1 PR - A . No Spacing nmar errors aren t being checked in this document Turn on proofing I Don't show again Encounter Note Jane Smith Styles "] © o o o = Q © - " Jane Smith, a 55-year-old female, presented to my office for a follow-up regarding recurrent carcinoma of the left breast. She was last seen in my office when she completed treatment two years ago but experienced recurrence following a recent screening mammogram revealing suspicious calcifications, A diagnostic mammogram and stereotactic core needle biopsy confirmed carcinoma of the left upper quadrant breast. Her medical history includes depression managed with Zoloft and hypertension managed with Lisinopril. Family history includes a mother with breast cancer. g On review of systems, Jane denies constitutional symptoms, cardiovascular or 3 respiratory issues, gastrointestinal disturbances, neurological deficits, musculoskeletal : complaints, hematological issues, lymphatic enlargement, or endocrine disturbances. She is currently tearful, consistent with her psychiatric history. Physical examination revealed a well-nourished female with normal vital signs, unremarkable HEENT, neck, chest, lungs, heart, and benign abdomen. Examination of g her left breast revealed tenderness and a palpable mass, whereas the right breast exam was benign. Discussion ensued regarding treatment options. Considering the recurrence, a modified radical mastectomy with axillary lymph node removal is recommended. A PET with CT oA TR SRS 0 P RN P CAtessaenn oy AR A B A R R A I R N N I R R EE R L #
