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| Physical Exam | 06/02/XX |
Right breast: 5 x 3 cm mass noted on physical exam by family physician. No pain or tenderness; no nipple discharge; no skin changes. Slight nipple retraction; freely movable mass. Left breast: No masses palpated No enlarged lymph nodes bilaterally |
| Imaging | 06/13/XX |
Chest X-Ray: Within normal limits |
| 07/01/XX | Bone Scan: No evidence of skeletal mets; questionable early stage osteophytosis | |
| 6/20/XX | Thoracic and lumbar spine: Negative for metastases | |
| Laboratory | 06/13/XX | SMA 12: Within normal limits |
| 06/15/XX | Estrogen receptor assay: Positive for estrogen receptors | |
| Surgical Observations | 06/06/XX |
Biopsy right breast mass |
| 06/15/XX | Right modified radical mastectomy | |
| Pathological Reports | 06/06/XX | Biopsy right breast mass: Adenocarcinoma of right breast, margins involved. |
| 06/15/XX | R MRM: Infiltrating carcinoma of right breast with dermal invasion; no evidence of tumor in 32 regional lymph nodes; tumor is attached to fat; tumor size is 5.5 x 4.0 x 4.0 cm; lesion is located at 12:00; differentiation is grade 2. |
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| Treatment | 06/15/XX | Surgery: Right modified radical mastectomy with axillary lymph node dissection. |
| 08/01/XX | Hormone: Arimidex started. | |
