Ms. Rosalind Henderson is a 59 year old female inpatient with a personal history of a right mastectomy in 1990 with recurrent invasive carcinoma along the right chest wall in 2011. She presents today for evaluation of pain in her right axilla. ULTRASOUND:On physical examination, no discrete mass is palpated in the right axilla where the pain is located.A targeted right axillary ultrasound was performed for the patient’s area of pain, designated by the patient. There is no solid or cystic mass identified.
No sonographic evidence of malignancy in the right axilla. 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, left diagnostic mammogram is recommended annually, due in January, 2017. Results and recommendation were discussed with the patient.BIRADS: 1 - Negative.RECOMMENDATION: ND - Diagnostic Mammogram.