DIALOGUE

[doctor] sophia brown . date of birth , 3/17/1946 . this is a new patient visit . she's here to establish care for a history of dcis . we'll go over the history with the patient .
[doctor] hello , ms. brown .
[patient] hi . yes , that's me .
[doctor] wonderful . i'm doctor stewart . it's lovely to meet you .
[patient] you as well .
[doctor] so , you've come to see me today because you had a right breast lumpectomy last year . is that right ?
[patient] yes . on january 20th , 2020 .
[doctor] okay . and how have you been since then ? any problems or concerns ?
[patient] no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since .
[doctor] perfect . i want to back up and go over your history so i can make sure everything in your chart is correct and i do n't miss anything . so , i'll tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing . sound good ?
[patient] sounds good .
[doctor] great . so , i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram , or was it done because you felt a lump ?
[patient] it was just a normal one you're supposed to get every so often .
[doctor] i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters .
[patient] yes , that sounds right . hard to remember now , though .
[doctor] yep , definitely .
[doctor] based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5th , 2019 . pathology results during that biopsy came back as grade two , er positive , pr positive , dcis , or ductal carcinoma in situ .
[patient] yes . unfortunately .
[doctor] i know . scary stuff . but you had a lumpectomy on january 20th , 2020 , which removed the eight millimeter tumor and margins were negative . the pathology confirmed dcis . looks like they also removed 5 lymph nodes , which , thankfully , were negative for malignancy . that's great !
[patient] yeah , i was definitely very relieved .
[doctor] and your last mammogram was in january 2021 ? and that was normal .
[patient] yes .
[doctor] okay . so , i feel like i have a good grasp of what's been going on with you now . and you're here today to establish care with me so i can continue to follow you and make sure you're doing well , right ?
[patient] yes . fingers crossed .
[doctor] definitely . we'll keep a close eye on you and take good care of you .
[patient] okay , sounds good .
[doctor] i have a few more questions for you . when was your last colonoscopy ?
[patient] i had one in 2018 and , if i remember correctly , i had one polyp and that was removed and it was n't cancerous .
[doctor] okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular adenoma . okay . and when was your last menstrual period ?
[patient] gosh . it was probably around 30 years ago .
[doctor] okay . do you have children ?
[patient] i do . i have five .
[doctor] ah , big family then . that's nice .
[patient] yes . and they're all having kids of their own now , so it's getting even bigger .
[doctor] i bet . sounds like fun .
[patient] it is .
[doctor] did you have any other pregnancies that were miscarriages or terminations ?
[patient] really , i did not .
[doctor] okay . so for the record , that's g5 p5 . and now that you're post-menopausal , are you currently or have you ever been on hormone replacement therapy ?
[patient] my primary care doctor gave me the option years ago but i decided against it .
[doctor] okay . and on your review systems form , you indicated that you've not had any recent weight loss or gain , headaches , bone pain , urinary symptoms , or blood in the stools . but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those .
[patient] okay . so i've seen doctors for all of those . they've said , excuse me , the back and knee pain are age-related . and the cholesterol is a fairly new diagnosis , but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication .
[doctor] okay . and your primary care doctor is following you for that , right ?
[patient] that's correct .
[doctor] okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ?
[patient] yes , and that's all .
[doctor] okay . so for your medical history , it's high cholesterol and stage 0 er/pr positive invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ?
[patient] i did have my tubes tied after my last baby , but that's all .
[doctor] okay . and how about family history ?
[patient] my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it .
[doctor] all right . any family history of breast cancer ?
[patient] none .
[doctor] did any of your children have medical issues or siblings with medical problems ?
[patient] i do not have any siblings and , thankfully , my children are all healthy .
[doctor] wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ?
[patient] no drugs . i do drink socially , but never more than that . and i used to smoke , but really , everybody did back then and i probably quit about 30 years ago .
[doctor] excellent . i have that you're allergic to penicillin . any other allergies ?
[patient] nope , just penicillin .
[doctor] okay . i think that covers it . hop up here and let me take a look at you .
[doctor] okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes .
[doctor] in the result section , note that her ecog performance status today is zero .
[doctor] do you have ... did you have radiation after the lumpectomy ?
[patient] i did . we also talked about endocrine therapy , but i decided against that .
[doctor] okay . so your exam looks good , no masses , just some skin changes from that radiation . now , let's go over the plan for you .
[patient] okay , sounds good .
[doctor] as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy .
[doctor] so , based on all of that , we can just continue to observe you .
[patient] okay . that sounds great . and when do i come back in to see you ?
[doctor] in a year , but you should have another mammogram in april of 2022 before you come back to see me .
[patient] okay , i can do that .
[doctor] wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ?
[patient] i do n't think so .
[doctor] okay , great . my nurse will be in shortly to discharge you . take care !
[patient] you as well .

CLINICAL NOTE

CHIEF COMPLAINT

History of right ductal carcinoma in situ (DCIS).

HISTORY OF PRESENT ILLNESS

Sophia Brown is a 75 y.o. female who presents today for a new patient evaluation due to her history of right DCIS. She is doing well but wishes to establish care today for continued monitoring.

The patient underwent a screening mammogram in 10/2019 and was found to have a calcification in the right breast. She then had a right breast ultrasound on 11/03/2019 which revealed a mass at the 2 o'clock position, 11 cm from the nipple, in the retroareolar region. The report states the mass was 0.4 by 2.0 by 3.0 centimeters. She subsequently had an ultrasound-guided core needle biopsy on 12/05/2019 and pathology results revealed grade 2 ER-positive, PR-positive DCIS. The patient then had a lumpectomy with lymphadenectomy performed on 01/20/2020. The tumor was 8 mm with negative margins and the 5 lymph nodes removed were all benign. Pathology from the tumor confirmed DCIS. Her lumpectomy was followed by adjuvant radiation therapy. Endocrine therapy was also offered but the patient declined. She has since had a mammogram in 01/2021 which was normal. The patient also reports that she performs self-breast exams regularly at home.

Mrs. Brown is a G5P5 female and estimates that her last menstrual period was approximately 30 years ago. She is not currently and has never been on hormone replacement therapy.

The patient's last colonoscopy was done in 2018. She had a sigmoid polypectomy at that time and pathology showed a tubular adenoma.

Her cholesterol was recently noted to be elevated and the patient reports that she is exercising and reducing fatty food intake accordingly. This is being followed by her primary care provider.

PAST HISTORY

Medical
Hypercholesterolemia.
Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast, status post lumpectomy and adjuvant radiation therapy.

Surgical
Right lumpectomy, lymphadenectomy x5, 01/20/2020.
Bilateral tubal ligation.

SOCIAL HISTORY

Alcohol: Socially. No history of heavier consumption.
Illicit drug use: Never.
Tobacco: Former smoker. Quit approximately 30 years ago.
Patient has 5 children and multiple grandchildren.

FAMILY HISTORY

Mother: Non-Hodgkin's lymphoma.
Father: Prostate cancer, heart disease.
Her children are healthy. She has no siblings. Denies family history of breast cancer.

CURRENT MEDICATIONS

Co-Q 10.
Vitamin D.
Vitamin C.
Fish oil.
Elderberry fruit.

ALLERGIES

Penicillin.

REVIEW OF SYSTEMS

Negative for weight loss, weight gain, headaches, bone pain, urinary symptoms, blood in the stools.
Positive for back pain, joint pain, high cholesterol. Patient has sought care for these complaints. She reports that she was told the back pain and joint pain (knee) are age-related. She is being followed for the high cholesterol by her primary care provider.

PHYSICAL EXAM

The ECOG performance status today is grade 0.
Breast: There are no palpable masses; however, there is some skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes.

ASSESSMENT

Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast.
The patient is status post lumpectomy with removal of 5 lymph nodes which were benign. She also underwent adjuvant radiation therapy but declined endocrine therapy. Today's clinical examination shows no evidence of recurrent disease or other malignancy. She also had a negative mammogram in 01/2021.

PLAN

1. We will continue to observe the patient.
2. She is due for a mammogram in 04/2022.
3. She should follow up with me in 1 year after the mammogram.