A 47 yr old female Mrs.Revathi, housewife from Pattabiram belonging to low socioeconomic class presenting with the chief complaints of painless lump in the left breast for past 6 months.
HISTORY OF PRESENTING ILLNESS
Patient was apparently normal 6 months back after which she noticed a lump in the left breast
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- Insidious in onset, progressive, initially small in size gradually increased and attained the current size
- Not associated with pain
- No h/o nipple discharge
- No h/o recent onset of nipple retraction
- No h/o fever/trauma
- No h/o loss of weight
- No h/o loss of appetite
- No h/o bone pain
- No h/o difficulty in breathing
- No h/o cough with hemoptysis
- No h/o jaundice/abdominal pain/distension
- No h/o headache/blurring of vision/seizures
- No h/o swellings elsewhere in the body
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PAST HISTORY
- No h/o DM, HT, asthma, tuberculosis, epilepsy, jaundice, IHD.
- No h/o previous hospitalization
- No h/o previous surgeries.
- No h/o previous irradiation.
- No h/o intake of OCPs
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PERSONAL HISTORY
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- Consumes non-vegetarian diet
- Normal bowel and bladder habits
- No h/o additive habits
MENSTRUAL AND MARITAL HISTORY
Age at menarche: 13 years
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Age at marriage: 17 years
Age at first child birth: 19 years
2nd child: 20 years
3rd child: 22 years
Breastfeeding done for all children till 10 months
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Age at menopause: 44 years.
No h/o hormone replacement therapy.
FAMILY HISTORY
No h/o breast/gynaecological/gastrointestinal malignancy in first-degree relatives.
GENERAL EXAMINATION
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Patient is conscious, oriented, well-built and nourished
No pallor
No icterus
No cyanosis
No clubbing
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No pedal edema
No significant generalised lymphadenopathy
VITAL SIGNS
- PR-76/min, regular in rhythm, normal volume, no specific character, no radiofemoral, radioradial delay, equally felt on both sides in all palpable peripheral vessels, no vessel wall thickening
- RR-18/min, thoracoabdominal type
- BP-130/80 mm Hg in right upper limb, sitting posture
- Afebrile.
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LOCAL EXAMINATION
After getting consent from the patient and in the presence of a female attendant, the patient is stripped up to waist.
EXAMINATION OF LEFT BREAST
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Examined in sitting posture with arms by the side, arms raised above the head, arms at hip, leaning forward, and supine posture under bright light
INSPECTION
[Arms by the side]-left breast is slightly higher than the right breast, fullness is noted in the upper outer quadrant of breast,
Skin over the lump is normal,
No peau d'orange appearance
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No ulcers, nodules, fungation and dilated veins
No dimple/puckering seen
Nipple:
Size 1*1 cm, centrally placed
Left nipple is slightly higher than right nipple
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No retraction of nipples
No discharge from nipples
No ulcers, cracks, fissures
Areola:
Size 4*4cm, brown in colour, circumferential, no cracks, fissures and ulcerations
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Arms and thorax: no edema, no visible nodes/fullness
Axilla: no visible nodes
Supraclavicular fossa: no fullness
ON RAISING ARMS ABOVE HEAD
Both breasts move equally
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Undersurface of the breast appears normal
No peau d'orange /dimpling/puckering
No retraction of nipple
ON LEANING FORWARDS
Breast fall equally on both sides.
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ON CONTRACTING PECTORALIS MAJOR BY KEEPING HANDS AT HIP
The lump does not become prominent
PALPATION
- Not warm, not tender.
- Lump of size 7*5 cm hard in consistency, ovoid in shape, well-defined margins, irregular surface, felt in the upper outer quadrant, fixed to the breast tissue
- Skin over the lump is pinchable
- The Lump moves along with breast tissue on contracting and relaxing the pectoralis major there is no restriction of mobility along the line of muscle fibres
- No fixity to chest wall
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Nipple: no palpable mass deep to the nipple
No discharge from the nipple
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- Examination of axilla: A single node is palpable behind the anterior axillary fold, 1*1 cm, which is firm in consistency, mobile and skin is pinchable with normal skin surface
- No other lymph nodes palpable.
- Supraclavicular fossa: No nodes palpable
Examination of right breast: normal
Examination of right axilla: normal.
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Examination of right supraclavicular fossa: normal
Percussion
- Resonant note felt over parasternal areas
OTHER SYSTEMS
- Examination of abdomen: soft, not tender, no palpable mass, no organomegaly, no free fluid, hernial orifices are free, external genitalia normal.
- Examination of RS: Normal vesicular breath sounds heard. No added sounds
- Examination of CVS: S1 S2 heard, no murmurs
- Examination of CNS: No focal neurological deficit
- Examination of Spine and Cranium: Normal
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- Per rectal examination- to be done
- Per Vaginal examination- to be done
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DIAGNOSIS
CARCINOMA of left BREAST – T3 N1 Mx (STAGE IIIA).
MANAGEMENT
INVESTIGATIONS
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- Routine:
- Blood: TC, DC, ESR, Hb%, Blood grouping/typing, urea, sugar, creatinine.
- Urine: sugar, albumin, deposits
- X ray chest
- ECG
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- Specific: Mammogram FNAC, core needle biopsy
- Staging investigation: chest x-ray USG abdomen liver function test x-ray skull, pelvis, spine mammogram of contralateral breast CT chest CA 15-3/CEA
TREATMENT
- Neoadjuvant chemotherapy- downstage the tumour+Modified radical mastectomy in the left breast + adjuvant chemotherapy + radiotherapy
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This download link is referred from the post: MBBS Final Year Case Presentation (Clinical Case Examination, Discussion and Treatment)
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