Case Report

A-43-YEAR OLD WOMAN WITH LEFT BREAST TUMOUR

SUSPECT LEFT BREAST CARCINOMA DD MASTITIS
DD BREAST MASS

by:
LES YASIN
G99161112

Supervisor:
Kristanto Yuli Yarsa, dr., SpB(K)Onk.

SECRETARIAT OF SMF SURGERY

MEDICAL FACULTY OF UNS/RSUD DR MOEWARDI
SURAKARTA
2017
 MEDICAL RECORD

A. ANAMNESIS
I. Patient Identity
Name : Ny. K
Age : 43 y o
Sex : Female
Address : Magetan
Medical record number : 01362xxx
Occupation : Housewife

II. Chief Complain

A lump in left breast

III. Patient illness

A patient 43 years old come to a hospital complained the presence
of a lump in her left breast since half years ago. First time she felt its
presence with initial size was as small as a marble but appoximately 2
month ago, the lump getting bigger and reaching 5 cm in length and 5 cm
in width. She said that from her lump, she felt some kind of pain. The pain
getting worst whenever touching. The patient also complain reduced
weight in two months but not much. There was presence abit hard when
touching and without ulcer and nipple discharge from the left breast . The
lump was not found in her right breast and her axilla. The patient also feel
shortness of breath during night time. There is no symptomp life bone pain
cough, , headache, nausea

IV. Risk Factor

Age : 43 years old
Pregnancy history : P2A0, with first pregnancy was 36 years old
 Lactation history : the children were breastfeed for one and half years
Menstrual history : the patient was menarche by age 12 years
Contraception history : the patient used IUD for more than 15 years
Family history with breast cancer or ovarian cancer were denied.
Personal history of certain non cancerous breast disease was denied.

B. PHYSICAL EXAMINATION
I. General Status
a. Performance status based on karnofsky score 80 %
b. Vital sign
BP : 140/100 mmHg
RR : 28 x/minute
Pulse : 100 x/minute
T : 36.5C
II. General Survey
a. Head : mesocephal
b. Eyes : anemic conjungtiva (-/-), ictericsclera (-/-)
c. Ears : mucous (-/-), blood (-/-)hearing loss (-/-)
d. Nose : simetris, mucous (-), blood (-)
e. Mouth : sianotic (-).
f. Neck : tiroid enlargement (-),limphadenopaty cell (-).
g. Thorax : localized status
h. Pulmo
Inspection : movement of hemithorax left = right
Palpation : tactile fremitus left = right
Percussion: sonor/sonor.
Auscultation : vascular base sound (+/+) additional sound (-/-).
i. Heart
Inspection : ictus cordis not visible.
Palpation : ictus cordis palpable.
Percussion :heart border normal.
 Auscultation :heart sound normal, regular, no additional sound
j. Abdomen
Inspection : distended (-)
Auscultation: bowel sound (+)
Percussion : tympani
Palpation : pain (-)
k. Extremities
Oedem Cold hands and feet
- - - -
- - - -

l. Localized status
1. Left breast
Inspection : a lump in whole mammae region, skin color
changes to abit redness, different from the
surrounding area. Peau dorange (-) around nipple.
Ulcer (-), nipple retraction (-)
Palpation : a lump with 5x5 cm at area 2 oclock, stony
consistency, immobile, bumpy surface. Nipple
discharge (-). Pain (+)
2. Right breast
Inspection : there is no lump, skin discoloration not found. Peau
dorange (-), Ulcer (-), nipple retraction (-)
Palpation : there is no lump, pain (-)
3. Lymph nodes
Axilla right/left : Lump (-/+), pain (-/-)
Cervical right/left : Lump (-/-), pain (-/-)
Supraclavicular right/left : Lump (-/-), pain (-/-)
Infraclavicular right/left : Lump (-/-), pain (-/-)
Parasternal right/left : Lump (-/-), pain (-/-)
C. ASSESMENT I
Left breast tumour suspect left breast carcinoma dd mastitis dd breast mass

D. PLANNING I
1. Education : progression of breast tumour or cancer and action plan for
treatment (risks and complication of tumour in breast)
2. Diagnostic: mammography, Ultrasonography mammae, FNAB
3. Chest X-ray ( finding metastatic )
4. Consult oncology surgery

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