History

General Data

• 33/F • G4P2 (2012) • Roman Catholic• From Quezon City• Admitted: August 13, 2009

• CC: L breast mass

History of Present Illness

11 months PTA: - ~2x2cm breast mass, (L) - (+) slight tenderness- (-) accompanying skin changes/nipple

discharge/weight loss- (-) consults done/medications taken

History of Present Illness

8 months PTA:- (+) gradual enlargement of mass - consult at a local hospital- CNB: results showed fibrocystic changes- No medications/interventions- advised observation.

History of Present Illness

1 month PTA:- Mass continued to enlarge; noted to triple

in size - (+) nipple retraction- consult at BCC- Slide review of previous CNB slide:

invasive ductal CA

History of Present Illness

1 month PTA:- (+) missed menses for 4 weeks- (-) nausea/vomiting - (+) slight dizziness- pregnancy test: positive- (-) consults / medications

Review of Systems

• (-) fever• (-) weight loss• (-) rashes• (-) headache/dizziness• (-) nasal discharge• (-) difficulty of breathing / dyspnea• (-) chest pain• (-) urinary complaints• (-) bowel disturbance

Past Medical History

• (-) DM / HPN / PTB / allergies / asthma• No comorbidities

Family Medical History

• (-) CA, breast mass• (-) Hypertension, DM, asthma, thyroid

disorder, epilepsy

Menstrual History

• Menarche: 12 yrs. Old• interval of 30 days• lasting for 3-5 days• consumes 3 pads per day, fully soaked• (-) dysmenorrhea• LMP: May 23, 2009

Sexual History

• First coitus 26 y/o (current partner, nonpromiscuous)

• (-) dyspareunia• (-) post coital bleeding • (-) family planning method

Obstetric History

G Year AOG Via c/o FMC

1 2001 FT SVD Tondo General

(-)

2 2004 FT SVD Fabella (-)

3 2008; abortion c/o hilot

4 2009; abortion

Personal/Social History

• housewife• Non-smoker• Non-alcoholic beverage drinker• Denies illicit drug use

Physical Examination

Physical Examination

• Conscious, coherent, ambulates with assistance, not in cardiorespiratory distress

• Vitals: BP 120/80 HR 82 RR 20 T 36.8

Physical Examination

HEENT:• Pink palpebral conjunctivae, anicteric

sclerae, pupils ERTL• Supple neck, no palpable cervical lymph

nodes, Thyroid gland not enlarged

Physical Examination

Chest/Lungs:No retractions, Symmetrical chest

expansion, clear breath sounds

CVS: Adynamic precordium, AB at 5th LICS MCL,

no murmur

Physical Examination

Abdomen:Globular, NABS

Skin/Extremities:• Warm, moist skin, no active dermatosis• Full and equal pulses, no clubbing or

cyanosis of extremities, no edema

Physical Examination

Breast • 10x10 cm mass- hard, slightly tender, non

movable mass L breast, • (+) nipple retraction• (-) skin changes/nipple discharge• Essentially normal R breast• (-) palpable axillary/cervical nodes

Physical Examination

Genitourinary:• Normal external genitalia, no vaginal

discharge, no external lesion• Internal Examination: Cervix- soft, long,

closed; Uterus- enlarged to approximately 12 weeks, no adnexal mass/tenderness

Physical Examination

Neurologic Examination• Awake, alert, oriented to 3 spheres• pupils 2-3 mm ERTL, no visual field cuts, (+) ROR

– OU• full and equal EOM’s, V1-3 intact, can clench

teeth, Can smile, can raise eyebrows, can close both eyes, no asymmetry, Intact gross hearing, no lateralization on Weber’s, AC > BC on Rinne, tongue midline on protrusion, can raise shoulders

Physical Examination

Neurologic Examination• - Motor: (-) spasticity, rigidity, fasciculation,

MMT 5/5 on all extremities• ++ DTR’s on all extremities• (-) sensory deficit• (-) Babinski, (-) nuchal rigidity

Course in the Wards

Course in the Wards

• 8/13/09 (1st hospital day)– Admitted to W4B29

• 8/14/09 (2nd hospital day)– Referred to OB-GYN

Course in the Wards

• 8/15/09 (3rd hospital day)– OB-Gyn: TV-UTZ done, showing early fetal

demise; suggest cervical ripening with laminaria x 24h then reassessment of cervix.

– presented with possibility of D&C after MRM if Sx is amenable

Course in the Wards

• 8/16/09 (4th hospital day)– GS1: Noted OB entries– For OR scheduling: MRM, L– NPO– IVF: D5NR 1L x 8h – Cefazolin 1g IV LD ( ) ANST to be given at OR– OB may do D&C or insert laminaria– Anesthesiology: plan – GETA– pre-op meds – nalbuphine 5mg + promethazine

25mg as cocktail

Course in the Wards

• 8/16/09 (4th hospital day)– OB-Gyn: will do D&C after MRM– Anesthesiology: plan – GETA– pre-op meds – nalbuphine 5mg +

promethazine 25mg as cocktail– IVF: D5NR x 8h + K50 ext tubing on RUE (IV

Cannula g18)

Laboratory Examinations

Laboratory Examinations

• Blood Type: A+• CBC Hgb 122, Hct 0.394, WBC 9.78, RBC

4.33, Plt 302, N 0.660, L 0.272• PT 12.9/12.4/0.98/1.19• aPTT 36.9/33.0• BUN 2.68, Crea 50(L), Na 140, K 3.7, Cl

104

Ethical Considerations

Ethical Considerations

• 1st Trimester– MRM (procedure of choice), in spite of increased

risk spontaneous abortion following anesthesia– Chemotherapy - 12% risk of birth defects and risk

for spontaneous abortion• 2nd Trimester

– MRM (procedure of choice)– Chemotherapy – no evidence of teratogenicity

Ethical Considerations

• 3rd Trimester– Lumpectomy with axillary node dissection if

adjuvent radiation therapy if deferred until delivery

– Chemotherapy: no evidence of teratogenicity• Prognosis is similar, stage by stage, to that of

nonpregnant Breast CA patients

Ethical Considerations

• Upon questioning, the patient was willing to undergo chemotherapy and surgery in spite of the risk of spontaneous abortion to the fetus

• According to her and her family, it is more important to have her cured

• She finds herself unable to continue the pregnancy if she still has cancer

Ethical Considerations

• Philippine Constitution Article 2, Sec 12:– The State recognizes the sanctity of family life and

shall protect and strengthen the family as a basic autonomous social institution. It shall equally protect the life of the mother and the life of the unborn from conception. The natural and primary right and duty of parents in the rearing of the youth for civic efficiency and the development of moral character shall receive the support of the Government.

Ethical Considerations

• Grounds on which abortion is permitted in the Philippines:– To save the life of a woman YES– To preserve physical health NO– To preserve mental health NO– Rape/incest NO– Fetal impairment NO– Economic/social reasons NO– Available on request NO

Ethical Considerations

• Authorization of an abortion requires consultation with a panel of professionals

Source

• Brunicardi,et. Al. (2005). Schwartz’s Principles of Surgery. 8th Ed. McGraw-Hill, USA.

• Philippine Constitution• UN Abortion Policies: A Global Review (2002)

http://www.un.org/esa/population/publications/abortion/profiles.htm. accessed on 8/17/09