Breast Cancer / Breast Disorders
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Breast Cancer / Breast Disorders
Progression
- When did disease process start
- Initial versus subsequent visit
Location
- Right, left, quadrant (upper inner, lower outer, etc.), axillary tail, overlapping sites, nipple/areola, central portion
Acuity
Name
- Type of disorder-benign dysplasia, inflammatory, hypertrophy, deformity, disproportion, fissure, fistula, discharge, mastodynia, etc.
- Identify solitary cysts, fibroadenosis, fibrosclerosis, mammary duct ectasia, and other dysplasias
- Indicate the morphology of neoplasms-benign, carcinoma in situ, malignant primary or secondary site, metastatic, etc.
- Document if patient is being treated for an extension, metastasis, after initial treatment
Necessary Procedures
- Excision (partial organ removal), resection (complete organ removal), with or without lymph nodes, augmentation
Other
Why
- Any known causes or underlying conditions, comorbidities, associated problems, change in medications, smoking, etc.