Breast Surgeon-Vorlage
Breast Consultation Follow-Up
Eine professionelle Breast Surgeon-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Streamline your breast surgery follow-up documentation with this comprehensive clinical notes template. Specifically designed for breast surgeons, this template ensures all crucial details, from GP recommendations to patient summaries, are meticulously captured. It’s perfect for detailing diagnoses, treatment received, and ongoing follow-up plans, including screenings and medication. This template, when used with Heidi, automatically populates sections based on your consultation, ensuring consistent and thorough medical documentation. Enhance your patient care and save valuable time by clearly communicating complex medical information, offering a structured approach to every follow-up appointment.
Vorlagenvorschau
Clinician Specialty: Breast Surgeon
**Recommendations for GP:**
It is recommended that the patient continues with the prescribed Tamoxifen 20mg once daily for a duration of five years, as previously discussed. Please monitor for any side effects and advise the patient to report any concerns. Additionally, Vitamin D supplementation at 1000 IU daily is advised to support bone health.
**Recommendations for Hospital:**
During her recent admission, the patient received a prescription for a 7-day course of Co-amoxiclav 625mg three times daily to address a localised wound infection, which has since resolved. She was also provided with a 3-month supply of Tamoxifen 20mg daily, with a follow-up prescription to be issued by her GP.
**Diagnosis:**
The patient was diagnosed with Invasive Ductal Carcinoma, Grade 2, of the left breast. Tumour size was 2.5 cm. Nodal status was N1 (one positive axillary lymph node). The tumour exhibited Estrogen Receptor positive (ER+), Progesterone Receptor positive (PR+), and HER2 negative (HER2-) status. The Nottingham Prognostic Index score was 4.4.
**Treatment:**
The patient underwent a left wide local excision and sentinel lymph node biopsy on 1 November 2024. The procedure was uneventful, and the patient tolerated it well with good post-operative recovery.
**Follow-Up:**
She is scheduled for annual mammograms for the next five years, with the first follow-up mammogram due in November 2025. Additionally, she will have clinical reviews with the breast surgeon every six months for the first two years, followed by annual reviews for the subsequent three years.
"It was lovely to see you in my clinic today." It was wonderful to see you looking so well and your wound has healed beautifully since your surgery. We discussed your histology results, which confirmed a good response to treatment, and I've started you on Tamoxifen to help prevent recurrence. Your next step is to meet with the oncology team to discuss potential radiotherapy, and I've ensured you have an appointment booked with Dr. Smith. We've also scheduled your follow-up mammograms and discussed the importance of engaging with our breast care nurses for ongoing support and information about follow-up programmes. Please remember to attend all your upcoming appointments.
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