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| Physical Exam | 06/04/XX |
Left breast: Lump in LOQ present for three months. Firm, hard, with chronic intermittent pain. No skin lesions; no nipple discharge or retraction. Mass is freely movable; TS = 2.0 cm. Right breast: Within normal limits. No organomegaly, no palpable lymph nodes bilaterally. |
| Imaging | 06/01/XX |
Bilat mammograms: Left breast mass, rule out carcinoma; right breast is normal. |
| 06/11/XX | Chest X-Ray: Normal | |
| 06/30/XX | Liver/spleen scan: Normal | |
| Laboratory | 06/11/XX |
SMA 20: Within normal limits. |
| Surgical Observations | 06/12/XX |
Core needle biopsy left breast mass @4:00 position. |
| 06/20/XX | Excisional biopsy: L breast; 1.5 x 1.5 cm tumor excised, with sentinel lymph node biopsy X 1 and left axillary LN dissection. | |
| Pathological Reports | 06/12/XX |
Infiltrating ductal carcinoma, ER/PR positive. |
| 06/20/XX | Exc. Bx: Infiltrating duct carcinoma, WD, left breast, lower outer quadrant; TS: 1.5 x 1.5 cm, confined to breast tissue, surgical margins negative. One (1) sentinel lymph node and 6 axillary lymph nodes all showing no evidence of malignancy (0/7). | |
| Treatment | 06/20/XX | Left breast lumpectomy (excisional biopsy) with sentinel LN biopsy/axillary LN dissection. |
| 07/14/XX-08/28/XX | Radiation: External beam to left breast: 5040 cGy in 29 Fx, then 1000 cGy boost dose in 5 Fx for total dose 6040 cGy in 34 Fxs. | |
| 09/01/XX | Hormone: Arimidex started. | |
