DEMOGRAPHIC DATA: Name : Rosnani Binti Hamidon MRN : SB00066826 Age : 46 years old Gender : female Occupation : housewife Date Of Admission : 30 th November 2010 Ethnic : Malay Date of Discharge : not yet Religion : Muslim Date of Clerking : 20 th October 2010 Status : Married Address : Puncak Alam Informant : patient Reliability : Good Presenting Complaint Puan Rosnani, a 46 years old malay woman was reffered to the hospital Sungai Buloh because of breast lump on her left breast. History of presenting complaint She noticed the breast lump 5 months ago after doing self breast examination. She did not go to hospital for check-up until the lump grew with size of ping pong. The lump was painless and immobile; she also noticed that her nipple was retracted. However, she has no anorexia, no loss of weight, no nipple discharge and blood discharge,
Transcript
DEMOGRAPHIC DATA:
Name : Rosnani Binti Hamidon MRN : SB00066826
Age : 46 years old Gender : female
Occupation : housewife Date Of Admission : 30th November 2010
Ethnic : Malay Date of Discharge : not yet
Religion : Muslim Date of Clerking: 20th October 2010
Status : Married Address : Puncak Alam
Informant : patient Reliability : Good
Presenting Complaint
Puan Rosnani, a 46 years old malay woman was reffered to the hospital Sungai Buloh because of breast
lump on her left breast.
History of presenting complaint
She noticed the breast lump 5 months ago after doing self breast examination. She did not go to hospital
for check-up until the lump grew with size of ping pong. The lump was painless and immobile; she also
noticed that her nipple was retracted. However, she has no anorexia, no loss of weight, no nipple
discharge and blood discharge, no bone pain, no chest pain and no jaundice no jaundice. She also denies
of having skin changes such as color changes, ulceration.
Systemic review
Cardiovascular No palpitation, no cyanosis, no orthopnea
Respiratory No shortness of breath, no cough
Urinary No hematuria, no dysuria, not increase in frequency or urgency
Hematology No bleeding tendency and bruises
Skin No skin rashes or infection, no sign of jaundice
Endocrine No polydipsia, no heat or cold intolerance
Nervous systemNo headache, no vertigo, no syncope, no fits, no visual and hearing
disturbance
Ear, Nose & Throat No ear discharge, no runny nose, no sore throat
Musculoskeletal No muscle or joint pain
Past medical and surgical history
This is her first admission to the hospital. She was diagnosed to has hypertension on 2004
Drug history
currently she is taking losartan for the hypertension.
Diet history
She practices normal malay diet. She claimed that she’s taking food with a lot of cholesterol.
Reproductive history
She attained her menarche at the age of 14 with regular cycle with 8 days of bleeding. She has never
experienced intra menstrual bleeding. She never taking any contraceptive pill before. She also denies of
taking any hormonal pill. She also never did any pap smear before.
ALLERGY HISTORY
No known allergy
FAMILY HISTORY
She is the second of 3 siblings. Both of her parents were passed away because of old age. She is married
and has 3 children. Her older sister also has breast lump and was diagnosed to have breast cancer 3
years ago.
SOCIAL HISTORY
She is a full time house wife. She is not a smoker, non-alcoholic and never take any elicit drug. Her
husband is policeman, he is a smoker, non-alcoholic and never take any elicit drug. Her first daughter
was born when she was 31 years old. She lives with her family in her own house at Puncak Alam with
good basic amminities.
SUMMARY
Puan Rosnani, 46 years old malay woman came to the hospital with the complaint of breast lump. The
lump was painless with size of ping pong ball and immobile with nipple retraction. She has no associated
symptoms such as jaundice, anorexia, loss of weight, bone pain, chest pain and difficulty in breathing.
She has strong family history of breast cancer which is her sister.
PHYSICAL EXAMINATION:
Anthropometry
Height : 1.51 m
Weight : 75.5 kg
BMI on admission: 32.11
Interpretation – she is obese.
General Examination:
Puan Rosnani, 46 years old Malay woman, lying supine on a bed supported with 1 pillow. She is
alert, conscious, oriented to time, place, and person. He is pink, not in pain and not in respiratory
distress. There is no gross deformity, no muscle wasting and no involuntary movement noted.
Hydrational and nutritional status is adequate. There is intravenous branulla inserted at her right
Appearance : Normal placed eyes, nose and ears, no deformities of lips and
nose.
Shape of head : Normal head shape.
Hair : No hair loss, no bald spot
Face : No cyanosis, no pallor and no facial deformities
Oral cavity : Good oral hygiene, moist mucous membrane, no ulcers and no
central cyanosis
Eyes : No pallor and no jaundice.
Ear, mouth & throat : No ear and nose discharge, no throat swelling and redness.
Neck : No thyroid enlargement
Skin : pink, no rash, no lesions
Extremities : Warm peripheries, capillary refill time is less than two seconds,
no cyanosis, no clubbing of fingers and toes, no koilonychias, no pitting edema
and no muscle wasting
Impression: No abnormalities
Examination of the back
There are no prominent spine deformities such as scoliosis, lordosis and kyphosis, no tenderness and no
sacral edema. Negative renal punch.
Impression: No abnormalities detected
Lymph nodes examination
No palpable cervical, axillary and inguinal lymph nodes.
Impression: No abnormalities detected
SYSTEMIC EXAMINATION:
1. Abdominal Examination
Inspection -normal shape, normal skin, no scar, umbilicus is inverted and centrally located.
Palpation -abdomen is non-tender, no mass were palpable, no hepatosplenomegally, kidney is not
ballotable.
Percussion - no dullness is heard, no ascites.
Auscaltation - Normal bowel sound is present (4 bowel sound per minute).
Rectal examination - Patient refuse to do rectal examination
2. Respiratory System
Inspection - There is no chest deformity and no scar
- Chest move symmetrically with respiration.
- No usage of accessory muscle and no intercostals recession noted.
Palpation - Trachea is centrally located
- Normal chest expansion on both lungs
- Vocal fremitus is normal
Percussion - Resonance on both lung with liver dullness on the right and cardiac
dullness on the left
Auscaltation - Vesicular breath sound with no added sound heard
Impression: No abnormalities detected
3. Cardiovascular System
Inspection - There is no dilated veins, no visible pulsation, no pericardial bulging and
no scar.
Palpation - Apex beat is at the left midclavicular 5th intercostal space.
- There is no parasternal heave or thrills felt.
Percussion - Normal cardiac dullness present
Auscaltation - Dual rhythm, S1 and S2 are heard with no murmur
Impression: No abnormalities detected
4. breast examination
Inspection - breast is normal in shape, normal colour, both of breast have same sizes, no nipple
discharge, no ulceration, nipple on left breast is retracted.
Palpation - there is a mass felt oh her left breast at upper outer quadrant with size approximately
5cm x 5cm, non-tender, irregular margin, hard in consistency, smooth surface, not mobile, no axillary
lymph nodes were palpable.
Clinical summary
On examination reveals a mass on upper outer quadrant of left breast, non-tender, irregular margin,
hard in consistency, smooth surface and not mobile.
Provisional diagnosis
Breast Cancer
Points to supports :
1) Painless lump on left breast
2) Strong family history of breast cancer.
3) Nipple retraction.
4) Irregular margin.
5) Her first child was born after she was 31 years old.
Differential diagnosis
1) Benign fibroadenoma
- Points to support
o Lump.
- Points to against
o Usually present with painful lump.
o Mobile lump.
o Regular margin.
o Usually present in 15-25 years group age.
2) Intraductal papilloma
- Point to support
o Lump.
- Points to against
o Commonly presence with nipple discharge.
o Painful.
3) Breast abscess
- Point to support
o Lump.
- Points to against
o Painful.
o pus discharge.
o No history of fever.
General investigation
Indication: To monitor general condition of the patient and screen the patient’s status and if there is any
abnormal platelet count and white blood cells count.
Tests Result Unit Normal range Impression
White Blood Cell 18.5 10^3 L 2-20 Normal
Red Blood Cell 5.43 10^6 L 2-10 Normal
RBC Distribution Width 35.4 fl 30-100 Normal
Hemoglobin 14.5 g/dl 10-20 Normal
Hematocrit 42.2 % 30-45 Normal
Mean Cell Hemoglobin 26.7 pg 27-31 Normal
Mean Cell Volume 77.7 fl 70-86 Normal
Mean Cell Hemoglobin
Concentration
28.5 g/dl 27-33 Normal
Platelet count 220 10^3 L 150-400 Normal
Automated Differential
Indication: To know specific parameters within the white blood cells that are elevated or reduced in
order to rule out infection and narrow down the possible causative agent.
Test Result Unit Normal range Impression
Neutrophil (%) 66.7 % 40-75 Normal
Lymphocyte (%) 23.7 % 20-45 Normal
Monocyte (%) 3.7 % 0-8 Normal
Eosinophil (%) 2.5 % 0-5 Normal
Basophil (%) 1.7 % 0-2 Normal
Neutrophil count 3.22 10^3 L 2.9-7.9 Normal
Lymphocte count 1.90 10^3 L 1.8-4.0 Normal
Monocyte count 0.07 10^3 L 0-1.6 Normal
Eosinophil count 0.50 10^3 L 0.4-2.1 Normal
Basophil count 0.03 10^3 L 0-0.2 Normal
Urea & Electrolytes
Indication: To assess the extent of electrolytes loss that might compromise renal function
Test Result Unit Normal range Impression
Urea 3.6 mmol/L 1.7-6.4 Normal
Sodium 140 mmol/L 135-150 Normal
Potassium 4.0 mmol/L 3.5-5.1 Normal
Creatinine 56.1 umol/L 27-62 Normal
Chloride 107.0 mmol/L 98.0-107.0 Normal
Liver Function test
Indication: To assess the status of the patient’s liver and liver disease. It’s important to do this
investigation in this patient to assess the liver function.
Test Result Unit Normal range Impression
Total protein 67 g/L 66-87 Normal
Albumin 36 g/L 35-50 Normal
Total bilirubin 4.3 umol/L 0-30 Normal
Alkaline phosphatase 62 u/L 53-128 Normal
Alanine
aminotransferase
17 u/L 0-43 Normal
Globulin 35 g/L 19-33 High
Other investigation :
Hematology
Prothrombin time (PT) 11 sec
International normalize ratio (INR) 1.01
Activated partial thromboplastin time (aPTT) 27.8 sec
Imaging studies
1) Bilateral mammogram
Findings:
There is asymmetric density at the LB retroareolar region with irregular bordered dense lesion noted.
No suspicious clusters of micro calcification.
No suspicious lesion at the RB.
The nipples and overlying skin are normal.
2) Ultrasound on abdomen
Findings:
The liver is normal in size and echotexture. No focal lesion. Intrahepatic ducts and common bile duct are not dilated. Gallbladder is well distended - no calculi or polyps within.Pancreas and spleen are normal.Kidneys are normal in size and echogenicity.Bipolar lengths and cortical thickness : RK - 11.8/0.9cm , LK -11.7/0.8 cm. No calculi or hydronephrosis bilaterally. Urinary bladder is well distended and appears grossly normal. Normal uterine size and echotexture. No pelvic mass.
Impression:
Normal study.
Biopsy
Biopsy was done to her and the results are below:
Section shows three strips of fibrocollagenous and fatty tissue, infiltrated by sheets, clusters and singly distributed malignant cells with no obvious tubular formation. The malignant cells exhibit marked pleomorphic and hyperchromatic nuclei, with prominent red nucleoli. Mitoses are occasionally seen. The cytoplasm is moderate and eosinophilic.
Immunohistochemical stains show the tumour cells are:
Progesterone receptor : Negative
Estrogen receptor : Negative
Final Diagnosis
Ductal carcinoma in situ (DCIS)
MANAGEMENT
The patient was schedule for laparotomy on 2nd December 2010.
Preoperative care:
Antibiotic prophylaxis ( iv cefobid 1g, iv flagyl 500mg)
He was not allowed to take food by mouth
A full explanation was made to ensure that the patient was aware of the diagnosis, the
operation procedures, the risks involved, and consent was taken from parents.
Operative findings:
Noted mass, large tumour about 20 x 20cm arising from the body of stomach along the
greater curve, appear whitish, hard, lobular with presence of sister nodule. Tumour has not
invaded regional area particularly in axillary lymph nodes. Tumour debulking done and removed
en bloc.
Postoperative findings confirmed Ductal Carcinoma In Situ.
