77-year-old female with history of palpable breast mass and new right breast abnormality on screening mammogram. Patient has a history of right chest wall injections for pain as recently as 7/2/2015. Physical exam demonstrated a palpable mobile mass in the right breast at the 12 o'clock position approximately 10 cm from the nipple. The patient reported a palpable mass in the right breast 12 o'clock position approximately 6 cm from the nipple. A targeted right ultrasound was performed in the aforementioned locations.At the 12 o'clock position approximately 10 cm from the nipple, an oval, cystic lesion with internal echogenic foci and linear septations was present measuring 1.8 x 0.8 x 1.7 cm. There was no internal vascularity.At the 12 o'clock position approximately 6 cm from the nipple in the area of the patient's reported palpable mass, normal breast tissue is appreciated. No suspicious masses identified.
1. Cystic lesion with internal echogenic foci and septations likely representing an injection granuloma from recent pain injection. Follow-up ultrasound in 3 months and surgical consult is recommended.2. In the area of the patient's pain at the 12:00 position of the right breast 6 cm from the nipple, no suspicious masses or abnormalities were noted.Results and plan were discussed with the patient at length.BIRADS: 2 - Benign finding.RECOMMENDATION: B - Surgical Consultation.