Breast Surgeon Note

Subjective

54-year-old female referred for surgical evaluation of a biopsy-proven right breast invasive ductal carcinoma (IDC) and persistent right breast pain following core needle biopsy on 02/05/2026.

Pt noted a palpable right breast mass 4 weeks ago. Diagnostic mammogram and US on 28/04/2026 showed a 1.8 cm irregular hypoechoic mass at 10 o'clock, 4 cm from the nipple (BI-RADS 4C). US-guided core biopsy on 02/05/2026 confirmed Grade 2 IDC, ER+/PR+, HER2-. Reports mild localized aching at the biopsy site, rated 3/10, worsened by direct pressure and relieved by paracetamol. Denies nipple discharge, skin dimpling, or constitutional symptoms.

Past Medical/Surgical History

• HTN, diagnosed 2018.
• Laparoscopic cholecystectomy (2015), uncomplicated recovery.
• Total abdominal hysterectomy for fibroids (2019), uncomplicated.

Allergies

• Penicillin: maculopapular rash.
• Latex: contact dermatitis.

Medications

• amlodipine (Norvasc®) 5 mg PO daily
• paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN pain
• cholecalciferol (Vitamin D3) 1,000 IU PO daily

Family History

• Breast cancer: maternal aunt, diagnosed at age 62.
• Prostate cancer: father, diagnosed at age 71.

Social History

• Never smoker; 1-2 units of alcohol per week; denies recreational drug use; works as a high school teacher.
• Lives with spouse in a single-family home in Albany, NY.

Objective

• BP 128/78 mmHg, HR 72 bpm, Temp 36.8 °C, RR 14/min, SpO2 99 % on room air, Weight 68 kg.
• General: Alert, oriented, NAD. Heart RRR, lungs clear to auscultation bilaterally.
• Breast Exam: Inspection reveals symmetric breasts without skin retractions, erythema, or peau d'orange; well-healed bruising at right 10 o'clock biopsy site. Palpation confirms a firm, mobile 1.8 cm mass in the right upper outer quadrant (UOQ) at 10 o'clock, 4 cm from the nipple. No nipple discharge expressed. Left breast without palpable masses. Bilateral axillae, supraclavicular, and infraclavicular fossae negative for palpable lymphadenopathy.

Assessment & Plan

1. Right Breast Invasive Ductal Carcinoma (cT1c N0 M0)

• Stage IA (cT1c N0 M0) Grade 2 IDC of the right breast (ER+/PR+/HER2-), favorable breast-to-tumor ratio for breast-conserving surgery.
• Differential for axillary staging includes occult micrometastatic disease vs reactive lymphadenopathy post-biopsy.
• Pre-operative CBC, CMP, and coagulation profile ordered. Wire-free radar reflector localization scheduled for 18/05/2026.
• Scheduled for right breast wire-free localized lumpectomy and sentinel lymph node biopsy (SLNB) using dual tracer (technetium-99m sulfur colloid and isosulfan blue) on 20/05/2026. Anticipated outcome is complete tumor excision with negative margins. Risks discussed include bleeding, infection, seroma, hematoma, asymmetry, lymphedema, blue skin staining, and 10-15 % risk of positive margins requiring re-excision.
• NPO after midnight on 19/05/2026. Hold morning dose of amlodipine if SBP < 110 mmHg; ensure latex-free operating room environment.
• Outpatient day-surgery procedure. Post-op pain management with paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q8H and ibuprofen (Advil®) 400 mg PO Q8H PRN. Wear supportive sports bra continuously for 1 week. Keep Dermabond dressing dry for 48 hours. Follow-up in breast surgery clinic on 03/06/2026 to review final pathology.
• Referred to Medical Oncology and Radiation Oncology for adjuvant therapy planning following final pathology results.

2. Post-Biopsy Ecchymosis and Mastalgia

• Mild resolving ecchymosis and localized tenderness secondary to recent core needle biopsy on 02/05/2026, without evidence of expanding hematoma or infection.
• Continue conservative management with supportive bra and PRN paracetamol until surgical excision.

Additional Notes:

• Discussed the equivalence of overall survival between breast-conserving therapy (lumpectomy plus radiation) and mastectomy. Patient verbalized understanding of risks, benefits, and alternatives, and signed informed consent for right lumpectomy and SLNB.
• Instructed patient to return to ED or call clinic immediately for fever > 38.0 °C, rapidly expanding breast swelling/hematoma, purulent wound drainage, or uncontrolled pain.
• Patient expressed concern regarding post-operative lymphedema risk; reassured that SLNB carries a low (< 5 %) risk compared to complete axillary lymph node dissection.