Ms. Smith is a 59-year-old female with a personal history of right lumpectomy and sentinel lymph node biopsy in 2009 for IDC, grade 3, ER/PR positive. The patient currently reports breast tenderness and tightness on the right. On Arimidex. Upon physical exam at the mammographic area of concern, no discrete mass was appreciated.Targeted ultrasound of the right breast 6:00 position was performed, demonstrating a hypoechoic mass with irregular margins and internal calcifications 6 cm from the nipple measuring 0.7 x 0.6 x 0.8 cm, with mildly increased vascularity peripherally.
New suspicious mass in the right breast 6:00 position, for which ultrasound-guided biopsy is recommended. All results and recommendations were discussed with the patient. The patient is not on any blood thinning medications.BIRADS: 4 - Suspicious Abnormality.RECOMMENDATION: H - Percutaneous Biopsy/Aspiration.