intraductal and infiltrating duct carcinoma of right breast; 2 of 5 axillary lymph nodes positive at level I; 10 negative lymph nodes at levels II and III. Tumor size = 4.5 cm, margins clear, ER/PR negative.

Expand Treatment

01/16/XX

Surgery: R Partial mastectomy with axillary LN dissection.

02/20/XX

Chemo: Adriamycin/Cytoxan followed by Taxotere.

07/30/XX-09/18/XX

Radiation: Beam radiation to R breast, total dose 6060 cGy in 33 Fxs.