Ms. Johnson is a 62-year-old female with a personal history of left breast lumpectomy in 2008 for DCIS status post adjuvant radiation therapy. In clinic today, Dr. Chhablani palpated a possible enlarged right axillary lymph node. She presents today for ultrasound evaluation. Upon physical exam at the area marked by Dr. Chhablani, no discrete mass is appreciated. There are several enlarged superficial veins identified in the axillary and upper arm area.A targeted right axillary ultrasound was performed for the palpable area of concern. Three normal axillary lymph nodes identified in the area marked by Dr. Chhablani. No suspicious cystic or solid mass is identified.
Normal axillary lymph nodes in the right axilla. No sonographic evidence of malignancy. All findings relayed to Dr. Chhablani in person at time of dictation.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram.