Ms. Gaevskiy is a 44-year-old female with history of palpable right breast lesions, previously worked up with mammogram and ultrasound at an outside hospital. A targeted right ultrasound was performed for the palpable area of concern. In the right breast at the 10:00 position, approximately 1 cm from the nipple, are several scattered simple cysts, the largest of which measures 6 x 3 x 6 mm, without internal vascularity. In the right breast at the 5:00 position, approximately 1 cm from the nipple, is a cluster of cysts and microcysts, with the largest individual cyst measuring 4 x 4 mm, and the entire cluster measuring approximately 13 x 6 x 9 mm; there is no associated internal vascularity within the cysts themselves.
Scattered cysts and a cluster of microcysts in the right breast correlating to the patient's palpable areas of concern. Please note, diagnostic mammogram is recommended for palpable breast lesions, however her referring provider Dr. Jacobson declined that test. No mammographic evidence of malignancy. As long as the patient's physical examination remains normal, bilateral diagnostic mammogram and right breast ultrasound are recommended in 6 months. Results and recommendation were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at Short Interval (1-11 Months).