Medical Specialty:
Consult - History and Phy.

Sample Name: Consult - Breast Cancer


Description: Patient presents with complaint of lump in the upper outer quadrant of the right breast
(Medical Transcription Sample Report)


CHIEF COMPLAINT / REASON FOR THE VISIT: Patient has been diagnosed to have breast cancer.

BREAST CANCER HISTORY: Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.

PATHOLOGY: Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.

STAGE: Stage I.

TNM STAGE: T1, N0 and M0.

SURGERY: S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.

PAST MEDICAL HISTORY: Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.

SCREENING TEST HISTORY: Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.

IMMUNIZATION HISTORY: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.

FAMILY MEDICAL HISTORY: Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.

PAST SURGICAL HISTORY: Appendectomy. Biopsy of the left breast 1996 - benign. Cholecystectomy.

PERSONAL AND SOCIAL HISTORY: Marital status: Married. Smoking history: Smoked 1 PPD, quit 12 years ago and after smoking for 30 years. Alcohol history: Drinks socially. Denies any history of drug abuse.

ALLERGIES: There are no known drug allergies.

CURRENT MEDICATIONS: Aspirin 1 tab x 1 / day. Calan SR 120 mg. x 1 / day.

REVIEW OF SYSTEMS:
General: Patient feels fairly well. Patient denies history of fever, chills, night sweats and weight loss.
Head and Eyes: Patient denies any problems relating to the head and eyes.
Ears Nose and Throat: Patient has no problems related to the ears, nose or throat.
Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.
Cardiovascular: Chest pain in the retrosternal area, Occasional anginal pain and patient describes it as a sensation of tightness. It radiates to the left shoulder. Patient denies any palpitation, syncope, paroxysmal nocturnal dyspnea and orthopnea.
Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.
Genitourinary: Denies any genito-urinary complaints.
Musculoskeletal: The patient denies any musculoskeletal complaints.
Neurological: Patient denies any focal motor, sensory or other neurological symptoms.

PHYSICAL EXAMINATION:
General: Patient appears well developed, well nourished and healthy. Personality: pleasant and cooperative. Mental status: Alert and oriented. Stature: slender. ECOG performance score 0.
HEENT: Examination of head, eyes, ears, nose and throat is unremarkable.
Hematologic / Lymphatic: There is no palpable adenopathy in the inguinal, axillary, or cervical areas.
Cardiovascular: Heart: Regular rhythm, normal rate without any murmurs or gallops.
Breast: RIGHT BREAST: Within normal limits. LEFT BREAST: Consistency: slight induration noted due to recent surgery.
Respiratory: Chest symmetrical, normal, breath sounds equal, bilateral symmetrical, no rales or rhonchi and no
dullness to percussion.
Abdomen / Gastrointestinal: Abdomen is soft, non-tender, and without palpable masses. No hepatosplenomegaly is appreciable.
Extremities: Peripheral pulses are normal. There is no edema, cyanosis, clubbing or significant varicosities. No skin lesions identified.
Musculoskelatal: No evidence of joint swelling, bone tenderness or muscle tenderness is appreciable.
Neurological: Brief neurological examination reveals motor power grossly normal in all groups and no gross sensory or other abnormality appreciable.

RADIOLOGY: Mammogram: A mass measuring 2X2 cm. in the upper outer quadrant of the left breast. Lab:

LAB DATA: CMP (comprehensive metabolic panel): WNL. Liver function tests are WNL. CBC with diff shows WBC 3.2 / cmm. Hemoglobin 12.0 grams / dl, Platelets 250000 / cmm and it is dated 1/4/2000.

IMPRESSION / DIAGNOSIS : Carcinoma of the left breast (174.9 - female), Upper outer quadrant (174.4)

PATHOLOGY: Infiltrating ductal carcinoma. S/P lumpectomy and axillary node dissection. (Details as per HPI).

DISCUSSION: Discussed in detail the diagnosis, prognosis and treatment alternatives. Options of treatment discussed. Side effects of Tamoxifen discussed in detail.

RECOMMENDATIONS: Hormonal therapy with Tamoxifen and Radiation therapy to the breast is recommended.

TESTS ORDERED: The following labs are to be drawn about a week or so prior to next appointment:
HEMATOLOGY: CBC.
CHEMISTRY: comprehensive metabolic panel (CMP) and liver function panel (LFT).

MEDICATIONS PRESCRIBED: Nolvadex 20 mg. 1 time a day.

FOLLOW-UP INSTRUCTIONS: Return to see William Smith.M.D. for follow up in 3 month (s). Make appointment to Radiation therapy.

Keywords: consult - history and phy., breast cancer, lump, progesterone receptor, estrogen receptor, her 2 neu, tnm, axillary node dissection, tamoxifen, infiltrating ductal carcinoma, upper outer quadrant, ductal carcinoma, breast, carcinoma, axillary, chest, mammogram,