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Case #5

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Expand Physical Exam

09/08/XX

Right breast: 2 cm mass present for 2-3 weeks prior to admission; discovered by patient. Associated with slight discomfort but no pain. No tenderness; peau d'orange noticed overlying the mass. No nipple discharge. Mass freely movable. No bone pain.
Left breast: No masses palpated. No palpable lymph nodes.

Expand Imaging

09/12/XX

Mammogram: Suspected malignant lesion of right breast.

09/13/XX

Chest X-Ray: No evidence of metastatic lesions.

10/01/XX

scan: No evidence of skeletal metastases.

Expand Laboratory

09/13/XX

SMA 20: WNL

09/14/XX

ERA/PRA: Both are negative

Expand Surgical Observations

09/14/XX

Right breast biopsy

09/20/XX

Right simple mastectomy with lymph node dissection.

Expand Pathological Reports

09/14/XX

R breast bx: Intraductal carcinoma; 1 cm lesion located 1 cm from nipple in upper outer quadrant.

09/20/XX

R mastectomy: No residual tumor at original biopsy site; no infiltration to pectoralis muscle or fascia. Metastatic carcinoma to 2 of 13 right axillary lymph nodes.

Expand Treatment

09/14/XX

Surgery: Right breast excisional biopsy; 9/20/XX Right simple mastectomy with right axillary lymph node dissection.

11/2/XX

Chemotherapy: Adriamycin/Cytoxan followed by Taxotere.

03/21/XX

Radiation: Beam radiation to right chest, total dose 6000 cGy.