Ms. Muniz is a 21-year-old female with a personal history of high probability benign fibroadenomata of the right breast. Patient reports that her right breast masses are enlarging and associated with tenderness. Targeted ultrasound of the right outer breast, 9:00 position 5 cm from the nipple, reveals an oval parallel hypoechoic mass measuring 1.9 x 1.1 x 1.7 cm, previously 2.2 x 1.1 x 1.7 cm.Targeted ultrasound of the right lower outer breast, 8:00 position 4 cm from the nipple, reveals a 1.9 x 1.0 x 1.2 cm gently lobulated hypoechoic mass, previously measuring 1.9 x 1.5 x 2.1 cm.
Stable fibroadenomas of the right breast (8:00 mass stable in size dating back to 2014 and the 9:00 mass stable dating back to 2015). As long as the patient's physical examination remains normal, right ultrasound for the right breast 9:00 mass is recommended in 6 months. If findings remain stable, patient will have been followed for two years, confirming these lesions to be benign fibroadenomas. Results and recommendation were discussed with the patient.BIRADS: 3 - Probably benign finding. RECOMMENDATION: B - Surgical Consultation.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.