I need assistance with this HPI on a new patient seeing the Oncologist. Documentation states:
Ms. XX is a pleasant middle-aged woman who presented with abnormal right breast mammogram. Biopsy was consistent with ER/PR positive, HER 2neu negative, invasive ductal carcinoma. She underwent rt. breast mastectomy, final pathology is consistent with T1N0 right upper outer quadrant, intermediate grade ER/PR positive, HER 2 neu negative invasive ductal carcinoma. Recovering well from surgery. Presents to establish care for further management.
GRPR, post menopausal, family history of breast cancer in sister in her 30's, uterine cancer in her mother, prostate cancer in her father and pancreatic cancer in maternal uncle.
Location: Rt. Breast
Quality: Invasive Ductal Carcinoma
Modifying factor: Biopsy/mastectomy
Associated Signs and Symptoms: ?????? Could it be the findings on the final path report of T1N0 rt. upper outer quadrant...carcinoma
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