Ms. Goodman is a 20-year-old female presenting with bilateral palpable breast masses for the past 6 years. According to the electronic medical record, patient has had multiple prior ultrasounds, a biopsy revealing fibroadenoma in 2013 and recommendations to see a breast surgeon. This history was gathered after the exam was done, as at the time of examination today the patient did not provide any of this history. 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: 3.1 x 1.6 x 2.2 cm, compared to 3.3 x 1.8 x 2.6 cm.- 9 o'clock location: 1.6 x 1 .0 x 1.7 cm, compared to 1.8 x 1.1 x 1.8 cm- 10 o'clock location: 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: 3.2 x 1.2 x 3.6 cm, compared to 3.7 x 2.0 x 3.5 cm.- 3 o'clock location: 1.1 x 0.7 x 1.2 cm- 12 o'clock location: 0.9 x 0.8 cm, compared to 0.9 x 1.2 cm.- 12 o'clock location: 1.1 x 0.6 cm
Multiple bilateral hypoechoic masses, likely representing fibroadenomata. Surgical consultation is recommended for this patient. All results and recommendations were thoroughly discussed with the patient.BIRADS: 3 - Probably benign finding.RECOMMENDATION: B - Surgical Consultation.