Breast Surgeon Note (custom)

Subjective: The patient, a 45-year-old female, presents for consultation due to concerns about a palpable mass in the right breast, which has been present for approximately three months. The mass has increased in size and is associated with occasional pain. The patient reports no alleviating factors and has not sought previous treatment. Past Medical/Surgical History: - The patient has a history of a lumpectomy in the left breast five years ago, with no complications post-surgery. Allergies: - The patient is allergic to penicillin, which causes a rash. Medications: - Currently taking ibuprofen for pain management. Family History: - Mother diagnosed with breast cancer at age 50. Social History: - The patient is a non-smoker, consumes alcohol socially, and works as a school teacher. She lives with her husband and two children in a suburban area. Objective: - Vitals: Blood pressure 120/80 mmHg, heart rate 72 bpm, temperature 98.6°F. - Physical examination reveals a 2 cm firm, non-mobile mass in the upper outer quadrant of the right breast. No axillary lymphadenopathy noted. Assessment & Plan: 1. Right breast mass - Assessment: Likely diagnosis is a benign breast tumor, but malignancy cannot be ruled out without further investigation. - Differential diagnosis includes fibroadenoma and breast carcinoma. - Investigations planned: Mammogram and ultrasound of the right breast, followed by a core needle biopsy. - Surgical treatment planned: Possible excisional biopsy depending on biopsy results. - Pre-operative preparation: Patient advised to avoid NSAIDs 7 days prior to surgery. - Post-operative care plan: Discussed expected hospital stay of 1 day, pain management with acetaminophen, wound care instructions, and follow-up appointment in 1 week. - Relevant referrals: Referral to an oncologist for further evaluation if malignancy is confirmed. Additional Notes: - Patient education and informed consent: Discussed the procedure, potential risks, benefits, and alternatives. The patient expressed understanding and consented to proceed with the planned investigations. - Instructions for emergency care: Advised to watch for signs of infection or excessive bleeding post-procedure and to seek immediate care if these occur. - Addressed patient concerns about the impact of surgery on daily activities and reassured her about the recovery process.