Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertension, Intraductal proliferative breast lesion, Invasive papillary breast carcinoma, Joint stiffness, Mammogram abnormal
Clinical narrative: Document Type: Hem Onc OP Provider Note   Document Subject: AMB Hem/Onc Progress Note   Performed By: MD on March 11, 2022 22:48 EST   Verified By: MD on March 11, 2022 22:48 EST   Encounter Info: Oncology, Outpatient, 03/09/22 - 03/09/22    * Final Report *        Chief Complaint   FU  Subjective        Diagnosis: DCIS on Left Breast dx in 6/2021, Breast Cancer genetic testing is negative.   HISTORY OF PRESENT ILLNESS:  The patient is a 72-year-old very healthy woman, noted to have  abnormality on screening mammogram that was obtained at Hospital  sometime in April.  In view of this finding, further workup was  obtained and underwent stereotactic core biopsy on 04/19/2021 in view  of abnormality in the left breast with microcalcifications.  Pathology was significant for papillary features and it could not be  excluded if there is any invasive malignancy and also DCIS.  The  patient was seen by Dr. and the patient was able to undergo  needle localized lumpectomy on 06/01/2021.  The pathology is  significant for papillary ductal carcinoma in-situ DCIS.  Margins are  uninvolved.  Anterior margin was very close, less than 1 mm and this  was resected and all the margins came back negative.  There is no  evidence of any invasive malignancy noted.  The DCIS size is 13 mm  and nuclear grade is intermediate.  Two sentinel nodes were  identified and both of them were negative.  Benign breast tissue with  single focus of atypical ductal hyperplasia is noted at the new  margin of the left breast lumpectomy site.  AJCC staging:  pTis (DCIS) N0 sentinel node.  Estrogen is highly positive at 91% to 100%  and progesterone is also positive at 91% to 100%.  In view of very  good functional status and very small focus of the DCIS, the patient  was seen by Dr. and received SAVI treatment from 07/12 to  07/18/2021.     She is initiated on Arimidex on 8/30/21.  Subjective:   She is here for f/u.  She is tolerating Arimidex well. She is having some hot flashes but not much joint pains or stiffness.  She is able to do daily activities without any difficulty.  She is not doing any exercise.  She does have grand children on Weekend.   She is having only 30 day supply as she was not able to get 90 day supply.  Staging       No information available        Review of Systems     Constitutional: Other: denies ros  Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.6 DegC  Heart Rate:       60 bpm  BP #1:       178 / 78 mmHg  SpO2 (%):       98 %     No qualifying data available.   Last 6 Weights  Weight KG: 88.7 kg (03/09/22 09:18:00)  Weight KG: 86.8 kg (11/01/21 08:34:00)  Weight KG: 88 kg (08/30/21 15:20:00)  Weight KG: 85 kg (06/01/21 10:17:00)  Weight KG: 84.1 kg (05/25/21 07:00:00)  Weight KG: 87.6 kg (07/15/19 13:13:00)   Performance Scales and Status  Karnofsky Performance Scale: Normal Activity with Effort; Some Symptoms of Disease.  Karnofsky Performance Score: 80   Physical Exam     GENERAL:  The patient is alert, oriented, well built, and well  nourished, and appears younger than stated age and no respiratory  distress at rest noted.  HEENT:  Pupils reacting to light.  There is no icterus.  Oral mucosa  is normal.  NECK:  Negative for any palpable lymph nodes.  There is no JVD and  thyroid is not enlarged.  LUNGS:  Clear to auscultation.  HEART:  S1 and S2 regular.  BREASTS:  Bilateral breast examination is significant for normal  breast on the right side without any mass or tenderness.  Left breast  is lumpectomy scar at upper quadrant and  left axillary scar intact.  ABDOMEN:  Soft.  Liver and spleen are not palpable and bowel sounds  are present.  LYMPH NODES:  Bilateral cervical, axillary, and inguinal nodes are  not palpable.  EXTREMITIES:  Lower extremity examination is negative for any  swelling or pedal edema.    Assessment/Plan       1. Ductal carcinoma in situ (DCIS) of left breast   D05.12   She is remaining in remission and tolerating Arimidex. She will need bilateral mammogram as she has not had 6 month f/u study in December.     2. H/O bone density study   Z92.89   She is noted to have normal study at hospital in 10/25/21. She is noted to have normal Vitamin D on 2/10/2022 at 49 level.     3. Hypertension   I10   She is noted to have elevated BP but always normal. She has been complaint with all medications.  She is following with PCP.     4. Health care maintenance   Z00.00   She is following with PCP.     Breast cancer   C50.919     Ordered:   anastrozole, 1 mg, = 1 Tablet, Orally, Daily, Maintenance, Dispense: 30 Tablet, Refills: 2, Total Refills: 2, 03/11/22 10:26:00 EST, Pharmacy: 1 Tablet Orally Daily, 160, cm, 03/09/22 9:18:00 EST, Height CM, 88.7, kg, 03/09/22 9:21:00 EST, W...     Time spent with patient in counseling and discussing all the above is over 30'       Chronic Problem List    Breast cancer in female  Ductal carcinoma in situ (DCIS) of left breast  GERD (gastroesophageal reflux disease)  H/O bone density study  Health care maintenance  Hyperlipidemia  Hypertension  Type 2 diabetes mellitus  Procedure/Surgical History  ?Lumpectomy of left breast (06/01/2021) ?Colonoscopy (08/13/2019) ?Dilation and curettage (11/01/2009) ?Colonoscopy (06/17/2009) ?Esophagogastroduodenoscopy (06/17/2009) ?breast surgery (08/05/2002) ?Cholecystectomy (2001) ?Tubal ligation (1979)   Medications  Home Medications (9) Active  Arimidex 1 mg oral tablet 1 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, QPM  calcium-vitamin D3 600 mg-5 mCg (200 intl units) oral capsule 1 Capsule, Orally, BID  chlorthalidone 25 mg oral tablet 12.5 mg = 0.5 Tablet, Orally, QAM  metFORMIN 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  metoPROLOL succinate 50 mg oral tablet, extended release 50 mg = 1 Tablet, Orally, QAM  Nitrostat 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  pantoprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, QAM  telmisartan 40 mg oral tablet 40 mg = 1 Tablet, Orally, QAM  Allergies   lisinopril (Dizziness)  sulfa drugs (Swelling)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Breast cancer: Sister.  Diabetes mellitus: Mother.  Malignant tumor of lung: Brother.  Malignant tumor of pharynx: Brother.  Parkinson disease: Mother.