Ms. Goodman is a 21 year old female presenting with bilateral palpable masses. Patient has had prior FNA of the left breast revealing fibroadenoma in 2013. She currently states that these masses have decreased in size since compared to prior examination. Upon physical exam of the right breast, at least 3 palpable masses are identified, the largest of which is in the right lower inner breast.Targeted right breast ultrasound is performed for the patient's areas of concerns.- 5 o'clock location: 3.0 x 1.6 x 2.4 cm, compared to 3.1 x 1.6 x 2.2 cm.- 9 o'clock location: 1.6 x 1.2 x 1.7 cm, compared to 1.6 x 1 .0 x 1.7 cm.- 10 o'clock location: 0.8 x 0.5 x 0.9 cm, compared to 1.0 by 0.4 x 1.2 cmUpon physical exam of left breast, at least for palpable masses are identified, the largest of which is in the left lower inner breast.Targeted left breast ultrasound is performed for the patient's area of concerns.- 7 o'clock location: 3.4 x 1.5 x 3.4 cm, compared to 3.2 x 1.2 x 3.6 cm.- 3 o'clock location: 1.0 x 0.7 x 1.2, compared to 1.1 x 0.7 x 1.2 cm- 12 o'clock location: 2.4 x 1.6 x 1.5 cm, compared to 0.9 x 0.8 cm.- 12 o'clock location: 1.8 x 1.6 x 1.8 cm, compared to 1.1 x 0.6 cm.
Interval increase in size of two left breast masses. Multiple additional bilateral masses are relatively unchanged in size, all of which likely represent fibroadenomata. Continued surgical observation is recommended for this patient. All results and recommendations were discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: B - Surgical Consultation.