mlemon
Networker
NEW PATIENT CONSULTATION
HISTORY OF PRESENT ILLNESS:
This is a 63-year-old white female who comes in to establish and transfer care for her history of breast cancer. She is referred by Dr. Smith. She moved here from California in October 2013 so that she could be close to her grandchildren. The patient was diagnosed in 2008 with left breast cancer after finding an abnormality on a mammogram. She does not know the details of her pathology but knows that on 09/09/2008 she underwent a lumpectomy in which she was found to have a HER-2/neu-positive breast cancer. The patient says it was small, but she is not sure if it involved the lymph nodes or not. She did receive Taxotere, carboplatin, and Herceptin for 6 cycles and then continued on the Herceptin to complete 1 year. She was not given adjuvant hormonal therapy but did receive radiation therapy. She last saw her oncologist, Dr. John Doe, at the University of Alaska Medical Center in March 2012. The patient's insurance changed, so she saw another oncologist nearby in December 2012. She was scheduled for 1-year followup in December 2013 but moved here in October 2013, so she has not followed up with an oncologist in about 1-1/2 years. She has not noted any changes to her breasts. The patient is feeling well and comes in to establish contact with a medical oncologist.
PAST MEDICAL HISTORY:
Bilateral trigger finger surgeries on her 4th fingers.
Left carpal tunnel surgery.
Total abdominal hysterectomy with bilateral salpingo-oophorectomy about 14 years ago.
Tonsillectomy as a child.
Appendectomy as a child.
Benign left breast lump removed in 2000.
Left breast cancer in 2008 as noted above.
Anal fistula times 2.
She had a syncopal episode in 2012 in which she passed out while driving a car and ran into a pole. The patient saw a cardiologist, but they were unable to determine the etiology. She is trying to get in with a cardiologist now.
Hyperlipidemia.
Anxiety.
GERD (gastroesophageal reflux disease).
Her last colonoscopy was about 14 years ago; she is scheduled for one on 07/03/2014 by Dr. Curtis.
Her next mammogram is scheduled on 06/20/2014.
Her last Pap smear was in 2012.
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ASSESSMENT AND PLAN:
History of breast cancer almost 6 years ago. This sounds like it was a HER-2/neu-negative, ER-negative breast cancer and she received appropriate therapy. I will try to get the pathology report and some of the oncologist's notes from the University of Alaska Medical Center. I will see her again in another year unless she is found to have some evidence of recurrent disease or a new cancer.
HISTORY OF PRESENT ILLNESS:
This is a 63-year-old white female who comes in to establish and transfer care for her history of breast cancer. She is referred by Dr. Smith. She moved here from California in October 2013 so that she could be close to her grandchildren. The patient was diagnosed in 2008 with left breast cancer after finding an abnormality on a mammogram. She does not know the details of her pathology but knows that on 09/09/2008 she underwent a lumpectomy in which she was found to have a HER-2/neu-positive breast cancer. The patient says it was small, but she is not sure if it involved the lymph nodes or not. She did receive Taxotere, carboplatin, and Herceptin for 6 cycles and then continued on the Herceptin to complete 1 year. She was not given adjuvant hormonal therapy but did receive radiation therapy. She last saw her oncologist, Dr. John Doe, at the University of Alaska Medical Center in March 2012. The patient's insurance changed, so she saw another oncologist nearby in December 2012. She was scheduled for 1-year followup in December 2013 but moved here in October 2013, so she has not followed up with an oncologist in about 1-1/2 years. She has not noted any changes to her breasts. The patient is feeling well and comes in to establish contact with a medical oncologist.
PAST MEDICAL HISTORY:
Bilateral trigger finger surgeries on her 4th fingers.
Left carpal tunnel surgery.
Total abdominal hysterectomy with bilateral salpingo-oophorectomy about 14 years ago.
Tonsillectomy as a child.
Appendectomy as a child.
Benign left breast lump removed in 2000.
Left breast cancer in 2008 as noted above.
Anal fistula times 2.
She had a syncopal episode in 2012 in which she passed out while driving a car and ran into a pole. The patient saw a cardiologist, but they were unable to determine the etiology. She is trying to get in with a cardiologist now.
Hyperlipidemia.
Anxiety.
GERD (gastroesophageal reflux disease).
Her last colonoscopy was about 14 years ago; she is scheduled for one on 07/03/2014 by Dr. Curtis.
Her next mammogram is scheduled on 06/20/2014.
Her last Pap smear was in 2012.
---------------------
ASSESSMENT AND PLAN:
History of breast cancer almost 6 years ago. This sounds like it was a HER-2/neu-negative, ER-negative breast cancer and she received appropriate therapy. I will try to get the pathology report and some of the oncologist's notes from the University of Alaska Medical Center. I will see her again in another year unless she is found to have some evidence of recurrent disease or a new cancer.