Ms. Victorya Harlan is a 29 year old female presents for evaluation of a palpable and painful concern in her right breast. As she has a strong family history of breast cancer in her mother (diagnosed at the age of 32), maternal great aunt, maternal great great aunt, paternal great aunt, paternal grandmother, and paternal great grandmother. ULTRASOUND:On physical examination, no discrete mass is palpated.A targeted right ultrasound was performed for the palpable area of concern, which is at the 6:00, 7 cm from the nipple.. There is no solid or cystic mass identified.
No mammographic evidence of malignancy. Further evaluation of a clinically suspicious abnormality should not delayed by negative imaging. Rather, negative imaging may serve to reinforce a negative clinical impression. Therefore, continued clinical management is recommended. As long as the patient's physical examination remains normal, bilateral screening mammogram is recommended annually at age of 40 or based on patient's risk assessment. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: NS - Screening Mammogram.