Malignant neoplasm of overlapping sites of right male breast

C50.821

Clinical Vignette:

Patient Profile:

* Age: 65 years old

* Sex: Male

* Name: George

History of Present Illness:

George, a 65-year-old retired Navy officer, has always been a keen advocate for personal health, maintaining a balanced diet and regular exercise. It was during one of his routine morning self-examinations that George first noticed a hard, painless lump under the nipple of his right chest area about two months ago. Initially, he shrugged it off, attributing it to old age and the wear and tear of his body. However, as weeks passed, he noticed that the lump didn't decrease in size. It was also accompanied by slight skin changes, such as dimpling and discoloration, which he couldn't ignore.

After discussing these changes with his wife, George decided to consult his primary care physician, who immediately ordered a mammogram due to the palpable lump and visible skin changes.

Physical Examination:

On physical examination, George was found to be generally healthy. The primary focus was on his right chest area, where the firm, non-mobile lump was palpable. The overlying skin showed dimpling and slight discoloration.

Investigations and Diagnosis:

The mammogram revealed an irregular mass in George's right breast, indicating the need for a biopsy. A core needle biopsy was performed, and the sample was sent for histopathological examination. The results confirmed the presence of invasive ductal carcinoma, a type of breast cancer. Genetic testing was also done, which revealed a mutation in the BRCA2 gene, a gene associated with increased risk of breast cancer in both men and women.

George's diagnosis was a wake-up call that reminded him that breast cancer, though far less common, can also affect men. He is currently working with his medical team to develop a comprehensive treatment plan.

Diagnosis and ICD-10-CM Code:

Malignant neoplasm of overlapping sites of right male breast (C50.821)