Introduction (Age, gender)

What is the patient coming in for?

Any masses or nipple discharge?

Any prior breast cancer history (**For implants – saline or silicon), hx of excisional biopsy

Any prior ovarian history

mMGP@OCP/HRT/Genetic Testing + Tyrer Cruzik score of ___

Breast cancer family history (age dx, alive or deceased)

Imaging results and biopsy results for current condition

Pathology

IDC/ILC/DCIS/Other

R/L ___mm ___ o'clock ____ from nipple

ER__ Pr__ HER2__ Stage__ , Grade __,T_N_M_

KI67 __%

**Physical

Eye: Scleral icterus

LN: no palpable cervical, clavicular, axillary adenopathy

Breast: check for scars from previous surgery or biopsy, check for asymmetry, report any lesions, masses
or ulcerations

i.e. The breasts are symmetric and have no visible skin changes or nipple changes, pagetoid changes or
nipple discharge. Patient has breast augmentation with saline implants bilaterally. No scars noted. Has a
dominant right upper outer quadrant mass measuring 5cm that is freely mobile.

Example:

Ms. Phillips is a lovely 80-year-old female comes in with abnormal imaging, The patient denies any
current palpable masses or nipple discharge. She did have a previous left breast excisional biopsy 1963
that was benign by history. Her menarche was at age 12, menopause at age 50.She is a gravida 2 para 2.
Significant family history is that of a sister with breast cancer at age 78 who passed away at age 79 of
other causes. On 12/20/2022 the patient underwent routine screening mammography showed the
presence of a medial right breast spiculated density. A follow-up right breast ultrasound on January of
this year showed a solid mass with angulated margins and a biopsy has been recommended The patient
approximately 3 weeks ago underwent a biopsy on the right breast. the biopsy showed invasive ductal
carcinoma well differentiated ERPR positive, HER2 negative, high Ki-67 of 40%. The patient is now here
for evaluation and definitive care.

Ms. White who is a lovely 69-year-old female comes in with a newly diagnosed left breast cancer. The
patient denies any palpable masses nipple discharge or previous breast surgery. Her menarche was at
age 13, menopause at age 59. In 2021 she also underwent hysterectomy for postmenopausal bleeding.
There was no evidence for cancer. She still has ovaries in place. She is gravida 2 para 2 her 1st child was
born at age 22. There is a 10 year history of birth control pills in the past no history of hormonal therapy.
Significant family history is that of a sister with breast cancer at age 36 currently alive without disease at
age 56. No genetic testing has been done. The patient underwent routine screening mammography in
December of last year that showed the presence of a left breast shadow in the lower inner quadrant.
Follow-up diagnostic imaging showed the presence of a 2 cm mass. On 02/09/2023 she underwent
ultrasound- guided biopsy showed the presence of invasive ductal carcinoma grade 3 ER positive PR
negative HER2 was also negative with a high Ki