Identifying Data

Date: November 25, 2019

Sex: female

Age: 36 years old

Location: St. Francis

Source of information: self

 

Chief Complaint: “I’m here for my mastectomy”

 

HPI

36-year-old female with PMHx of scoliosis, depression, anxiety and asthma, presents with multifocal invasive ductal carcinoma of the right breast, diagnosed two months ago. The breast cancer was determined to be up to 7cm in diameter, ER+, PR- and Her2-. Pt was placed on Tamoxifen while she consulted with several specialists, before determining the best course of treatment. Pt presets today for bilateral skin sparing mastectomy with sentinel node biopsy with DIEP flap reconstruction. Pt is G0 and experienced menarche at age 11, LMP 11/23/19. Pt was on and off of birth control pills for 17 years and denies history of hormone replacement, in vitro fertilization, and family history of breast cancer. Pt denies breast tenderness, weight loss, chills, fever, CP, SOB, dizziness, headache.

Past Medical history:

• Depression
• Anxiety
• Scoliosis
• Asthma
• Eczema

Denies surgical history

Medications:

• Clonazepam 2mg BID PRN
• Fluoroimide 0.05% cream, topically BID
• Hydrocortisone 0.5% cream topically BID PRN
• Hydroxyzine 25mg Q8H PRN for itching
• Tamoxifen 10mg daily
• Tizanidine 2mg Q8H PRN
• Trazodone 25mg before bed

Family history:

• Mother: osteoarthritis, hyperlipidemia
• Father: prostate cancer, hypertension, anxiety disorder, depression

Allergies: mold, ragweed, adhesive tape, aripiprazole, bacitracin, benzalkonium chloride, clindamycin, Gardasil vaccine, neomycin, nickel.

• Reactions: rash

Social History:

36-year-old female, lives with boyfriend in condo.

Habits: pt denies smoking cigarettes and illicit drug use. Admits to drinking alcohol socially

 

Review of Systems:

General: Denies fatigue, weakness, chills, fever, loss of appetites, fever, night sweats, recent weight loss or gain.

Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes and changes in hair distribution.

Head: Denies headache, vertigo, head trauma, unconsciousness, coma, fracture.

Eyes: denies visual disturbances, fatigue, lacrimation, photophobia or pruritis.

Ears: denies deafness, pain, discharge, tinnitus, and hearing aids

Nose/sinuses: denies discharge, epistaxis, and obstruction

Mouth and Throat: Denies SOB, sore throat, bleeding gums, sore tongue, mouth ulcers, voice changes, or dentures.

Neck: denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary System: Denies orthopnea, dyspnea, SOB, PND cough, wheezing, hemoptysis and cyanosis.

Cardiovascular: Denies CP, HTN, edema, palpitations, irregular heartbeat, and syncope.

Breast: Admits to mass in right breast, denies tenderness or abnormal breast discharge bilaterally.

Gastrointestinal system: Denies abdominal pain, nausea, vomiting, decreased appetite, intolerance to foods, hemorrhoids, dysphagia, pyrosis, flatulence, eructation, diarrhea, jaundice, change in bowel habits, constipation, rectal bleeding, blood in stool, pain in flank

GYN: Denies vaginal bleeding or clots, pain or discomfort, unusual discharge.

Nervous: Denies headaches seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system: Denies muscle/joint pain, deformity of swelling, redness or arthritis

Peripheral vascular system: Denies varicose veins, peripheral edema, intermittent claudication, coldness or trophic changes, or color change

Hematological system:  Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric: Admits to history of anxiety and depression.

 

Physical Exam

General: Anxious female in no acute distress, average height and weight, well nourished, good hygiene. A/O x3.

 

Vital signs: BP 110/55, P 77 regular, O2 100% room air, T 98.6, RR 18 BPM, height 5’0”, weight 150 lb.

 

Skin: warm & moist, good turgor.

Hair: normal hair distribution
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear

Visual fields full OU. PERRLA, EOMs full with no nystagmus.

Ears: Symmetrical and normal size. No evidence of lesions/masses/trauma on external ears.
No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/intact with light reflex in normal position AU.

Nose: Symmetrical, no obvious masses/lesions/deformities/trauma/discharge.

 

Mouth: mucosa pink, moist, no evidence of masses, edema or lesions. Injected oropharynx, no evidence of exudate, angioedema or inflammation.

 

Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM. No JVP

Heart: RRR, S1, S2, no S3, S4, no gallops, rubs or murmurs

 

Chest: symmetrical, no deformities, no evidence of trauma. Non-tender to palpation.

Lungs: lungs clear to auscultation, no wheezing, rales or rhonchi. Chest expansion symmetrical.

 

Breast:

• Right breast: fullness to palpation deep to the nipple and in upper inner breast with multiple palpable hard, irregular, fixed masses. No skin changes or abnormal nipple discharge.
• Left breast: no masses or tenderness to palpation, no skin changes or abnormal nipple discharge.
• Lymph nodes: rubbery axillary lymph nodes palpable in right axilla, measuring 1.5 x 1.5cm. no palpable adenopathy on left axilla.

 

Abdomen: Symmetrical, no evidence of striae, caput medusae or abnormal pulsations, BS present in all four quadrants. Non-tender to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

 

Extremities: Full ROM, no edema, erythema, or deformities. Pulses intact throughout. No clubbing or cyanosis. Capillary refill <2 seconds throughout.

 

Neurological: A/O x 3

 

Radiology/Labs:

Chest x-ray (11/18/19): unremarkable, right biopsy clip visible. No focal pulmonary parenchymal consolidation, pleural effusion or pneumothorax.

 

Operative note: 11/26/19

• Bilateral skin sparing mastectomy performed by Dr. Derisi.
  • 5cc of blue dye injected into Para areolar area in order to identify sentinel node. Circum-areolar incision was made, and breast tissue was removed without incident. Sentinel nodes were removed and sent for pathology
• DIEP flab reconstruction performed by Dr. Korn.
  • The Superficial inferior epigastric vessels were used for the DIEP harvest. Three medial perforator vessels on the left and a single medial perforator vessel on the right were harvested.
  • Inferior mammary vessels were used for the flap anastomosis bilaterally.
  • Two Blake drains were placed beneath the mastectomy skin flaps bilaterally; two Jackson-Pratt drains were placed beneath the abdominal skin upon closure.
  • Mastectomy skin flaps were deemed viable with proper blood flow, and Vioptix were placed on the mastectomy skin flaps.
  • Estimated blood loss 300cc.

 

Assessment: 36-year-old female with PMHx of scoliosis, depression, anxiety and asthma, presents with multifocal invasive ductal carcinoma of the right breast, diagnosed two months ago. Bilateral skin sparing mastectomy and DIEP flap reconstruction was successfully completed. Vioptix functioning well and flaps appear healthy. Patient stable.

 

Plan:

• Monitor Vioptix and mastectomy flap capillary refill
• Encourage ambulation
• Pain management
• Remove Foley once ambulating
• Start patient on liquid diet.