Sanjay Gandhi Post Graduate Institute Of MedicalSeiences, Lucknow
(Department Of Radiodiagnosis And Imaging)
ULTRASOUNDREPORT
DATE 12/03/2025
NAME MITHILESH LATA AGE/ 59/F
SHUKLA SEX
REFERRING DRGAURAV AGARWAL
CR. NO 2025195575
DOCTOR
CLINICAL DETAILS: Right breast lump with pain for last 2-3 days
LEFT
FINDINGS RIGHT
Heterogenous fibroglandular Heterogenous fibroglandular
Breast composition
DESCRIPTION OF A mass is seen in 9 o' clock position,
No e/o any mass/dilated ducts.
FINDINGS 1.8 cm away from NAC, and
measuring 31*34*38 mm at a depth
of 6 mm from skin. It is irregular in
shape with microlobulated margins,
hypoechoic with large central
anechoic cysticnecrotic area. Solid
component shows no appreciable
vascularity on color doppler.
significantly enlarged axillary
Lymph nodes Multiple rounded lymph nodes with No
fatty hila and cortical
Iymph nodes seen.
Axilla effaced
thickening noted, largest of9 mm
SAD with corticalthickness of 3.2
mm
Nil
Skin Thickening Nil
1
BIRADS 4C
guided FNAC from
biopsy from solid component of the right breast mass with
Advise USG guided
right axillary lymph nodes.
DR.ASMITA
ABHRANEEL/ DR LIPIKA
DR
Lucknow
Medical Sciences,
Graduate Institute Of
Sanjay Gandhi Post
(Department Of Radiodiagnosis
And Imaging)
MAMM0GRAPHY REPORT
12/03/2025
AGE/ 59/F DATE
MITHILESH LATA
NAME SEX
SHUKLA DR GAURAV AGARWAL
REFERRING
CR. NO 2025195575
DOCTOR
with pain for last 2-3 days
CLINICAL DETAILS: Right breast lump
LEFT
DESCRIPTION RIGHT fibroglandular
Scattered areas of
Breast composition Scattered areas of fibroglandular
density. (ACR-B)
density. (ACR-B)
Description of findings A round, high density mass
is seen
quadrant of size Noobvious mass/ asymmetry/
in upper outer architectural distortion.
49*40*39 mm, approximately 3.5
cm away from NAC. It has
predominantly circumscribed with
indistinct margins anteriorly. There
is associated mild architectural
distortion and trabecular
thickening. Few linear densities
seen projecting from anterior
margin of the mass towards the
retroareolar region. There are no
internal calcifications.
Best DBT slice (CC view- 43/80:
MLO view-44/88)
No No
Suspicious
Calcifications
Benign calcification Nil. Yes,few scattered round calcification.
Skin thickening/ Nil Nil
Nipple retraction
Axilla Few rounded axillary lymph nodes Few subcentimetric axillary lymph
are noted with effaced fatty hila nodes are noted with maintained fatty
and smooth margins, however hila and smooth margins.
cortical thickening noted.
BI-RADS 4A
DR ABHRANEEL/ DRLIPIKA DR.ASMITA
Sanjay Gandhi Post Graduate Institute of Medical Sciences
RaebareliRoad, Lucknow - 226 014 ,India
Department of Pathology Name: Histopathology
LRNO: 2025:95575 Status: OP Unit: UNIT-1 Department: Endocrine Surgery
Nae: Mithilesh Lata Shukla /59 Y/F
Lab id: L150118U 503498 Specimen: Tissue
Consultant:Gaurav Agarvial Coilected On: 18/03/2025 09:03 AM
Test Name: 01. EndoSCcpic/ Needle/ Small Biopsy/Cell Block Test On: right breast iump
Gross: H-3498/ 25 Received five linear cores. longest measured 1.5cm in length. Whole embedded.
Microscopic: Multiple serial sections examined, show breast tissuecores with few terminai duct-lobular units lined by
benign cuboidai to columnar epithelium. Focal ductal hyperplasia is noted. The intervening stroma shows
mild to moderate inflammation comprising of few scattered histiocytes, mature lymphocytes in
lobulocentric distribution along with fibrocollagenous tissue only. There is no evidence of DCIS component
or ind nancy in this biopsy.
Concusion:
RIGHT BREAST LUMP BiOPSY: NO EVIDENCE OF DCIS COMPONENT OR MALIGNANCY (See remarks)
Remarks: If suspicion of malignancy is high, then a radiology guided, repeat biopsy from more representative site is
advi ed.
Reported '2te: 25/03/2023 18:03 PiM Reported By : Ojas Gupta
Ger " 257 RS.
Sanjay Gandhi Post GraduateInstituteof Medical Sciences
Raebareli Road, Lucknow - 226 014 ,India
Department of Pathology Lab Name: Hematology
CRNo: 2025195575 Status: OP Unit: UNIT-1 Department: Endocrine Surgery
Name: Mithilesh Lata Shukla 59 Y/ F
Lab ld: L150207032500474 Specimen:Blood - EDTA
Collected On: 07-Mar-2025
3:07 PM
Consultant:Gaurav Agarwal
Reference Range
Result Unit
Test Name
x1000/ul 4-10
01. TLC 5.41
million/cmm.
02. RBC 5.03
gm/dl
10.2
03. HGB 150-400
x1000/cmm.
211
05. PLT
08. DLC
66
Neutrophils
29
Lymphocytes
1
Eosinophils
Monocytes
Reported Bv: AlkaYadav
07-Mar-2025 5:15 PM
tod Date:
Sanjay Gandhi Post Graduate Institute of Medical Sciences
RaebareliRoad, Lucknow- 226 014 ,India
Department of Pathology Lab Name: Coagulation Laboratory
CRNO: 2025195575 Status: OP Unit: UNIT-1 Department: Endocrine Surgery
Name: Mithilesh Lata Shukla 59 Y/ F
Lab td: L150307032511957 Specimen: Blood - Citrate
Cansuitant: Gair dl A-rwal Collected On: 07-Mar-2025 3:39 PM
Result Unit Reference Range
Prothroniin Time
15.3 SEC.
13.1 REF.T
1.18 INR.
Thor:hoplastin Tims
27.7 SEC.
30.8 REF.T
a:
s.):
Sanjay Gandhi Post Graduate Institute of Medical Sciences
Raebareli Road, Lucknow 226 014 ,India
Department of Gast: venterology Lab Name: GE Serology
CRNo: 2025195575 Status:OP Unit: UNIT-1 Department: Endocrine Surgery
Name: Mithilesh Lata Shukla 59 Y/F
Lab ld: L120307032504309 Specimen:Blood - Plain
Consultant:Gaurav Agarwal Collected On: 07-Mar-2025 3:05 PM
Unit Reference Range
Test Name Result
Anti-HCV antibody Negative
HBSAg Negative
Reported Date: 08-Mar-2025 12:53 PM Reported By: Anshuman Elhence
COMPUTER GENERATED REPORT - NO SIGNATURE REQUIRED
Dost Grad IucknoW-226 Date &T
roint
17-Mar-2025 2:
Sanjay Gandhi Post Graduate Institute of Medical
Raebareli Road, Lucknow - 226 Sciences
014 Andia
Departmentof. Pathology
CRNo: 2025195575 Lab Name:
Status: OP
Unit: UNIT-1 Clinical Chemistry
Name: Mithilesh Lata Shukla
Lab ld:
59 Y/F .Department: Endocrine Surgery
L150407032500637
Consultant: Gaurav Agarwal Specimen:.Blood -Plain
Test Name Collected On: 07-Mar-2025 2:33
PM
03. S. Glucose (R) Result
Unit
87 Reference Range
05. S. Creatinine mg/dl
0.69
09. S. Sodium mg/dl .5-1.6
139.00
10. S. Potassium mmol/L 133-146
4.47
11. S. Proteins, Total mmol/L 3.8-5.4
7.72 g/dL
12. S. Albumin 6-8.4
3.97
13. S. Bilirubin, Total g/dL 3.5-5.5
0.63
mg/dl .1-1.3
14. S. Bilirubin, Conjugated
0.15
mg/dl 0-.4
15. S. AST (SGOT) 58.8
u/L 5-40
16. S. ALT (SGPT) 57
u/L 5-40
17.S. Alkaline Phosphaiase 188.3
u/L 35-150
32. S. Calcium
8.94 mgld.
8.5-10.8
Reported Date: 08-Mar-2025 10:11 AM
Reported By: Aarti
COMPUTER GENERATED REPORT - NO SIGNATURE REQUIRED
1/1
a017
12-3-2025 11:29:21
Printed on
,n Date &
Inst 014
Graduate
226
17-Mar-20252:45PN
Lucknow
-
Post
G a n d h i
Receipt Req.
Road,
abareli
B i l l i n g
17-Mar-2025 2:*
T a r i f f
Receipt No.
-oral
Amo
-419043
IR5.:
SANJAY GANDH INTEGRATED
HIV TEST
DEP COUNSELLIREPORT FORM
NG
ARTMENT OF MICROBIOLOGY TESTING CENTRE &
Name: Surname
Gender:.
POSTGRADUATE
RaibarelyRoad, INSTITUTE
Luckow-226014 OF
MEDICALSCIENCES
Middle Name
CR No. Age First Name
Years PID#
Date and time GCSAICTCUP LNO00925° |kog MiHh lh lade
Test Details
bloOd drawn Referring Clinic
192
Specimen type (DD/MM) (HH:MM)
used for
Date and time testing:
Serum/PlasmaWhole Blood
specimen tested 73lr
Note:
(DDIMMY. (HH:MM)
Golumn 2 and 3 to be
No cell has to filled
be left blank: onlv when HIV 1&2
indicate as NA whereantibody discriminatory test(s) used
Column 1 not applicable
Name of HIV test Column 2
kit
Reactive/Nonreactive (R/NR)
for HIV-1 antibodies
Column 3
Test I:nn Reactive/Nonreactive
(RINR) for HIV-2
Column 4
Reactive/ Nonreactive (R/NR)
Test Il: antibodis for HIbantibodies
Test lI: Nen Boeetive
Interpretation of the result: Tick (
)relevant
Specimen is negative for HIV
antibodies
N Specimen is positive
for HIV-1 antibodies
Specimen is positive for HIV
antibodies (HIV 1 AND HIV2; OR HIV 2alone)
Specimen is indeterminate for HIV antibodies. Collect fresh
sample in twa weeks
Confirmation of HIV 2 sero-status atidentifiedreferral
laboratory through ART
End of report centers
Laboratotyréchnologist Laboratoy In-Charge
ID: 1960
17-03-2025 J0:18:17 AM Diagnosis Information:
HR : 78
Male bpm
Years P : 102 ms th ythm
Sinus
p r o g r e s s i o n
PR 140 ms
Poor R wavc
Borderline ECG
QRS 80 Ms
QT/QTc 372/424
P/QRSST 20/3/9
PoGansdhti RV5/SVi : 0.649/0.494mV Report Confirmed by:
0.15~3SHz ACS0 25mm/s 10mm/m V 2*S.0s78SE-1200Express VT:21 LUCKOW..
SGPGIFUJICOA
FUJICOA Glasgow. V28.6.0
31COA
FU'ICOA
Sanjay Gandhi Post Graduate Institute of Medical Sciences
Raebareli Road, Lucknow 226 014 ,India
Department of Pathology Lab Name: Cytopathology
CRNo: 2025195575 Status: OP Unit: UNIT-1 Department: Endocrine Surgery
Name: Mithilesh Lata Shukla /59 Y/F
Lab ld: L150501052503326 Specimen: Slides
Consultant: Gaurav Agarwal Collected On: 01/05/2025 16:05 PM
Test Name: 02. Guided FNAC
Test On: USG-Guided FNA Right breast lump and Right
Axillary lymph node
Aspiration: Cy-3326/25 USG-Guided FNAwas performed from Right breast lump (measuring 31mm x
34mm x 38mm, irregular and lobulated) and Right axillary lymph node (13mm x6mm with
increased cortical thickness).
Microscopic: The FNAsmearsfrom right breast lump are richly cellular and show sheets, clusters and singly scattered
population of atypical cells on a hemorrhagic background. These atypical cells show high nucleocytoplasnmic
ratio, marked nuclear pleomorphism, coarse chromatin, conspicuous nucleoli and moderate to scant
cytoplasm. The FNA smears from right axillary lymph node are cellular and show few clusters of atypical cells
with similar morphology as described above, along with singly dispersed mature lymphocytes on a
hemorrhagic background.
Conclusion: USG-GUIDED FNAC FROM RIGHT BREAST LUMP: POSITIVEFOR MALIGNANT CELLS (DUCTAL CARCINOMA).
USG-GUIDED FNAC FROM RIGHT AXILLARY LYMPH NODE: METASTATIC DUCTAL CARCINOMA.
47ncon4.0 A
1-257
Sanjay GandhiPost Graduate Institute of Medical Sciences
Raebareli Road, Lucknow -226 014 ,India
Department of Pathology Lab Name: Hematology
CRNo: 2025195575 Status: OP Unit: UNIT-1 Department: Endocrine Surgery
Nome: Mithilesh Lata Shukla 59 Y/F
Lab id: LI50202052500324 Specimen Blood- EDTA
onsutiant: Gaurav Agarwal Collected On: 02-May-2025 12:48 PM
Test Narne Result Unit Reference Range
4.07 x1000/ul 4-10
9.6 gm/di
33.1 %
D4, HCT
x1000/cmm. 150-400
OE.PLT 218
55
leutiophils
35
phOcytes
02
opis
08
00
sopails
-NO.
Sanjay Gandhi Post Graduate Institute of Medical Sciences
Raebareli Road, Lucknow - 226 014 ,India
Department of 24 Hour Lab Lab Name: 24 hr Microbiology
CRNo: 2025195575 Status: OP Unit: UNIT-1 Department:Endocrine Surgery
Name: Mithilesh LataShukla 59 Y/F
24hr00502052500042 Specimen: Blood -Plain
0 a n : G:taV garwal Collected On: C2-May- 2023 :41 PM
sName Result Unit Reference Range
3SAg RAPID Non-Reactive ng/ml Non-reactive
VRAPID Non-Reactive Non-reactive
LPID Non-Reactive G.0-0.0
Reported Date: 02-May-2025 3:11 PM Reported By: Kusum Goe!
COMPUTER GENERATED REPORT - NO SIGNATURE REQUIRED
Nan - h Lat:
Sanjay Gandhi Post Graduate Institute of Medical
Sciences
Raebareli Road, Lucknow- 226 014 ,India
Department of Patholngy Lab Name: Coagulation Laboratory
CRNo: 2025195575 Status: OP Unit: UNIT-1 Department: Endocrine Surgery
Name: Mithilesh Lata Shukla 59 Y/F
Lab ld: L150302052522194 Specimen: Blood -Citrate
Consultant: Gaurav Agarwal CollectedOn: 02-May-2025 12:49 PM
Test Name Resuit Unit Reference Range
1. Prothrombin Time
PT 13.7 SEC.
Control 13.1 REF.T
INR 1.05 INR.
02. Act. Partial Thromboplastin Time
APTT 25.7 SEC.
- Control 30.8 REF.T
ooted Date: 02-May-2025 5:33 PM Reported By: Ankita Singh
COMPUTER GENERATED REPORT - NOSIGNATURE REQUIRED
a t a Shukla
me
Sanjay Gandhi Post Graduate
Institute of Medical Sciences
Raebareli Road, Lucknow - 226 014 ,India
Department of Pathology Lab Name: Histopathology
CRNo: 2025195575 Status: OP Unit: UNIT-1
Department:Endocrine Surgery
Name: Mithilesh Lata Shukla /59 Y/F
Lab ld: L150105052505815 Specimen: Tissue
Consultant: Gaurav Agarwal
Collected On: 05/05/2025 16:05 PM
Test Name: 01. Endoscopic/ Needle/ Small Biopsy/Cell Block Test On:
RIGHT BREAST LUMPBIOPSY
Gross: 5815/25 Received multiple linear tissue cores longest
embedded.
measuring 1.2 cm in length. All were
Microscopic: The sections show fibroadipose tissue bits displaying an
infiltrative tumor disposed in, trabeculae, cords and
few tubules. The tumor cells are markedly pleomorphic
with round to oval hyperchromatic nuclei, irregular
nuclear margin, dispersed to vesicular chromatin, inconspicous to
conspicious nucleoli and moderate
amount of cytoplasm. Mitotic figures (~22-25/10hpf) are seen. The stroma is dense
and fibrous.
Conclusion: RIGHT BREAST LUMP : INVASIVE DUCTAL CARCINOMA, NO SPECIAL
TYPE (GRADE 3).
Remarks: Nottingham Histologic score: (9/9): Tubular differentiation-3, Nuclear pleomorphism-3, Mitotic rate -3.
Reported Date: 10/05/2025 12:05 PM Reported By: Dr. Ritu Verma
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