57-year-old female status post fall on 1/18/16 with trauma to the left anterior chest. Now feels a "knot" in the left breast, superior to the nipple. Rule out hematoma. According to the patient today, the palpable area is improving significantly in the past week and was also not present before the fall. On physical exam, a small lump was palpable in the 1:00 position 3 cm from the nipple. A targeted left breast ultrasound was then performed in the palpable area of concern. In the 1:00 position approximately 1 cm from the nipple is a heterogenous, predominantly hyperechoic area measuring 9 x 10 mm without appreciable vascular flow.
Physical exam and ultrasound findings likely represent a evolving hematoma/fat necrosis in the left breast. However, a three month follow-up is recommended to ensure resolution. These findings and recommendations were discussed with the patient who agreed with the plan.BIRADS: 3 - Probably benign finding.RECOMMENDATION: 3B - Followup at Short Interval (1-11 Months).