Identifying Data:
Full Name: MM
Address: Bronx, NY
Date of Birth: xx/xx/1973
Date & Time: 4/1/2022
Source of Information: Self
Reliability: Reliable
Chief Complaint: new right breast lump for 3 months, f/u s/p right breast biopsy (3/17).
History of Present Illness:
49 y/o premenopausal female with past medical history of GERD presents to clinic today for follow-up after right breast biopsy (3/17), which revealed DCIS (ER +, PR+). Prior to biopsy, patient c/o a new painful lump in her right breast for 3 months. Patient reports the lump is more noticeable when laying supine and its size has stayed constant over the past 3 months. The associated tenderness is described as dull, non-radiating, at a severity of 2/10 and it only occurs upon palpation. Patient states the symptoms do not vary with her menstruation cycle. Patient admits to decreased appetite, fatigue, and 10 lb unintentional weight loss over the past 2 months. Denies cancer history in first degree relatives, use of birth control pills/implants, skin changes, nipple discharge, nipple inversion, fever, chills, chest pain, and SOB.
Past Medical History:
DCIS (ER +, PR +) of right breast
GERD
Mammogram (3/16/22): microcalcification of right breast
Immunization up to date, including COVID and flu vaccine
PCP: Dr. S
Past Surgical History:
Right breast core biopsy (3/17/22)
Medication:
Omeprazole, 40mg, PO, once daily before breakfast
Denies used of herbal or supplement
Allergies:
NKDA
Denies food and environmental allergy
Family History:
Mother: 82 yo, hypertension, diabetes
Father: Deceased at age 80 due to heart disease
Brother: 59, alive and well
Son: 26 yo, alive and well
Son: 24 yo alive and well
Daughter: 16 yo, alive and well
Denied family history of cancer
Social History:
Habits: Denies tobacco and illicit drug use. Drinks one cup of coffee every day
Travel: Denies recent travel
Marital History: Single
Sexual History: Not sexually active. Denies history of STD
Occupation: Cleaning
Home: Lives with her daughter. Independent in all ADLs and IADLs . Sons are in Mexico
Diet: Reports that she consumes a balanced diet.
Exercise: Reports does not exercise regularly.
Review of System:
General – Admits to fatigue, decreased appetite, 10 lb unintentional weight loss over 2 months. Denied fever, chills and night sweats.
Skin – Denied change of skin texture, rash, and lesions.
Head – Denied headache, light-headedness, and recent head trauma.
Eyes – Denied visual changes.
Ears – Denied tinnitus, pain, discharge, or use of hearing aids.
Nose – Denied discharge, obstruction, epistaxis, loss of smell, itchiness.
Mouth/throat – Denied sore throat, mouth ulcers, and voice change.
Pulmonary system – Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.
Cardiovascular system – Denied chest pain, palpitations, and syncope.
Gastrointestinal system – Denied dysphagia, abdominal pain, constipation, and diarrhea.
Genitourinary system – Denied urinary frequency, urgency, oliguria, and incontinence.
Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.
Musculoskeletal system – Painful lump in the right breast. Denied joint pain, muscle pain, and back pain.
Endocrine system – Denied polydipsia, polyphagia, heat intolerance, goiter, or excessive sweating.
Hematologic system – Denied history of lymphadenopathy or anemia
Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.
OB/GYN – G3P3, normal vaginal delivery. Menarche at age 10. 20 yo at first live birth. Breastfeed for 1 year for the first 2 children. Premenopausal. Reports regular menstruation, range 8-10 days. Denied dysmenorrhea, menorrhagia, and metrorrhagia.
Physical Examination:
Vitals:
Temp: 97.2 F, oral
BP:121/64, sitting
Pulse: 74, regular
RR: 16/min, unlabored
O2 saturation: 100% room air
Ht: 58 in
Wt: 130 lb
BMI: 27.2
General – AAO X3. Not in acute distress. Appears her stated age. Well-developed and well-groomed.
Skin –Warm and dry, good turgor. No lesions, no rashes, no jaundice.
Hair – Average quantity and distribution
Nails – No clubbing, capillary refill <2 seconds on fingers and toes.
Head – Normocephalic, atraumatic, non-tender to palpation throughout
Ears – Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex.
Eyes – Symmetrical OU. EOMs intact with no nystagmus. No conjunctival injection, pallor, or scleral icterus.
Oropharynx – Moist, no erythema, no exudates, no masses/lesions. Uvula midline and rises symmetrically with phonation.
Neck – Supple. No lymphadenopathy.
Chest – Symmetrical, no deformities. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.
Breast – A firm, round, 1.8 cm mass noted on the right breast, at 4 o’clock position, 2.6 cm away from the center of the nipple. Mild tenderness when palpating the mass. Non-mobile. Breasts are symmetrical. No dimpling, spontaneous or non-spontaneous nipple discharge, nipple inversion, erythema, rash, lesions of breast. No axillary lymphadenopathy noted.
Lungs –Clear to auscultation bilaterally, no wheezes/rhonchi/rales.
Heart – Regular rate and rhythm. S1 and S2 are distinct. No murmurs or friction rubs appreciated.
Abdomen –Soft, NT/ND, BS present, no hepatosplenomegaly.
Musculoskeletal – Full passive and active range of motion in shoulders, elbows, wrist, hips, knees, and ankles. No soft tissue swelling, erythema, deformities in bilateral upper and lower extremities. Non-tender to palpation.
Neurologic – Sensation intact to touch in bilateral upper and lower extremities. Strength 5/5 in bilateral upper/lower extremities.
Peripheral Vascular – Extremities are symmetric in color, size, and temperature. Pulses are 2+ bilaterally in upper and lower extremities.
Assessment:
49 y/o female with PMH of GERD c/o 3 months history of right breast lump and associated tenderness. Patient presents to clinic today for f/u s/p right breast core biopsy. Biopsy revealed DCIS (ER+, PR+).
Problem list:
- Newly diagnosed DCIS
- GERD
Plan:
Newly diagnosed DCIS
- Surgical pathology results reviewed and discussed with patient
- Order MRI to confirm the extent of disease
- Refer to breast radiation oncologist for evaluation for adjuvant radiation following lumpectomy
- Heme/onc appt scheduled for 4/5
- Refer to social worker for mental and financial support program
- F/u after MRI for imaging result and surgical planning, (plan to f/u in ….. need to specify time)
GERD
- Continue omeprazole 40mg PO, once daily
- F/u with PCP as needed
