Ms. GWENDOLYN COLEMAN is a 65 years old female with history of left mastectomy 12/2013 for invasive ductal carcinoma and DCIS. Patient received radiation and chemotherapy. Benign right breast biopsies. She presents today for pain in the right axilla. On physical examination, no discrete masses are palpated at the area of pain in the right axilla.A targeted right axilla ultrasound was performed for the patient’s area of pain. There is no masses or abnormal lymph node identified in the area over pain. A normal morphology lymph node is noted in the right axilla.
No sonographic evidence for malignancy or for patient's pain in the right axilla. The patient should follow up with her primary care physician as clinically warranted, presuming these results are concordant with the physical exam findings. Routine diagnostic right breast mammogram is recommended, due in July 2016. Results and recommendations were discussed with the patient. BIRADS: 1 - Negative.RECOMMENDATION: ND - Routine Diagnostic Mammogram.