Tammytude
Contributor
[U]Which HPI elements can you find?[/U] I would really appreciate all responses this. :
Diagnosis: Infiltrating intraductal carcinoma of the left breast, status post lumpectomy.
Chief complaint: Left breast cancer.
History of Present Illness: Mrs. Patient is a 79 year old woman who has a history of fibrocystic breast disease for many years. She has had several aspirations of cyst in her left breast which was always negative. After menopause she stopped getting lumps; however, when she was put on hormonal therapy she began to have fibrocystic disease again. She stopped her hormones due to the presence of cysts and also changes in personality and vaginal bleeding. She underwent screening mammogram this year and an irregularity was found. She was sent for diagnostic mammogram and ultrasound which ultimately lead to her diagnosis. She was referred to Dr. A. Doctor and underwent a lumpectomy on March 19, 2009. Pathology revealed intraductal papillary carcinoma, greatest dimension 0.5 cm, nuclear grade 1, no mitosis seen, proliferative fibrocystic changes, focal adenosis, usual ductal hyperplasia, micro calcification within benign ducts. There was a focus of atypical ductal hyperplasia therefore the margins were re-excised and were ultimately negative. She was seen by Dr. B. Doctor and placed on Tamoxifen as of April 1, 2009. She is not having any problems with Tamoxifen at this time. The patient is seen today for discussion and evaluation of postoperative radiotherapy to her left breast.
Diagnosis: Infiltrating intraductal carcinoma of the left breast, status post lumpectomy.
Chief complaint: Left breast cancer.
History of Present Illness: Mrs. Patient is a 79 year old woman who has a history of fibrocystic breast disease for many years. She has had several aspirations of cyst in her left breast which was always negative. After menopause she stopped getting lumps; however, when she was put on hormonal therapy she began to have fibrocystic disease again. She stopped her hormones due to the presence of cysts and also changes in personality and vaginal bleeding. She underwent screening mammogram this year and an irregularity was found. She was sent for diagnostic mammogram and ultrasound which ultimately lead to her diagnosis. She was referred to Dr. A. Doctor and underwent a lumpectomy on March 19, 2009. Pathology revealed intraductal papillary carcinoma, greatest dimension 0.5 cm, nuclear grade 1, no mitosis seen, proliferative fibrocystic changes, focal adenosis, usual ductal hyperplasia, micro calcification within benign ducts. There was a focus of atypical ductal hyperplasia therefore the margins were re-excised and were ultimately negative. She was seen by Dr. B. Doctor and placed on Tamoxifen as of April 1, 2009. She is not having any problems with Tamoxifen at this time. The patient is seen today for discussion and evaluation of postoperative radiotherapy to her left breast.