HISTORY: The patient returns for followup visit. She has no complaint. She denies any pain or tenderness. No discharge from the breast.

PHYSICAL EXAMINATION: Physical examination shows a well-nourished, well?developed female in no apparent distress. Chest shows a reconstructed left breast. Right breast shows no masses, tumor or tenderness. There is no peripheral lymphadenopathy. Lungs are clear to auscultation and percussion. Cardiac exam shows normal sinus rhythm. Abdomen is soft. There is no organomegaly.

LABORATORY DATA: CBC done a week ago shows hemoglobin 11.2, hematocrit 35.2, white cell count 7900, platelets 265,000, granulocytes 55.4%, lymphocytes 35.2%, BUN 16, creatinine 1.0, bilirubin 0.1, SGPT 21, SGOT 23, and alkaline phosphatase 91. CA15-3 is 10.2.

IMPRESSION: Breast cancer, DCIS.

PLAN: My plan is to continue to see the patient in three months with followup blood test and tumor marker. The patient is also reminded to have a mammogram done this month.