Patient Case Presentation

A.Z. is a 33 y.o. white female who was referred by her primary care provider to a surgical oncologist after she detected a hard mass in her left breast while showering. She stated that the mass was not painful upon palpation. She has had a single pregnancy. Her child was breastfed. She was placed back on birth control (exogenous hormones) after her pregnancy. She reported no increase in caffeine consumption, no unilateral nipple discharge after breastfeeding, no history of Type I diabetes mellitus, no history of autoimmune thyroid disease, and the mass has not changed in size neither since her discovery of it nor throughout her menstrual cycle.

PAST MEDICAL HISTORY

  • Moderately overweight since age 21
  • Menses started at age 10
  • First child at age 32
  • Oral contraceptive use from 25 y.o. – 30 y.o. and 32 y.o. – 33 y.o.

PAST SURGICAL HISTORY

  • Appendectomy at age 18
  • Caesarean section at age 32
  • Tonsillectomy at age 8

RELEVANT FAMILY HISTORY

  • Mother diagnosed with breast cancer at age 47 but alive at age 61
  • Grandmother (maternal) diagnosed with breast cancer at age 53
  • Grandmother (paternal) diagnosed with ovarian cancer at age 63
  • Sister alive and healthy at age 23
  • Father alive and healthy at age 64
  • Brother alive and healthy at age 19

RELEVANT SOCIAL HISTORY

  • Diet high in saturated fat
  • Married
  • Has worked as an RN full-time on a medical-surgical unit for 9 years
  • Reports frequent work-related stress & anxiety
  • No tobacco usage
  • No increase in caffeine intake
  • Frequently consumes multiple alcoholic beverages in a single day