Flux Notes Lite Demo Script

Flux Notes Lite Demo Script (10/31/2017)

REASON FOR VISIT:
breast cancer follow up

HISTORY OF PRESENT ILLNESS:
Ms. Ortiz is a 43-year-old premenopausal Hispanic woman who recalls an unremarkable mammogram December 3, 2013. She recalls feeling a sharp pain in her right breast about 8 months later, and feeling a palpable lump two months after that. A diagnostic mammogram on August 13, 2015, revealed a 2 cm mass in the right breast at 7 o'clock and an indeterminate lymph node in the right axilla, 13 mm. A right breast ultrasound on August 29, 2015 revealed mass measuring 1.6 cm, indeterminate right axillary lymph nodes, measuring 1.4 cm with the cortex of 3 mm - indeterminate, and another measuring 12 mm with cortex of 4 mm - indeterminate.

She underwent right breast mass core biopsy and right axillary lymph node core biopsy on August 29, 2014 which revealed infiltrating poorly differentiated ductal carcinoma, grade 3, estrogen receptor 0, progesteron receptor weakly positive 1% to 4%, HER2 was negative 0%, and Ki-67 ranged 85% to 95%. Right axillary lymph node was negative for malignancy. Stage IA T1c N0 M0 disease. BRCA1/2 testing was negative. In preparation for treatment, a Port-A-Cath was placed on October 13, 2015. TTE done on October 15, 2015 showed normal systolic function, with ejection fraction 60-65% and trace mitral regurgitation.

She underwent neoadjuvant cyclophosphamide (ddAC) followed by taxol (T) from October 20, 2015 to February 23, 2016. Taxol was dose reduced to 60mg/m2 for the last 2 cycles and stopped after 11 doses due to neuropathy. She received 11 of 12 planned doses.

She underwent right lumpectomy with Dr. Ford on March 12, 2016. Pathology report on March 16, 2016 showed no residual disease, 0/2 SLNs, pathological complete response pCR, stage pT0N0.

She completed adjuvant radiation therapy with Dr. Bruno from May 18, 2016 to June 29, 2016.

She started Tamoxifen July 6, 2016.

A bilateral 3D mammogram on September 15, 2016 showed benign findings. Her Gyn exam with her PCP on January 6, 2017 was unremarkable.

REVIEW OF SYSTEMS: A complete 15 point ROS was done as was unremarkable except for amenorrheic since chemotherapy, numbness and tingling of extremities. ALLERGIES: NKDA

MEDICATIONS: tamoxifen 20 mg tablet, Take 1 tablet by mouth daily lisinopril 20mg tablet, Take 1 tablet by mouth daily ibuprofen 600mg tablet, Take 1 tablet by mouth three times daily as needed with food hydrocortisone 2.5% ointment, Apply a small amount to the affected area twice daily as needed for itch

PHYSICAL EXAM:
Very pleasant woman, appears stated age, dressed in hospital scrub uniform, well nourished and in no acute distress. BP 131/67 mmHg | Temp 36.3°C (97.3°F) | Resp 14 | Ht 167 cm | Wt 68.221 kg | BMI 22.3 | Pulse 72. Pupils are equal, round, and reactive to light. Extraocular movements intact. Neck is supple. No JVD. No lymphadenopathy. Lungs are clear to auscultation and percussion bilaterally. Regular rhythm and rate, without murmur, rub or gallop. S1-S2 present. Abdomen is soft, nontender, nondistended, with active bowel sounds. No hepatosplenomegaly. No clubbing, cyanosis, or edema. Alert and oriented x3, nonfocal. CN II-XII grossly intact. Normal gait. Status post bilateral nipple sparing mastectomy and reconstruction with surgical scars well healed. No axillary lymphadenopathy bilaterally. Scar from Port-A-Cath removal in right chest. ECOG performance status of 0.

ASSESSMENT:
Ms. Ortiz is a 45-year-old premenopausal nurse assistant with Stage IA T1c N0 Mx right breast poorly differentiated infiltrating ductal carcinoma, BRCA1/2 negative, triple-negative, estrogen 0%, progesterone receptor 1-4%, HER 2 negative 0%, Ki-67 85-95%. She underwent neoadjuvant ddAC-T from 10/20/15 to 2/23/16 (received 11/12 doses of Taxol due to neuropathy); s/p right lumpectomy with no residual disease, 0/2 SLNs; pCR, stage pT0N0. She underwent adjuvant radiation therapy from 5/18/2016 to 6/29/2016. Clinically she is doing well without evidence of recurrent disease. She has minimal residual neuropathy affecting her fingers bilaterally. She is on Tamoxifen, and she tolerates it well.

PLAN: Will continue on Tamoxifen to complete 10 years, through 7/6/2026. She had b/l 3D mammogram on 9/15/2016, with benign findings, follow up in 1 year recommended. Gyn exam due annually in January with her PCP. She will follow up with me in 6 months.

Today, a total of 30 minutes spent in face-to-face patient care, with 18 minutes in discussion, counseling, and coordination of care.