Consult - History and Phy.
Sample Name: Consult - Breast Cancer - 1
Description: The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Left breast cancer.
HISTORY: The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center. On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial). The biopsy returned showing infiltrating ductal carcinoma high histologic grade. The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging. She prior to that area, denied any complaints. She had no nipple discharge. No trauma history. She has had been on no estrogen supplementation. She has had no other personal history of breast cancer. Her family history is positive for her mother having breast cancer at age 48. The patient has had no children and no pregnancies. She denies any change in the right breast. Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y. I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy. The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning. The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact. CT scan of the neck, chest, and abdomen is negative for metastatic disease.
PAST MEDICAL HISTORY: Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.
MEDICATIONS: She is currently on omeprazole for reflux and indigestion.
ALLERGIES: SHE HAS NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.
SOCIAL HISTORY: The patient works as a school teacher and teaching high school.
GENERAL: The patient is a white female, alert and oriented x 3, appears her stated age of 57.
HEENT: Head is atraumatic and normocephalic. Sclerae are anicteric.
HEART: Regular rate and rhythm.
BREASTS: Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle. There are no nipple retractions. No skin dimpling. There is some, at the time of the office visit, ecchymosis from recent biopsy. There is no axillary adenopathy. The remainder of the left breast is without abnormality. The right breast is without abnormality. The axillary areas are negative for adenopathy bilaterally.
ABDOMEN: Soft, nontender without masses. No gross organomegaly. No CVA or flank tenderness.
EXTREMITIES: Grossly neurovascularly intact.
IMPRESSION: The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.
RECOMMENDATIONS: I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy. We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection. The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient. The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained. Local numbness, paresthesias or chronic pain was explained. The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers. She was certainly encouraged to obtain further surgical medical opinions prior to proceeding. I believe the patient has given full informed consent and desires to proceed with the above.
Keywords: consult - history and phy., mesothelioma, t1c, nx, m0, invasive ductal carcinoma, breast carcinoma, pectoralis muscle, ductal carcinoma, breast cancer, invasive, breast, carcinoma, cancer,