History of Present Illness:
Patient presents with
a lump at breast - LEFT/RIGHT
Abnormal breast imaging
She does not feel a lump, no pain, no skin changes, or nipple discharge
She does not perform routine exam
She does have routine mammogram
No h/o abnormal mammogram
No h/o breast bx
No h/o breast procedure
No h/o HRT
No Fhx breast/ovarian CA
Past Medical History -reviewed
Past Surgical History - reviewed
Family History - reviewed
Social History - reviewed
Medication - Reviewed
Allergies - Reviewed
REVIEW OF SYSTEMS: All pertinent positives and negatives are stated in HPI and below, all other systems reviewed and are negative.
GENERAL: No malaise. No weight loss. No fever. No chills.
HEENT: No headache.
Eyes: No decreased vision.
Ears: No decreased hearing.
Nose: No bleeding.
Throat: No sore throat.
LUNGS: No shortness of breath. No cough. No COPD. No asthma.
CARDIAC: No chest pain. No palpitations. No orthopnea, no PND, no lower extremity edema.
GI: No Abdominal pain. No nausea. No vomiting. No constipation. No diarrhea. No change in weight. No change in appetite.
GU: No frequency. No hesitancy. No hematuria. No pyuria.
NEUROLOGIC: No dizziness. No neuropathy. No CVA. No headache.
MUSCULOSKELETAL: No neck pain or lower back pain.
Skin/Integuments - No breakdown
Physical Examination
Vitals: Reviewed
GENERAL APPEARANCE: Patient is alert, awake, resting, talking in complete sentences with no acute distress.
HEENT: No facial trauma or abnormalities. No tonsillar hypertrophy, no uvula deviation. No tongue swelling.
NECK: Supple, no lymphadenopathy. Trachea midline. No mass. No JVD
LUNGS: Clear to auscultation bilaterally. Normal breath sound. No Wheezing, rales or rhonchi.
HEART: Auscultation: RRR. Normal heart sound. No Gallop. No Murmur or rubs.
Palpation: Normal cap refill. Normal skin turgor. No JVD. No Pedal edema
ABDOMEN: Normal bowel sounds. Soft, nontender, nondistended. No mass or hernia appreciated. No hepatosplenomegaly. No peritonitis
EXTREMITIES: Patient ambulatory. Good muscle tone. Moving all extremities equally. Good range of motion.
NEUROLOGIC: GCS 15. Patient is ambulatory with no gait abnormalities. Cranial 2-12 is grossly intact.
VASCULAR: Bilateral radial pulses, strong, equal.
SKIN: Pink, warm, dry. No pathological skin rash or lesion.
PSYCH: normal mentation, awake, alert, not suicidal, not homicidal.
Breast Exam:
Bilateral breasts symmetrical, no masses, skin changes, dimpling, nipple discharge, tenderness, or lymphadenopathy.
Imaging Results:
Mammogram:
Ultrasound:
Labs/path:
I have personally reviewed the lab results
Assessments and Plans:
Abnormal mammogram/US
Breast lesion
I have discussed with the patient the
diagnosis and findings.
I have also discussed with the patient the treatment
options including surgery and non-surgical options as well as alternatives:
Observation/follow imaging vs image guided biopsy/aspiration vs surgical excision
For surgical procedure proposed, we discussed the risks which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, or need for further procedures or workup.
Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications.
The patient understands and agrees to proceed with the proposed procedure.
Pt opted for
- repeat right/left/bilateral breast ultrasound in 6 months
- screening mammogram 6 months
*urgent* core needle biopsy + clip placement
with Dr Young Tran / Dr David Lieu
location(s) =
- follow up after testing
- Surgical excision, please obtain