A 55 yr old female Mrs. Usha Rani, house wife from Perambur belonging to low socioeconomic status presents with the chief complaints of lump in the Right breast for the past 6 months.
HISTORY OF PRESENTING ILLNESS
Patient was apparently normal 6 months back, after which she noticed a lump in the outer aspect of her right breast
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- insidious in onset,
- progressive,
- initially small in size gradually increased in size and attained the current size
- not associated with pain
No h/o nipple discharge/ retraction of nipple
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No h/o ulceration over breast
No h/o fever/trauma
No h/o loss of weight
No h/o loss of appetite
No h/o bone pain
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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
Pt is a K/C/O Diabetes mellitus for 3 years. (On regular medication Tab. Metformin 1BD)
No H/O HT/ Bronchial asthma/ Pulmonary tuberculosis/ Seizures
No h/o previous hospitalization
No h/o previous surgeries.
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No h/o previous irradiation.
No h/o intake of OCPs
PERSONAL HISTORY
Consumes non vegetarian diet
Normal bowel and bladder habits
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No h/o additive habits
No h/o drug/food allergy
MENSTRUAL HISTORY
Age at menarche : 13 years
Attained Menopause 5 years ago (At the age of 50)
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No h/o bleeding PV
OBSTETRIC HISTORY
Obstetric score: P3 L3
Age at marriage : 17
Age at first child birth : 18
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2nd child : 20
3rd child : 22
breastfeeding done for all children till 10 months
FAMILY HISTORY
No h/o breast/ gynaecological/ gastrointestinal malignancy in first degree relatives.
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GENERAL EXAMINATION
On Examination,
patient is conscious
oriented
moderately built and nourished
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No pallor
No icterus
No cyanosis
No clubbing
No pedal edema
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No significant generalized lymphadenopathy
VITAL SIGNS
PR-76/min, regular in rhythm, normal volume, no specific character, no radiofemoral, radioradial delay, felt in all peripheral pulses, nature of vessel wall normal
RR-18/min, thoracoabdominal type
BP-130/70 mm Hg in right upper limb, sitting posture
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Afebrile.
LOCAL EXAMINATION
EXAMINATION OF RIGHT BREAST
After getting consent from the patient and in the presence of a female attender, the patient is stripped upto waist.
Examined in sitting posture with arms by the side, arms raised, arms at hip, leaning forward, and supine posture under bright light
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INSPECTION
[Arms by the side]-
Right breast is larger than the left breast
fullness is noted in the upper outer quadrant of breast,
skin over the lump is normal,
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No peau d'orange appearance
no ulcers, sinuses, nodules, fungation and dilated veins
No dimple/puckering seen
Nipple :
size 1*1 cm, centrally placed
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same level as the contralateral nipple
no retraction of nipples
no discharge from nipples
no ulcers, cracks, fissures
Areola ;
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size 4*4cm, brown in colour
circular, no cracks, fissures and ulcerations
Arms and thorax : no edema, no visible nodes/fullness
Axilla: no visible nodes
Supraclavicular fossa : no fullness
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ON RAISING ARMS ABOVE HEAD
Both breast move equally
undersurface of the breast appears normal
No prominence of lump
no peau d' orange /dimpling/puckering
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no retraction of nipple
ON LEANING FORWARDS
Breast fall equally on both sides.
ON CONTRACTING PECTORALIS MAJOR BY KEEPING HANDS AT HIP
The lump does not become prominent
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PALPATION
Not warm, not tender.
Single Lump of size 4*3 cm, hard in consistency, ovoid in shape, well defined margins, irregular surface, felt in the the upper outer quadrant.
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
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No fixity to chest wall/ serratus anterior
Nipple: no palpable mass deep to the nipple
no discharge from the nipple
no retraction of nipple
Examination of rt axilla: No lymph nodes palpable
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Rt Supraclavicular fossa: No nodes palpable
Examination of contralateral breast :normal
Examination of contralateral axilla :normal.
Examination of contralateral supraclavicular fossa : normal
Percussion
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Resonant note felt over parasternal areas
Per rectal examination- to be done
Per Vaginal examination- to be done
EXAMINATION OF OTHER SYSTEMS
Examination of abdomen : soft, not tender, no organomegaly
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no palpable mass, no free fluid
hernia orifices- free
external genitalia- normal
Examination of RS : Normal vesicular breath sounds heard
No added sounds
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Examination of CVS: S1, S2 heard
no murmurs
Examination of CNS: No focal neurological deficit
Examination of thyroid gland: Normal, No swelling
DIAGNOSIS
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CARCINOMA of Right BREAST - T2 NO M0 (STAGE IIA).
MANAGEMENT
INVESTIGATIONS
Routine:
Blood: Complete hemogram- TC, DC, Hb%, ESR, BT, CT
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Blood urea, sugar, creatinine
Urine: sugar, albumin
X ray chest, ECG
Specific: Mammogram of Right breast
FNAC of Right breast lump
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core needle biopsy
Sentinel node biopsy
Staging investigation: X-Ray Chest
USG abdomen
liver function test
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bone scan
x-ray skull and pelvis
mammogram of contralateral breast
TREATMENT
1.WIDE LOCAL EXCISION (Breast conservative surgery)+adjuvant radiotherapy of Right Breast
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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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