Ms. Bautista is a 22 year old female presenting with a palpable mass in the right breast for the past one year. Per patient, she had an ultrasound evaluation at St. Anthony Hospital whereby she was told she had a fibroadenoma. Patient presents at the University of Chicago for second opinion. Upon physical exam at the patient's area of concern, there is a soft mobile mass appreciated.Targeted right breast ultrasound was performed:-In the right breast 10:00 location, approximately 5 cm from the nipple, there is an oval hypoechoic mass measuring 1.9 x 1.2 x 1.5 cm. -In the right breast 10:00 location, immediately inferior to the previously described mass is an additional oval hypoechoic mass measuring 0.9 x 0.8 x 1.0 cm.
Benign morphology masses in the right breast, likely representing benign fibroadenomata. Given that these are palpable, a surgical consultation is warranted for further evaluation. As long as the patient's physical examination remains normal, right breast ultrasound is recommended in 6 months in order to confirm stability of these findings. All results and recommendation were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: C - Clinical Correlation Needed. 