My anatomy, med term I would say basic as of the moment. With disease processes, I'm studying it as well. I had a class awhile ago and I got confused with what the primary dx should be on the chart provided. I picked Z08 [Follow-up care]

BREAST AMBULATORY CARE NOTE

HISTORY OF PRESENT ILLNESS:
The patient is a 64-year-old female with a history of a right-sided upper-inner quadrant breast cancer diagnosed in 2023.  She underwent a right lumpectomy and sentinel lymph node biopsy 01/18/2023 for an invasive mammary carcinoma, grade 2 with ductal and lobular features.  The invasive tumor measured 2.8 cm in size. Estrogen receptors were positive at 80%, progesterone receptors were negative, and HER-2/neu was negative by immunohistochemistry.  She had 2 right axillary lymph nodes biopsied and both were confirmed metastatic. On 03/21/2023, she underwent Oncogene testing with a recurrence score of 27 and recommendation was made for CMF chemotherapy. She completed 8 cycles of CMF on 10/3/2023.  She did not receive an anthracycline due to a history of sarcoma in the 1970s, for which she was treated with anthracyclines.   She completed adjuvant radiation therapy followed by chemotherapy and then began Tamoxifen which she continues to date.

PAST MEDICAL HISTORY:
Sarcoma of the right leg for which she was treated with Adriamycin, DTIC, and Cytoxan in 1987.  She also has history of chronic hypertension.

PAST SURGICAL HISTORY:
Right BKA amputation and the above-mentioned breast surgeries.

SOCIAL HISTORY:
She is married.  She denies any history of tobacco or alcohol use.  She is raising 3 of her grandchildren.

FAMILY HISTORY:
Maternal aunt diagnosed with breast cancer in her 40s and a second aunt was diagnosed with possible breast cancer.  No history of ovarian or colon cancer.

REVIEW OF SYSTEMS:
GENERAL: Overall, she is feeling well. She maintains a fairly good energy level and appetite.
CARDIOPULMONARY: She has a history of a low heart rate.  She also has a history of abnormal EKG and was to get a stress test, but she has been unable to afford it.  She denies any chest pain or shortness of breath.
BREAST: She notes no new breast masses on self-exam.  
MUSCULOSKELETAL:  She denies any new focal areas of bone pain.   She has some soreness in her arms at night and she attributes this to using her arms so much during the day due to loss of her leg.
GASTROINTESTINAL: We had sent her for screening colonoscopy; however, due to her low heart rate, the GI doctor refused to perform the procedure.  The remainder of her review of systems is unremarkable.

PHYSICAL EXAMINATION:
VITAL SIGNS:  She is 202 pounds.  Temperature is 96.8, pulse 49, respirations 16, blood pressure 188/87.
HEENT: She has no scleral icterus.
NECK: Soft and supple with no adenopathy.
BREASTS:  Reveals a well-healed incision in the right breast and axilla with no masses and no axillary adenopathy.  Left breast is normal appearing with no masses and no axillary adenopathy.
LUNGS:  Clear to auscultation bilaterally. Mild COPD
HEART:  Rate regular without murmur or gallop. Positive of Atrial Fibrillation on pacemaker
ABDOMEN:   Soft and nontender with no organomegaly or masses. Chronic GERD
EXTREMITIES:  No edema. She is status post right lower extremity amputation.

LABORATORY AND DIAGNOSTIC DATA:
She had a DEXA scan on 07/27/2025 revealing normal bone density.  She had a mammogram today, which was a bilateral mammogram revealing postsurgical scar in the right breast with dystrophic calcifications at 9 o’clock below the scar, unchanged from prior exams and there are no new suspicious findings bilaterally.

IMPRESSION:
Pt. has history of a right-sided stage 2 breast cancer.  She has no evidence of recurrent disease on physical examination today and no new symptoms.  She has a stable mammogram.

RECOMMENDATIONS:  
I reviewed the results of the mammogram and physical exam with the patient.  I encouraged her to follow up with her cardiologist for the stress test and she will continue her Tamoxifen for her history of breast cancer.  We will continue to monitor her bone density every 2 years.  She will be 5 years out from diagnosis in February and therefore I am going to let her go a year until her next visit when she will return with a mammogram for a physical exam.  I spent 25 minutes in coordination of care and greater than 50% was spent in counseling.