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| Physical Exam | 09/08/XX |
Right breast: 2 cm mass present for 2-3 weeks prior to admission; discovered by patient. Associated with slight discomfort but no pain. No tenderness; peau d’orange noticed overlying the mass. No nipple discharge. Mass freely movable. No bone pain. Left breast: No masses palpated. No palpable lymph nodes. |
| Imaging | 09/12/XX |
Mammogram: Suspected malignant lesion of right breast. |
| 09/13/XX | Chest X-Ray: No evidence of metastatic lesions. | |
| 10/01/XX | scan: No evidence of skeletal metastases. | |
| Laboratory | 09/13/XX |
SMA 20: WNL |
| 09/14/XX | ERA/PRA: Both are negative | |
| Surgical Observations | 09/14/XX |
Right breast biopsy |
| 09/20/XX | Right simple mastectomy with lymph node dissection. | |
| Pathological Reports | 09/14/XX |
R breast bx: Intraductal carcinoma; 1 cm lesion located 1 cm from nipple in upper outer quadrant. |
09/20/XX |
R mastectomy: No residual tumor at original biopsy site; no infiltration to pectoralis muscle or fascia. Metastatic carcinoma to 2 of 13 right axillary lymph nodes. | |
| Treatment | 09/14/XX |
Surgery: Right breast excisional biopsy; 9/20/XX Right simple mastectomy with right axillary lymph node dissection. |
| 11/2/XX | Chemotherapy: Adriamycin/Cytoxan followed by Taxotere. | |
| 03/21/XX | Radiation: Beam radiation to right chest, total dose 6000 cGy. |
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