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| Physical Exam | 01/10/XX |
Right breast: 4 x 5 x 3 cm hard mass near 6:00. Normal nipple without discharge. Lesion not attached to fascia or muscle. Left breast: Normal. No enlarged lymph nodes bilaterally and no abdominal masses palpated. |
| Imaging | 01/15/XX |
Chest X-Ray: Normal |
| 02/01/XX | Bone scan: Abnormality in left knee, consistent with known arthritis; otherwise normal. | |
| 02/08/XX | L-S scan: WNL | |
| Laboratory | 01/15/XX |
SMA 20: Within normal limits |
| Surgical Observations | 01/10/XX |
R breast aspiration biopsy |
| 01/16/XX | R partial mastectomy/axillary lymph node dissection: Lesion located in the lower inner quadrant. | |
| Pathological Reports | 01/10/XX |
Aspiration bx: Right breast: Cells compatible with adenocarcinoma. |
| 01/16/XX | R partial mastectomy/ALN dissection: Intraductal and infiltrating duct carcinoma of right breast; 2 of 5 axillary lymph nodes positive at level I; 10 negative lymph nodes at levels II and III. Tumor size = 4.5 cm, margins clear, ER/PR negative. | |
| Treatment | 01/16/XX |
Surgery: R Partial mastectomy with axillary LN dissection. |
| 02/20/XX | Chemo: Adriamycin/Cytoxan followed by Taxotere. | |
| 07/30/XX-09/18/XX | Radiation: Beam radiation to R breast, total dose 6060 cGy in 33 Fxs. | |
