PRE OP CASE PROTOCOL

CASE # 1

General Data

SDV. 28/M, Single, Roman Catholic. Born 1/26/87 at Iligan City, currently lives at Adriano Matias Compound
Sampaloc Street Bagumbong, Caloocan City.

Chief complaint: Mass on the left breast

History of Present Illness

1 year PTC, patient noted a 1x1 cm nevus on his left flank associated with pruritus and bloody discharge. Patient
noted the nevus was friable when it was accidentally hit during a basketball game. No immediate medications nor
consult was done.

7 months PTC, nevus was accidentally sloughed off during a basketball game. After a week the patient noticed a
regrowth of the said nevus in the same area which was slow growing with irregular borders, non-erythematous,
grayish-black color, with watery, foul smelling discharge. No immediate medications nor consult was done.

6 months PTC, still with above sign and symptoms, the lesion wa s noticed to increase in size exponentially to
5x6cm along with a palpable mass on his left breast and axilla measuring 1x1cm. The mass was firm, rubbery with
irregular borders. No immediate medications and consultation was done.

During the interim, said lesion and mass increased in size with no associated symptoms. No medications and
consultation was done.

2 months PTC, due to the increasing size of the lesion, patient sought consult at a private hospital were biopsy was
done. The Histopath result was unknown to the patient and he was given unrecalled medications. Patient was then
lost to follow up.

10 days PTC, still with above signs and symptoms, now with undocumented fever and pain on lesion site, patient
prompted consult at a private physician and was given Paracetamol + Tramadol that provided temporary relief. Breast
UTZ was done revealing a heterogenous soft tissue mass. Patient was then referred to our institution of evaluation
and management.

Past Medical History

(-) asthma (-) blood dyscrasia (-) DM (-) HPN (-) CA (-) Hospitalization (-) Exposure to radiation

Family History

(-) DM (-) HPN (-) CA (-) PTB (-) blood dyscrasia

Personal and Social History

(-) smoker (-) alcohol beverage drinker (-) prohibited drug use

Physical Examination
● Conscious, coherent, not in cardio-respiratory distress
● BP : 110/70 HR: 74 RR: 22 T: 37.4 Wt: 50kg
● Anicteric sclerae, pink palpebral conjunctiva, (-) CLAD (-) NAD
● Symmetrical chest expansion, no retractions, noted a 6x5cm, firm, doughy mass with no ulceration or nipple
discharge and 2 3x3cm, firm, non tender mass on the left axilla, clear breath sounds
● A dynamic precordium, normal rate, regular rhythm, no murmurs
● Flat, soft, (-) surgical scars, noted a 3x3cm, pedunculated, friable, foul smelling discharge
● Grossly normal extremity, no cyanosis, no edema, full equal pulses
Breast UTZ
Heterogenous breast soft tissue mass, left breast
5.46 x 3.08 x 4.07 cm lobulated, heterogenous solid mass, left breast with central necrosis
2.07 x 2.94 and 2.63 x 2.56 cm soft tissue masses localized on the left axillary area

Histopathology Result
(Withheld)
***end***

* Use of this clinical case abstract is or academic purposes only