CC: “I am scheduled for a lumpectomy on my right breast”

HPI:

46 y/o pre-menopausal female with PMHx of asthma and HTN, and family history of breast cancer, presenting today for right breast resection with sentinel lymph node biopsy. Patient states she went for her routine mammogram, which revealed a “suspicious mass” in her right breast. Patient had the mass biopsied which was consistent with infiltrating breast cancer. Patient states she has been getting annual mammograms since age 38, which have all been normal. Patient performs monthly breast exams due to her family history, and did note a small lump in the superior inner quadrant of her right breast. Denies any pain in her breasts b/l, changes in nipples, nipple discharge, or discoloration. Denies fever, weight loss, night sweats, loss in appetite, CP, SOB.

PMH:

HTN

Asthma

Surgical History: none

Allergies: NKDA or environmental 

Meds: Albuterol 2 puffs PRN

Lisinopril 10 mg PO qD

Family History: Paternal grandmother breast cancer diagnosed before age 45. Deceased age 87. 

Mother breast cancer diagnosed age 48. Alive.

Father alive

Social history: non smoker. ETOH 1 glass wine on weekends. Works as a high school teacher.

ROS:

Constitutional: Denies weight loss, fatigue, night sweats

Head: denies LOC, headaches, trauma, changes in vision

Neurologic: Denies tingling, numbness, syncope, focal weakness.

Eyes: denies itching, tearing, visual acuity issues.

ENT: denies tinnitus, hearing loss, vertigo, stuffiness, sore throat or neck pain.

Cardiac: Denies palpitations, murmurs, chest pain.

Pulmonary: Denies cough, hemoptysis, fibrosis.

Hematology: Denies bruising, petechiae, or purpura.

Skin: Denies edema, bruises or excoriations.

GI: Denies abdominal pain, change in bowel habits.

Breast: See hpi.

GU: Menarche age 11. Monthly menses. G3P3 NSVD. Last PAP 2019 normal. Sexually active with husband of 21 years. Denies STIs. Denies urgency, dysuria, polyuria or nocturia.

Psychiatric: denies stress, anxiety, depression or mood changes.

Physical Exam

Vitals: 131/81 pulse: 68 Resp: 18 SpO2: 100% RA. Temp 98.1. BMI 23.76 kg/m2

General: A&Ox3. In no acute distress. Well developed, good hygiene, appears stated age.

Head: Normocephalic, no scars or lesions or trauma.

Eyes: Symmetrical. Iris brown. No erythema over sclera and conjunctiva. No ptosis, icterus. EOMI without nystagmus. PERRLA. Fundoscopic exam: Vessels sharp, no cotton-wool spots or papilledema. Visual acuity deferred.

Ears: Symmetrical. No TTP over tragus, lobe or helix. AU-EAC unobstructed. TMs pearly gray, no injection or bulging TM noted.

Nose: Septum midline. Patent airway. No rhinorrhea. Inferior turbinates observed. No hematoma, discharge or foreign body.

Mouth/Throat: Teeth intact and no evidence of loose teeth or dentures. Tongue, uvula midline. Tonsils present grade 2. Uvula midline. No PND.

Neck: Supple, no palpable goiter or TTP.

Lymph nodes: No palpable lymphadenopathy. No TTP.

Lungs: No adventitious lung sounds.

Heart: S1, S2. RRR without gallops, rubs or murmurs.

Breast: Symmetric, no dimpling, nipples without discharge. Left breast no masses/ nipple discharge, axilla negative. Right breast ~2 cm hard, mobile mass at 2:00, 2 cm from areolar border with no overlying dimpling of skin. Right axilla: No hard fixed nodes in central chain.

Abdomen: No straie, scars or visible hernias present. Bowel sounds +, Soft, NT ND. No guarding, rigidity, masses or organomegaly appreciated. 

Gentourinary: deferred.

Skin: Noted clubbing of fingers. No edema, ecchymosis or rashes.

Extremities: No edema.

Neurological exam: Cranial nerves: II-XII grossly intact. 

Mammogram: Right breast 2.3 cm x 2.9 cm x 3.2 cm mass with irregular borders. 6 Y shaped microcalcifications extended toward nipple. Assessment highly suggestive of malignancy

Biopsy: Consistent with infiltrating breast cancer, 3-5 mitotic division per high power field, mild pleomorphism, positive for estrogen and progesterone receptors. Negative for HER2/Neu 1+. 

Assessment

46 y/o pre-menopausal female with PMHx of invasive ductal carcinoma, asthma and HTN, and family history of breast cancer, presenting today for right breast resection with sentinel lymph node biopsy.  

Plan

Right breast resection with sentinel lymph node biopsy

D/C home after stabilized