Followup Visit
Subjective:
Patient has no complaints, no fever, chills
Pain is well controlled, no issues with incision, no drainage
Objective:
Vitals - Reviewed
General - no acute distress
Lungs - no resp distress
Breast incision clean, dry, intact with no erythema, warmth, tenderness
Drain output min serosang
Extremities - WNL, axillary incision is clean dry intact with no erythema, warmth, tenderness, good range of motion, no edema
Skin/Integuments - WNL
Path:
Assessments and Plans:
Patient is status post Right/Left Mastectomy/Lumpectomy and SLN bx for
Right/Left CA,
Doing well, incision is healing well with no evidence of infection
Drain was removed during this office visit
Light activity for 4 weeks
Need f/u with radiologist oncologist regarding adjuvant radiation
will see back in 4 weeks for follow up
Maintain routine medical, oncology visit