Hypothetical Chief Complaint. “ I have left nipple swelling”. History of Present Illness.
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“ I have left nipple swelling”
75 y.o. male was noted to have a painful left nipple swelling on 3/15/06. The nurse noted that it was an easily palpable lump, with tenderness upon palpation. A surgical consult was sought, and suggested to perform mammogram and ultrasound.
Social History: No smoking, drinking, or drugs
Family History: No history of cancers
Gen: AAO x 3, NAD
HEENT: NC/AT, PERRLA, EOMI, no LAD, OP clear
Neck: supple, no thyromegaly
Chest: CTA b/l, + aw entry, + left breast mass, palpable at about 12 o’clock, + tenderness on palpation
CV: S1S2 nl, RRR
Abd: soft, NT/ND, + BS, no HSM
Neuro: no focal neurological deficit, AAO x 3
Nulliparity or 1st pregnancy >30 y.o.a.
Family history of breast cancer
Genetic predisposition (BRCA 1, BRCA 2, Li Fraumeni Syndrome)
Prior personal history of breast cancer
DCIS or LCIS
Atypical ductal or lobular hyperplasia
Congenital inguinal hernia
Positive family history
Elevated endogenous estrogen
Jewish ancestryRisk Factors for Breast Cancer
American College of Radiology Diagnostic Code
2. Core Needle Biopsy
3. Vacuum-Assisted Biopsy (Mammotome)
4. Large Core Surgical (ABBI)
5. Open Surgical Biopsy