Ms. Philbin is a 55 year old female with a personal history of right breast lumpectomy in 2011 with positive margins. She had an additional biopsy for new calcifications of the right breast in 2013 with results of DCIS. Since then patient has declined additional treatment/surgery. Family history of breast cancer in mother, maternal grandmother, and paternal grandmother. She presents today for a surgeon detected mass in the right medial breast. The skin has been marked by Dr. Chhablani. Targeted ultrasound was performed of the medial right breast at the site marked by the clinical service. In the right breast 3:00 location, there is no suspicious cystic or solid mass appreciated.
No suspicious finding at the site of palpable concern. The patient will follow up with Dr. Chhablani. The BiRads code below reflects the known DCIS in the right breast.BIRADS: 6 - Known cancer.RECOMMENDATION: B - Surgical Consultation.