Ms. Smith is a 16 year old female presenting with a physician detected mass in the right breast. The patient herself does not palpate any abnormality. Upon physical exam at the palpable area of concern, a soft, mobile nontender mass is appreciated in the right lower, inner breast.A targeted right breast ultrasound was performed for the palpable area of concern. In the right breast 5 o'clock location, approximately 2 cm from the nipple, there is a 3.0 x 1.1 x 2.0 cm lobulated hypoechoic solid mass. There is moderate amount of associated vascularity.
Sonographic findings compatible with a fibroadenoma. Due to the size and palpability of this lesion, a surgical consultation is recommended at this time. All results and recommendations were relayed to the patient and her mother at time of dictation.BIRADS: 2 - Benign finding.RECOMMENDATION: B - Surgical Consultation.