DISCHARGE SUMMARY
ADMITTING DIAGNOSIS
Infiltrating ductal carcinoma, right breast.
PROCEDURE
Needle biopsy of mass, right breast, with frozen section positive for infiltrating ductal carcinoma, and right modified radical mastectomy.
COMPLICATIONS
None.
HISTORY
This is an 87-year-old woman who had been in the hospital recently because of cardiopulmonary problems. Shortly after discharge, she noted a mass in her right breast and called this to the attention of her physician. A fine-needle biopsy was done after mammograms, which showed a suspicious lesion. Fine-needle was reported out as probably infiltrating ductal carcinoma.
Patient with her family was seen and the options of treatment reviewed. Patient opted to go for a modified radical mastectomy rather that lumpectomy and followup radiation. A Tru-Cut needle biopsy was made of the mass prior to doing the mastectomy to assure the diagnosis. The Tru-Cut needle biopsy was positive for carcinoma.
Following surgery, the patient has done well. The wound is clean and dry. There is little duskiness in the upper central portion of the wound, and there is 1 small blister near the wound edge. The Jackson-Pratt catheters have been removed this date. Patient has been advised that she may get some accumulation of fluid there that may need to be withdrawn as an outpatient.
She is anxious to go home. She states she has pain medication at home. She will be seen in the office in about 3 days for followup and removal of half the skin clips.
At this juncture the final reports on lymph node status are not as yet available, nor do we have the results for estrogen and progesterone receptors. At this patient’s age and frailty, the ultimate prognosis insofar as the tumor is concerned probably is not all that bad.
FOOTNOTE
Line 45 (Page 1). The dictated period was changed to a comma for proper punctuation.
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