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    Mrs - Lakshmi Aged 54 Years Who Is A Flower Seller Residing at

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    Hari
    A 54-year-old woman presented with a painful lump in her right breast that had grown over the past 1.5 months. On examination, the physician found a solitary hard lump fixed to the breast tissue, measuring 7x8 cm with an enlarged axillary lymph node. Based on the examination, the doctor's diagnosis was probably carcinoma of the right breast, stage IIIA. Further tests were recommended to confirm diagnosis and staging before treatment.

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    Mrs - Lakshmi Aged 54 Years Who Is A Flower Seller Residing at

    Uploaded by

    Hari
    115 views5 pages
    A 54-year-old woman presented with a painful lump in her right breast that had grown over the past 1.5 months. On examination, the physician found a solitary hard lump fixed to the breast tissue, measuring 7x8 cm with an enlarged axillary lymph node. Based on the examination, the doctor's diagnosis was probably carcinoma of the right breast, stage IIIA. Further tests were recommended to confirm diagnosis and staging before treatment.

    Original Description:

    Carcinoma breast history taking and examination

    Original Title

    ca Breast

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    A 54-year-old woman presented with a painful lump in her right breast that had grown over the past 1.5 months. On examination, the physician found a solitary hard lump fixed to the breast tissue, measuring 7x8 cm with an enlarged axillary lymph node. Based on the examination, the doctor's diagnosis was probably carcinoma of the right breast, stage IIIA. Further tests were recommended to confirm diagnosis and staging before treatment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    115 views5 pages

    Mrs - Lakshmi Aged 54 Years Who Is A Flower Seller Residing at

    Uploaded by

    Hari
    A 54-year-old woman presented with a painful lump in her right breast that had grown over the past 1.5 months. On examination, the physician found a solitary hard lump fixed to the breast tissue, measuring 7x8 cm with an enlarged axillary lymph node. Based on the examination, the doctor's diagnosis was probably carcinoma of the right breast, stage IIIA. Further tests were recommended to confirm diagnosis and staging before treatment.

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    You are on page 1of 5

    Mrs.

    Lakshmi aged 54 years who is a flower seller residing at


    Thirumullaivoil came to OP with chief complaints of Lump in
    the Rt breast for past 1.5 months

    History of presenting Illness


    She was apparently normal before 1.5 months.
    Afterwhich she developed a lump in the Rt breast which is
    insidious in onset,initially small in size and progressed to the
    present size.
    The lump is associated with dull aching pain for past 1.5
    months ,intermittent in nature ,No radiation.The pain is severe
    for past 3 weeks.
    No H/o Nipple discharge
    No H/o recent retraction of nipple.
    No H/o trauma
    No H/o Swelling elsewhere in the body
    No H/o fever
    No H/o loss of weight,loss of appetite
    No H/o bony pain
    No H/o cough,hemoptysis,breathlessness
    No H/o Jaundice

    Past History
    No H/o Previous similar illness
    She is a k/c/o Diabetes mellitus for the past 3 year taking oral
    hypoglycemic medications and under control
    H/o sterilisation surgey at 19 years of age
    Not a k/c/o Hypertension, Epilepsy,Bronchial asthuma,IHD.

    Personal History
    Non smoker,Non alcoholic
    Takes non-veg diet
    Normal sleep pattern
    Normal bladder and bowel movements
    Menstrual History
    Attained menarche at 14 yrs of age.
    Regular cycles 5/30,Normal flow,No clots
    Attained menopause at 50 years of age.

    Marital and Obstetric history


    Married at 15 years of age. Non-consanguinous marraige
    First child birth at 16 years of age - Normal vaginal delivery-
    breast fed for 3 years
    Second child birth at 19 years of age - Normal vaginal
    delivery- breast fed for 1 year.
    No relevant Family history

    EXAMINATION
    General Examination
    Conscious and oriented
    Moderately built and nourished.
    No pallor,icterus,cyanosis,clubbing,jaundice,Gen
    lymphadenopathy,Pedal edema.

    Vital signs
    Pulse rate - 68 beats/min
    BP - 110/74 mm Hg
    Resp rate - 16 breaths/min
    She is afebrile

    Local examination
    After consent and with female attender the patient is asked to
    expose up to waist.

    Inspection - On sitting posture arms by the side of the body


    Position, symmetry,and Size of the Rt is normal compared to
    the opp breast
    No obvious lump made out on inspection.
    No ulcer present
    Skin over the breast normal
    No dilated veins
    No dimple/puckering/retraction
    No pleu de orange appearance
    No nodules,ulceration,fungation.
    Rt nipple lies at a higher level compared to normal side.
    Areola is normal.

    Arms raised above the head


    No change in the shape of the breast after lifting upwards.
    No tethering, fixing
    Inframammary region was normal,Axilla normal.

    Leaning forward
    The lump is not fixed to the chest wall.
    Falls equally on both sides.

    Palpation
    No warmth,Tenderness present.
    Solitary lump of size 7 x 8 cm is present over the inner upper
    and inner lower quadrants of the Rt breast with uneven
    shape,ill-defined margins,hard in consistency
    Not fixed to the skin
    Mobile with the breast tissue
    Fixed to the breast tissue
    Not fixed to pectoralis muscle
    Not fixed to the chest wall
    Rt Nipple is harder compared to normal side.

    Lymph note
    Central,axillary lymph node +
    Single,2×2,Firm in consistency and mobile.

    Examination of the opposite breast,axilla,and inframammary


    region normal.

    Other system
    Abdomen - Soft,No tenderness,No organomegaly,No clinically
    palpable mass.
    RS - BAE + ,Normal vesicular breath sounds
    Musculoskeletal system - Normal
    CVS - S1,S2 heard ,No murmers

    Summary
    Mrs.Lakshmi 54 y/o post menopausal women with ℅ painful
    Lump in Rt breast and on examination a solitary hard lump
    which is fixed to the breast tissue with axillary lymph node.

    Diagnosis
    Mrs.Lakshmi 54 y/o probably a case of carcinoma Rt breast -T3 N1
    Mx corresponds to stage IIIA

    Investigation
    Specific investigation
    Mammogram
    True cut biopsy
    USG breast
    MRI breast

    Staging investigation
    USG abdomen
    Bone scan
    CT chest

    Routine investigation
    Complete blood count
    Blood urea,Creatinine
    LFT
    Fasting and PP blood glucose
    Urine albumin sugar
    Blood grouping and typing
    Serology - HIV,HbsAg,HCV
    X ray chest,ECG all leads
    Echo

    Treatment
    Modified Radical mastectomy and sample to frozen section with
    chemotherapy and hormonal therapy follow-up.

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