CC: 40y/o F presented to the clinic for follow up of infiltrative ductal carcinoma
Vital signs:
weight : 180lb
height : 58in
BP: 135/96 mmHq
HR: 96 bpm
RR: 16 bpm
Allergies: patient has no known allergies
Medications:
Cyclophosphamide 2g injection IV 2 weeks for 4 cycles
Dexamethasone 4mg oral tablet take 5 tables by mouth one time a day before chemo
PMH:
Infiltrative ductal carcinoma of the right breast ER(-), PR(-), Her2Neu(-), s/p mastectomy in April 2021
HTN diagnosed in 2014
Family History:
Mother: deceased – HTN, breast cancer
Father: deceased
Social history:
Occasional alcohol (1-2 drinks) 6xyear
No tobacco product use
No recreational drugs use
Subjective
A 40 y/o F with PMH of infiltrative ductal carcinoma of the right breast ER(-), PR(-), Her2Neu(-), s/p mastectomy in April 2021, s/p 3 cycles on AC and 8 cycles of Talox and HTN presented to the clinic today for follow up. Patient is feeling well and has no acute complains today. She denies any chest pain, SOB, swelling, lumps, discharge, cough, abdominal pain, changes in bowel/bladder habits, fever, dizziness, headaches.
REVIEW OF SYSTEMS:
General: generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotoma, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Breast: Mobile 1 cm mobile non-tender node in the left breast at the edge of the incision from the mastectomy surgery. no change in size as per pt. Mastectomy scar healed, non-tender, no pus, erythema, or discharge.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness. No weakness, no tremor, no seizures, no changes in mentation, no ataxia
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
Objective
Physical exam
General: alert, oriented
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotoma, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Breast: Mobile 1 cm mobile non-tender node in the left breast at the edge of the incision from the mastectomy surgery. no change in size as per pt. Mastectomy scar healed, non-tender, no pus, erythema, or discharge.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness. No weakness, no tremor, no seizures, no changes in mentation, no ataxia.,.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
Labs (04/28/2021):
CBC: 8.6>13.2/38.6<336
CMP: 142/4.2/102/24/25/0.9<98;8.2
LFTs: 7.4/4.5/0.4/82/24/21
Mammogram (04/22/2021): no evidence of malignancy
ANY CANCER NEEDS STAGING
Assessment
A 40 y/o F presented to the clinic today for follow up of intraductal breast carcinoma. We will:
Plan
- Infiltrative ductal carcinoma of the right breast stage XY
– Pt educated and instructed to continue to self-examine the node and monitor closely
– Will continue to monitor - HTN
– Patient will follow up with PCP
– Will continue to monitor
** IF CHEMO IS PRESCRIBED, EXPLAIN SIDE EFFECTS AND GIVE WRITTEN INFO ABOUT THE DRUGS
RTC: 09/20/2021
PCP: Dr. XY