Mr. Jones is a 22-year-old female presenting with a superficial lesion in the left breast. Per patient, this lesion became an open wound with bleeding approximately 4 days ago. She denies any discrete mass or nipple discharge. Upon physical exam at the patient's area of concern, there is an open wound with serous drainage in the left lower inner breast. No discrete mass is appreciated at this site.A targeted left breast ultrasound was performed for the patient’s area of concern. In the left breast 8:00 location, approximately 6 cm from the nipple, there is a superficially located, hypoechoic lesion identified measuring 1.2 x 0.1 x 1.0 cm. Minimal associated vascularity is present. Sonographic findings are compatible with an epidermal inclusion cyst.
Benign epidermal inclusion cyst of the left breast. No sonographic evidence for malignancy. Patient should keep the wound dry and covered, use bacitracin daily, and warm compresses. The patient should follow up with her primary care physician as clinically warranted for this area, presuming these results are concordant with the physical exam findings. All results and recommendations were relayed to the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: C - Clinical Correlation Needed.