4th Qtr 2016 MedSurg Nursing Case Study #1
50yof- Breast MRI (77059)
CIGNA SI-PPO/OAP
Per ACDS notes/webnotes : Other Specialty req MRI Bilat breast wwo for 50 yo F c/o lump in R breast, x few weeks. Reason : For further evaluation
FOV: not provided LOV: 10/16/16
PE: Right breast 1-1/2 cm smooth rounded fairly distinct subcutaneous nodule that is mobile and not adherent to the tissues above or below. It is medial to the areola of the right breast at about 3:00
PMH: no hx of cancer, related surgery or injury
TX: not provided
Prior imaging: Undated - Mammogram bilateral; US breast Rt - BI-RADS: 4
Labs: Biopsy 9/25/16: Rt axillary Lymphnode Negative for Malignant epithelial cells. Polymorphous lymphoid elements present-Surgical Path 9/25/16-Rt breast mass-Well to moderately differentiated invasive ductal carcinoma, with Carcinoma in situ
Reviewed ACDS notes and webnotes
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