Ms. Kaitlin Stalling is a 22 year old female with bilateral breast reduction in 2012. Biopsy of a left breast fibroadenoma in 2010. Patient stated that her left breast fibroadenoma been removed due to breast reduction in 2012. She presents for a new mass in her left breast. On physical examination, a mobile discrete mass is palpated in the lower inner left breast. A targeted left ultrasound was performed for the palpable area of concern. In the left breast, 8:00 position, 5 cm from the nipple, there is a circumscribed, hypoechoic, lobulated mass with small amount of internal blood flow, which measures 2.3 x 1.1 x 2.3 cm.
A 2.3 cm circumscribed mass in the left breast, 8:00 position, corresponding to patient's palpable concern, likely represents a fibroadenoma. Patient is scheduled to see the breast surgeon today. Biopsy/FNA can be considered using palpable or image guidance if clinically suspicious. Alternatively, this presumed fibroadenoma can be followed on ultrasound in 6 months to assess the stability. Results and recommendations were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: B - Surgical Consultation.