HPI B.D.

GETTING EVALUATED FOR MASTECTOMY

Mrs. B.D. is a 63 y.o. female with a PMH of hypothyroidism and HTN presented to the PAT for evaluation for her upcoming left breast mastectomy. Patient states she does not have any pain. Her right breast ductal carcinoma was discovered in July 2018 during a routine mammogram following a right breast mastectomy and a left breast lumpectomy (with a nipple removal). Her hypothyroidism and HTN are well controlled with medication. Patient admits to fatigue, weakness and recent weight gain (10lbs).

PMH:

Past illnesses – denies,

Present illnesses: left knee pain diagnosed as arthritis by her PCP, untreated. Hypothyroidism – well controlled with medication, HTN – well controlled with medication

Childhood illnesses – denies

Immunizations – up to date, last flu shot Oct 2018

PSH:

1993- C-section, does not recall hospital

10/31/2018 – right breast mastectomy and left breast lumpectomy

Denies any injuries, blood transfusions or surgery complications

Medications:

Levothyroxine 75mcg tablets (for Hypothyroidism) last dose today morning

Losatran 50 mg tablets(for HBP) last dose today morning

Allergies: NKDA, NKEA, NKFA

FH:

Grandparents unknown

Mother (HTN )– deceased at age 83, natural causes

Father (arthritis) deceased at age 59, cause unknown

Sister (breast cancer) – 60 y.o.

Son – 26 y.o. – alive and well

Social History:

Travel – denies

Diet – Mrs.B eats a healthy diet – she likes rice and beans, salads, sometimes eats meat (chicken).

Denies smoking, alcohol, caffeine and illicit substance use. She sleeps well although admits snoring. She used to work as a home attendant but recently retired. She lives with her son, doesn’t have any pets. She states she walks a lot to exercise, despite her knee pain.