[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 .
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."