History
Identifying Data
Full Name: D. Barkas
Address: Queens, NY
DOB: 5/5/1957
Date and Time: October 4, 2021
Location: NYPQH
Religion: Christian
Source of Information: Self
Reliability: Reliable
Source of Referral: Dr. Choi
Chief complaint: “The breast implants I got in 2008 are abnormal, and I need to get them fixed”
History of Present Illness: 64-year-old female with PMH of breast cancer, Hyperlipidemia and GERD, who presented to Pre-Admission Testing this morning to be evaluated for her upcoming breast implant revision, scheduled for October 13, 2021. In 2007, she had a bilateral mastectomy because of breast cancer in her right breast and had received her first breast implants in 2008. Since then, she states the implants have become mis-shaped and needs implant revision. The patient is otherwise feeling well. Admits to a slight cough, which she states is due to her post nasal drip. She denies pain, nausea, vomiting, diarrhea, night sweats, recent trauma, or fever.
Past Medical History
Right breast cancer, in remission 14 years ago, treated with bilateral mastectomy
Denies childhood illnesses
Immunizations- Up to date; flu vaccine 10/3/2021; COVID vaccines in April
Screening mammogram- July 2007
Screening colonoscopy- December 2020, benign
Past Surgical History
Excisional biopsy, right breast- 6/21/2002, Saint Vincent’s Comprehensive Cancer Center, atypical papilloma- benign
Excisional biopsy, right breast- 9/30/2005, South Nassau Community Hospital, cystic papillary carcinoma in situ and ductal carcinoma in situ
Re-excision, right breast biopsy site- 10/28/2005, South Nassau Community Hospital, residual cystic papillary carcinoma in situ and ductal carcinoma in situ
Re-excision right breast biopsy site- 11/18/2005, South Nassau Community Hospital, residual cystic papillary carcinoma in situ margins appear free and ductal carcinoma in situ margins appear free
Laparoscopic assisted vaginal hysterectomy and bilateral salpingo-oophorectomy with removal of fibroids and pelvic floor suspension- 5/9/2007, The New York Hospital Medical Center of Queens
Bilateral mastectomy with immediate reconstruction and right axillary sentinel lymph node biopsy- 9/10/2007, New York University Hospital Center, Recurrent in situ carcinoma, right breast
Immediate breast reconstruction with bilateral tissue expander insertion- 9/10/2007, New York University Hospital Center
Reconstruction bilateral breasts with breast implant placement, removal of tissue expanders bilaterally, open capsulectomy bilaterally, and revision of breasts and breast mounds bilaterally- 1/16/2008, New York University Hospital Center
Bilateral nipple reconstruction- 5/19/2008, New York University Hospital Center
Medications
Baby Aspirin 81mg, 1 tab PO daily, last dose today
Adderall XR 20 mg, 1 tab BID daily, last dose today
Xyzal 5 mg, 1 tab QHS, last dose yesterday
Crestor 20mg, 1 tab QHS, last dose yesterday
Magnesium 1000 mg, 1 tab QD, last dose today
Folic Acid 800 mg, 1 tab, QD, last dose today
Vitamin D 5000 IU, 1 tab QD, last dose today
Xelpros- 1 drop each eye QHS, last dose yesterday
Allergies
Bacitracin
Duricef/ Cefadroxil
Adhesive on bandage
Family History
Mother- Deceased at age 84, natural causes
Father- Deceased at age 75, peritonitis s/p appendicitis
Three Children- alive and well
Social History
D. Barkas is a married female, living with her husband. She is a retired accountant
Habits- She drinks socially at parties, up to 2 glasses of white wine. Denies present and past tobacco use. Denies history of substance abuse, denies history of illicit substance use. She drinks 1 cup of coffee a day
Travel- She travelled to North Caroline in August, and has not left the country in the past year
Diet- She tries to have a well-balanced meal by incorporating protein, fruits, and vegetables into her meals
Exercise- She does not exercise regularly, but states she is active when playing with her children and she stretches every day
Sexual Hx- She is heterosexual, monogamous, she stopped using protection after her hysterectomy in 2007, menopause at age 50. Denies history of sexually transmitted diseases
Review of Systems
General- denies recent weight loss or gain, loss of appetite, generalized weakness/ fatigue, fever or chills, or night sweats
Skin, hair, nails- Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair distribution
Head- denies headaches, vertigo, or head trauma
Eyes- Denies visual disturbances. Wears glasses. Last eye exam was September 2021.
Ears: States she has been hearing a “humming” in her ears since April 2013. She states this started when she began to wear earbuds in 2013.
Nose/Sinuses- Admits to postnasal drip. Denies obstruction or epistaxis
Mouth/throat- Denies bleeding gums, sore throat, sore tongue, mouth ulcers, voice changes or use of dentures. Last dental exam was September 2021, normal. She is scheduled to have a cavity filled on October 9, 2021.
Neck: States she has a benign lump on the anterior side of her neck, was told it was due to old scar tissue.
Breast- Bilateral mastectomy in 2007, with implants in 2008. Denies lumps, pain. Last mammogram was July 2007.
Pulmonary system- Admits to cough due to post nasal drip. Denies dyspnea, dyspnea on exertion, wheezing, hemoptysis, or orthopnea.
Cardiovascular system- denies palpitations, chest pain, hypertension, edema in the ankles/ feet, syncope or known heart murmur.
Gastrointestinal system- Has regular bowel movements daily. States she has 1 hemorrhoid. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, constipation, rectal bleeding or blood in stool.
Genitourinary system- Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain
Menstrual/ Obstetrical- G3P3003 (NSVD x 3), no complications. Menarche at age 12. LPM April 2007. Currently post menopausal. Denies hot flashes or associated menopausal symptoms. Denies breakthrough bleeding/ spotting or vaginal discharge
Nervous- Denies seizures, headache, loss of consciousness, loss of strength, change in cognition/ mental status/ memory, or weakness
Musculoskeletal system- Denies muscle/ joint pain, deformity or swelling, redness or arthritis
Peripheral vascular system- Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes
Hematological system- Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusion, or history of DVT/PE
Endocrine system- denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric- Denies depression/ sadness, anxiety. Admits to anxiety in the past due to her cancer, but did not go to a mental health professional
Physical
General:
Slender female, neatly groomed, looks like her stated age of 64.
Vital Signs:
Height- 64 in.
Weight- 154 lbs
T: 98.6 F
P: 91, regular
O2 sat: 98% room air
R: 16/ min, unlabored
BP: 128/84
Skin: Warm and moist, good turgor. Nonicteric, no lesions, no scars, no tattoos
Hair: Thick and full, even distribution throughout her head. No signs of nits.
Nails: No clubbing, capillary refill < 2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout
Ears: Symmetrical and appropriate in size. No masses, lesions, or trauma on external ears. No signs of discharge or foreign bodies in external auditory canals AU. TMs pearly white/ intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline/ Rinne reveals AC> BC AU.
Nose: Patient has deviated septum. Symmetrical, no masses, lesions, deformities, trauma, discharge. Nares patent bilaterally. Nasal mucosa is wellhydrated. No discharge noted on anterior rhinoscopy. No foreign bodies.
Sinuses: non tender to palpation and percussion over bilateral frontal and maxillary sinuses
Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink
Visual acuity uncorrected- 18/20 OS, 18/20 OD, 18/20 OU
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy- Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Lips: pink, moist, no cyanosis or lesions. Non-tender to palpation
Mucosa: pink; well hydrated. No masses; lesions noted. Non-tender to palpation
Teeth: good dentition/ no obvious dental caries noted
Gingivae: Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation
Oropharynx: well hydrated; no injection, exudates, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck: Trachea midline. Single mass noted on anterior side of neck; lesions; scars; pulsations noted. Supple; non-tender to palpation. No stridor noted, no thrills, bruits. No cervical adenopathy noted.
Thyroid: non-tender, no palpable masses; no thyromegaly
Chest: Symmetrical, no deformities, no trauma. Bilateral mastectomy noted. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. LAT to AP diameter 2:1. Non-tender to palpation throughout.
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: JVP is 2.5 cm above sternal angle with head of the bed at 30 degrees. PMI in 5th intercostal in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs
Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.
Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.
Breast: Breasts removed via bilateral mastectomy. Patient had implants inserted. Nipples symmetric without discharge or lesions
Assessment:
64-year-old female with PMH of breast cancer, Hyperlipidemia and GERD, presenting to PAT to be evaluated for her upcoming breast implant revision, scheduled for October 13, 2021.
Differential Diagnosis:
Surgical adhesion
Ruptured breast implants
Physical changes due to aging
Plan:
Breast Implant revision- patient is in stable condition, with no contraindications for breast implant revision scheduled for October 13, 2021
Hyperlipidemia- continue Crestor 20mg, 1 tab QHS
GERD- avoid spicy foods, caffeine, eat last meal at least 3 hours prior to sleeping
Post nasal drip/ Cough- Mucinex 200 mg every 4 hours as needed
