Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Document the reason for this visit. Is this a new diagnosis, follow-up to biopsy, or discussion of treatment options?
Inquire about any new breast symptoms (e.g., lumps, nipple discharge, skin changes).
Ask about any personal or family history of breast cancer.
Objective:
Physical Exam:
Breast exam: Carefully assess both breasts for palpable lumps, skin changes (dimpling, redness), nipple discharge.
Lymph node exam: Palpate axillary and supraclavicular lymph nodes for enlargement or tenderness.
Imaging (if recent mammogram or ultrasound not available, document plan to obtain them):
Review findings of prior mammogram and/or ultrasound that identified DCIS.
Mention breast density and extent of DCIS on imaging (if available).
Assessment:
Ductal carcinoma in situ (DCIS) diagnosed by [biopsy type, e.g., core needle biopsy, surgical biopsy].
Laterality (right, left, or bilateral) and extent of DCIS involvement based on imaging findings (if available).
ER/PR receptor status and HER2 status if testing has been performed on the biopsy specimen. These are hormone receptor and HER2 protein tests that help guide treatment decisions.
Plan:
Diagnostic workup (if not already completed):
Mammography and/or breast ultrasound of the other breast to evaluate for additional lesions.
Consideration of breast MRI depending on patient factors and imaging findings.
Treatment Options (discuss with patient and tailor to individual risk factors and preferences):
Surgery:
Lumpectomy (breast conserving surgery) with or without radiation therapy.
Mastectomy (removal of the entire breast) with or without reconstruction.
Radiation therapy (if opting for breast conservation): Discuss the type and duration of radiation treatment.
Active surveillance: This approach involves close monitoring with regular mammograms and clinical exams for women with low-risk DCIS.
Next Steps:
Schedule a follow-up visit to discuss biopsy results, treatment recommendations, and answer any questions the patient may have.
If surgery is planned, schedule preoperative testing and surgical consultation.
Provide information on support groups and educational resources related to DCIS.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding the diagnosis, clinical findings, imaging results, treatment plan, and follow-up considerations. Include discussion of prognostic factors and potential risks and benefits of each treatment option.