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1. Case Presentation ARUMUGAM . BERGONIA . BURGOS . CANILANG . FIGURACION . KAVI . MAADIL . ROSARIO . SALVADOR . TORRES. VIJAYAKUMAR . VIRADOR . WACLIN GROUP 4 - SUBGROUP 3 (GS-1)

2. HISTORY 01

3. GENERAL DATA Age 49 years Gender Female Address Bauang, La Union. Birthday 03/17/1975 Occupation: Maid Religion: Roman Catholic Date of Admission 05/24/2024 Name: E.P.V. Informant : Patient Reliability : 95%

4. Eschar, right breast Chief complaint:

5. 1 month and 9 days PTA Patient scratched her right breast causing 1x1cm abrasion on the upper inner quadrant of breast. On overnight, the abrasion progressed into a bean sized swelling that is warm to touch associated with undocumented fever, tenderness, erythema and pruritus. Pt took Biogesic which provided relief for her fever. 1 month 7 days PTA, (+) pus forming, erythematous, tender right breast Patient sought consult at BDH and was prescribed Amoxicillin 500mg Q8 for 7 days and Mupirocin Ointment HISTORY OF PRESENT ILLNESS Pt claims no relief from symptoms and noticed progression (increase in size) of symptoms with (+) nipple discharge (pus) 1 month PTA

6. 1 month PTA Consulted at ITRMC where she was given 2 unrecalled medication and was advised for sonomammogram at LORMA , which revealed solid right breast mass (BIRADS 4) coexisting edema or inflammatory process with unremarkable left breast. HISTORY OF PRESENT ILLNESS 3 weeks and 6 days Consulted at ITRMC surgery OPD with imaging result. She was then advised for biopsy and was done on that same day. FHPTC, patient came back for follow up check up with biopsy result which revealed microabscess, focal, breast (right) hence admission.

7. PAST MEDICAL HISTORY MEDICAL: (+) DM (2005) maintained on Metformin 500 mg/tab BID (non compliant) (-) Asthma (-) Hypertension (-) Cancer (-) PTB exposure (+) Food Allergies (Seafood) SURGICAL: (+) wound debridement - 6 y/o due to Vehicular Accident (+) salpingectomy (1986, Tondo)

8. OB HISTORY G1P0 (0010) (+) ectopic pregnancy LMP: April 26, 2024 M: 13 y.o I: Regular D: 3 days A: 3 pads moderately soaked S: (+) headache (+) breast tenderness (+) dysmenorrhea

9. SEXUAL HISTORY 2 sexual partners 1st husband (died 1990) 2nd partner (since 2015) Last sexual intercourse 1 month ago

10. FAMILY HISTORY (+) DM, mother (-) Asthma (+) Hypertension, mother (-) CVD (-) Cancer (-) PTB exposure

11. PERSONAL SOCIAL HISTORY (+) smoker 2 cigarettes/day since 20 years old (2.9 pack years) (+) occasional alcoholic drinker Lives in a bungalow house with husband and adopted son

12. GENERAL ( +)weight loss,(+)fatigue,(+)insomnia,(+)good appetite, (+) body weakness, (+) fever SKIN ( -) rashes, (-) lumps, (-) dryness HEAD ( -) headache, (-) dizziness, (-) head injury, (-) lightheadedness EYES (-) sunken,(-) redness, (-) blurring of vision, (-) diplopia EARS (-) hearing loss,(-) pain,(-) discharge NOSE (-) cold, (-) epistaxis, (-) nasal discharge, (-)sneezing REVIEW OF SYSTEMS

13. MOUTH & THROAT (-) hoarseness,(-) sore throat, (-) gum bleeding NECK (-) pain, (-) stiffness, (-) lumps RESPIRATORY (-) cough, (-) hemoptysis, (-) dyspnea CARDIOVASCULAR (-) palpitations, (-) cyanosis, (+) chest pains/discomfort , (-) orthopnea GASTROINTESTINAL (-) Nausea, (-) vomiting, (-) hematemesis, (-) abdominal pain, (-) jaundice, (-) constipation, (+) flatulence GENITOURINARY ( -) Incontinence, (-) dysuria, (-) hematuria, (-) oliguria, (+) urinary frequency,(+)urinary urgency,(+) nocturia,(+) polyuria

14. MUSCULOSKELETAL (-)muscle pain,(-)joint pains,(-)stiffness,(-)weakness,(-)muscle atrophy, (+)back pain NEUROLOGIC (-)headache,(-)syncope,(-)seizures HEMATOLOGIC (-)easy bruising,(-)excessive bleeding ENDOCRINE (-)heat/cold intolerance,(-)excessive sweating, (+)polydipsia ,(-)polyphagia

15. PHYSICAL EXAMINATION 02

16. PHYSICAL EXAMINATION GENERAL GCS 15, awake, coherent, not in CPD BP: 120/90 , CR: 90 , RR: 20, Temp: 36.7 C SpO2: 98% ON RA Height: 145cm Weight: 58 kg BMI: 27.6 (OVERWEIGHT ASIA CLASSIFICATION) SKIN Fair skin complexion, no noted rashes, no purpura HEENT: Head: Normal hair distribution (-) scars, (-) gross deformities Eyes: Anicteric sclera, pink palpebral conjunctiva, pupils 3-2 mm ERTL, intact EOMs EARS: Symmetric, (-) gross deformities, (-) discharge NOSE: (-) nasal discharges MOUTH: Pink, moist lips and buccal mucosa NECK: (-) cervical lymphadenopathy

17. PHYSICAL EXAMINATION CHEST AND LUNGS Symmetrical chest wall expansion, (+) clear breath sounds, (-) crackles (+) Necrotic wound, Right Breast (+) Purulent discharge (+) Right breast palpable mass (+) Right breast palpable mass (-) supraclavicular lymph nodes (-) axillary lymph nodes HEART Adynamic precordium, normal rate regular rhythm, (-) murmur GASTROINTESTINAL Flat, non-distended abdomen, normoactive bowel sounds, (-) tenderness NEUROLOGIC Cerebrum - GCS15, awake, alert, conversant, oriented to time, place, person Cerebellum - (-)ataxia, (-) disdiadochokinisia, (-) Dysmetria Cranial Nerves I: able to smell coffee on both nostrils II, III: Pupils are equally round and reactive to light and accomodation III, IV, VI: Intact EOMs V: Muscles of mastication intact VII: (-) facial asymmetry VIII: Intact sense of hearing IX, X: (+) gag reflex XI: can turn head side to side, can shrug shoulders against resistance XII: (+) protrudes tongue, (-) deviation

18. Focused Physical Examination (+) Asymmetric breast (+) Necrotic tissue on upper inner quadrant of Right Breast (+) Change in skin color, Right Breast (-) Dimpling / Retraction (-) Nipple Inversion (+) Purulent discharge, Right breast (+) Palpable, fluctuant mass, Right breast (+) Tender on palpation Non-swollen axillary lymph nodes Breast

19. Physical Examination

20. 03 DIAGNOSTICS

21. SONOMAMMOGRAM Both breasts were scanned showing normal parenchymal glandular structures. Ductal pattern is not dilated. There is shadowing area measuring approx. 5.5 cm in its widest diameter seen at the upper inner quadrant of the right breast. The surrounding fat and skin is thickened and echogenic with interspersed fluid. No nipple retraction is observed. The rest of the visualized soft tissue of the anterior chest wall including the axillary areas are clear. IMPRESSION: Solid right breast mass (Birads 4). Coexisting edema or inflammatory process. Sonographically unremarkable left breast.

22. CORE NEEDLE BIOPSY, RIGHT BREAST: DIAGNOSIS: MICROABSCESS FOCAL BREAST (RIGHT) GROSS AND MICROSCOPIC CONDITION DESCRIPTION: Specimen Consists Of 8 White Tissue Strips Aggregately Measuring 2x1.5x0.2 Cm

23. IMAGING: CHEST X-RAY

24. LABORATORY RESULTS

25. PRIMARY WORKING IMPRESSION BREAST ABSCESS T/C MALIGNANCY; DIABETES MELLITUS TYPE II, INSULIN REQUIRING

26. COURSE IN THE WARDS 04

27. 5/24/24 S: (+) breast pain, (+) wound discharge (+) eschar formation O> BP: 120/70, HR: 87 RR: 20 T: 36.6 SPO2: 98% A > breast abscess P > Please admit under the service of GS1 > Secure consent for admission > TPN Q8shift > NPO > IVF: PNSS 1L x 8H > DX: CBC Typing, BUN, Crea, Na, K, PT/INR, APTT, HBA1C > Meds: (1) Ampicillin subcutaneous 2g IV Q12 (2) Clindamycin 600mg IV Q6 (3) Omeprazole 40g IV OD (4) Tramadol 50g IV Q8 PRN x pain > OR Plan: ‘E’ Wound Debridement, Drainage of Abscess > Secure consent > Inform Anes & OR >Refer to IM-ER (Gen Med & Endo) for clearance and co-management > MVS Q4 > I & O Qshift > Refer IM ER S > (+) breast pain, (+) wound discharge (+) eschar formation O > awake, conversant, GCS 15 120/80 | 86 | 20 | 36.6 | 98 @ RA AS PPC SCWE (-) retractions (+) right breast mass/wound AP (-) heaves (-) thrills (-) murmurs Soft non-tender abdomen <2s CRT (-) edema 12L ECG NSR LAD, CXR: Normal, BHA1C: 13,6, BUN 4.59 Crea 58.66, Na 139.2, K 4.41, Hb 110, WBC 16.3, HCT 34.7, Plts 333 A > Breast Abscess, Right DM Type 2 IR P > Overall Risks Assessment : Low Risk > Refer as necessary 5/25/24

28. 5/25/24 GS NOTES HD1 S> (+) breast pain, (+) wound discharge (+) eschar formation, (+) breast heaviness O> BP: 120/80, HR: 74RR: 18 T: 36.6 SPO2: 99% A> breast abscess P> > NPO > PNSS 1L x 8 hrs > Meds: (1) Ampicillin subcutaneous 2g IV Q12 (2) Clindamycin 600mg IV Q8 (3) Paracetamol 600mg IV Q6 (4) Tramadol 30mg IV Q8 PRN (5) Omeprazole 80mg IV OD > IM notes highly noted > Pls carry out IM orders > Monitor I & O Qshift > Refer GS1 S> (+) breast pain, (+) wound discharge (+) eschar formation, (+) breast heaviness O> BP: 110/70, HR: 79 RR: 21 T: 36.7 SPO2: 99% A> breast abscess P> HD1 > NPO > PNSS 1L x 8 hrs > Meds: (1) Ampicillin subcutaneous 2g IV Q12 (2) Clindamycin 600mg IV Q8 (3) Paracetamol 600mg IV Q6 (4) Tramadol 30mg IV Q8 PRN (5) Omeprazole 80mg IV OD > MVS Q4 > I & O Qshift > CBG Q8 while on NPO > Refer 5/26/24

29. 5/26/24 S> (+) breast pain, (+) wound discharge (+) eschar formation, (+) breast heaviness O> BP: 120/70, HR: 79 RR: 18 T: 36.6 SPO2: 99% A> breast abscess, right P> IM ENDO > Patient known to service > Clearance a previously ordered > Refer GS1 S/O > (+) breast pain, (+) wound discharge (-) NV, (-) chest pain, 130/80 | 82 | 20 | 36.6 | 98 A> breast abscess, right > Maintain NPO > PNSS 1L x 8 hrs > Meds: (1) Ampicillin subcutaneous 2g IV Q12 (2) Clindamycin 600mg IV Q8 (3) Paracetamol 600mg IV Q6 (4) Tramadol 30mg IV Q8 PRN (5) Omeprazole 80mg IV OD > MVS Q4 > I & O Qshift > To OR on call > Refer 5/27/24

30. 5/25/24 IM ENDO S> ( +) breast pain, (+) wound discharge (+) eschar formation O> BP: 120/70, HR: 87 RR: 20 T: 36.6 SPO2: 98% CBG: 139-221mg/dl A> breast abscess > No objection for contemplating procedure of benefits outweigh the risks > Maintain CBG <180mg/dL > Ideally to maintain HB1AC <10% > Shift Insulin Isophane 12u SC in AM, 6u SC in PM Preop > Hold metformin 24H PT OR > Hold insulin on the day of OR > ↑ CBG monitoring to Q4 > Shift IVF to D5NSS 1L x 10 hrs once on NPO Postop > Resume once feeding Metformin 500mg/tab BID Insulin Isophane 12u SC in AM, 6u SC in PM > ↓ CBG monitoring TID pre-meals and bedtime once feeding > Shift IVF to PNSS 1L x 12 hrs > Please drop official referral letters to (1) Gen Med (2) IM Endo at ward level > Refer accordingly S> (+) breast pain, (+) wound discharge (+) eschar formation O> BP: 120/70, HR: 76 RR: 19 T: 36.5 SPO2: 98% A.> breast abscess P> ANESTHESIA PRE-OP ORDERS > Patient’s history, labs and diagnostics noted > OR plans noted > Please secure consent for anesthesia care plan > NPO PT OR: 8 hours for full meals, 2 hours for clear liquids > IVF: PLRS 1L x 8h PTOR > Please maintain IV line patency PTOR > Kindly bring 1 PLRS with the patient prior to OR transport for OR use > CBG PTOR > SKin test ketorolac PTOR > To OR on call > Refer Add: > Noted IM Gen Med and Endo clearances 5/25/24

31. 05 SALIENT FEATURES

32. SALIENT FEATURES 49 year old No cervical lymphadenopathy Female Soft, tender, fluctuant, Palpable breast mass, right, Asian- American Ethnicity (Filipino) (-) dimpling and nipple inversion (+) DM Tenderness NULLIPAROUS Erythema (+) SMOKER Fever Non-Lactating Nipple Discharge Skin Discoloration

33. DIFFERENTIAL DIAGNOSIS 06

34. DIFFERENTIAL DIAGNOSIS MASTITIS FAT NECROSIS BREAST CANCER BREAST ABSCESS PAIN (+) (-) (+) (+) ERYTHEMA (+) (-) (+) (+) TENDERNESS (+) (-) BUT TENDERNESS IN LATER STAGES (+) FEVER (+) (-) (-) (+) NIPPLE DISCHARGE (+) LESS COMMON (+) PALPABLE AND FLUCTUANT MASS (+) (+) +/- (+) UNILATERAL (+) (+) (+) (+) CHANGES IN SKIN COLOR (+) (+) (+) (+) NECROTISING TISSUE (-) (+) (+) +/- NON- LACTATING WOMEN (-) (+) (+) +/-

35. DIFFERENTIAL DIAGNOSIS MASTITIS BREAST ABSCESS BENIGN BREAST MASS MALIGNANT BREAST MASS PAIN (+) (+) (-) (-) ERYTHEMA (+) (+) (-) (+) TENDERNESS (+) (+) (-) (-) / (+) In later stages FEVER (+) (+) (-) (-) NIPPLE DISCHARGE (+) (+) (-) (+)/(-) PALPABLE AND FLUCTUANT MASS (+) (+) (+) (+)/(-) UNILATERAL (+) (+) (+) (+) CHANGES IN SKIN COLOR (+) (+) (-) (+) Peud’d orange NECROTISING TISSUE (-) +/- (-) (+) NON- LACTATING WOMEN (-) +/- +/- (+)

36. FINAL DIAGNOSIS: NON-PUERPERAL BREAST ABSCESS, RIGHT; DIABETES MELLITUS TYPE 2-UNCONTROLLED, INSULIN REQUIRING; S/P CORE NEEDLE BIOPSY, RIGHT BREAST (5/25/24, ITRMC); SALPINGECTOMY (1985, Tondo)

37. 09 PATHOANATOMY

38. EMBRYOLOGY

39. EMBRYOLOGY

40. EMBRYOLOGY

41. FUNCTIONAL ANATOMY OF BREAST Composed of 15-20 lobes BORDERS LANDMARKS Superior 2nd to 3rd rib Inferior 6th to 7th rib Medial Lateral to the sternum Lateral Anterior axillary line Deep/ posterior Rests on the fascia of pectoralis major, serratus anterior and external oblique abdominal muscles and upper extent of rectus sheath

42. FUNCTIONAL ANATOMY OF BREAST TOPOGRAPHICAL LOCATION -2nd to 6th rib -lies in the superficial pectoral fascia - retromammary space -attached by cooper’s ligament -covered by pectoralis major muscles -axillary tail of spence WEIGHT OF THE BREAST -non-pregnant 200g -pregnant nearing term 400-600g -lactation 600-800g SHAPE OF THE BREAST -protuberant conical form -base of the cone is roughly circular 10-12 cm in diameter

43. FUNCTIONAL ANATOMY OF BREAST

44. FUNCTIONAL ANATOMY OF BREAST

45. FUNCTIONAL ANATOMY OF BREAST Nipple-Areola Complex

46. BLOOD SUPPLY & LYMPHATICS ARTERIAL SUPPLY

47. VENOUS SUPPLY BLOOD SUPPLY & LYMPHATICS

48. BLOOD SUPPLY & LYMPHATICS

49. LYMPHATICS BLOOD SUPPLY & LYMPHATICS

50. PHYSIOLOGY

51. Trauma Infrequent Feedings Oversupply of Milk Epithelium integrity compromised Portal of entry for bacteria Bacteria from skin enters the body Inflammation of mammary gland Breast milk stasis obstructs normal flow Blockage of Milk duct Local Bacterial Overgrowth Breast swelling & tenderness Activation of innate immune response Associated fever, chills, malaise MASTITIS Local proliferation of WBCs to fight off infection Pain and swelling in axillary LN Localized painful, swollen, erythematous breast tissue Inadequate or delayed antibiotic treatment Unknown cause of Primary Disease Increase inflammatory material in peripheral breast tissue Localized collection of inflammatory fluid BREAST ABSCESS Enclosed Fluid Mass Spontaneous abscess fluid drainage Palpable, fluctuant mass in breast tissue / Localized drainable fluid collection visible on UTZ Nipple discharge PATHOGENESIS OF BREAST ABSCESS

52. COMMON PATHOGENS ASSOCIATED WITH BREAST ABSCESS: Staphylococcus aureus Staphylococcus epidermidis Streptococcus spp.

53. RISK ASSESSMENT AGE 49 y/o FIRST MENSTRUAL PERIOD 12-13 FIRST LIVE BIRTH FIRST- DEGREE RELATIVE W/ BREAST CA PREVIOUS BREAST BIOPSY 1 >/- 1 BREAST BIOPSY WITH ATYPICAL HYPERPLASIA RACE/ETHNICITY Asian-American

54. SCREENING MAMMOGRAPHY IN WOMEN >/- 50 y/o Reduce Mortality from breast cancer by 25 % MAMMOGRAPHY IN WOMEN < 50 y/o More controversial for several reasons: Breast density is greater and screening mammography is less likely to detect early breast cancer (reduced sensitivity) Screening mammography results in more false-positive test findings (reduced specificity), which results in unnecessary biopsy specimens Younger women are less likely to have breast cancer, so fewer women will benefit from screening AGES 40-44 YEARS Women should have the option to start screening with mammogram every year AGES 45-54 YEARS Women should get a mammogram every year AGE 55 AND OLDER Women can switch to a mammogram every other year, or they can choose to continue yearly mammograms.

55. SCREENING BY AGE 20 Monthly self breast exam (SBE) done 10-14 days after menstruation BY AGE 30 Annual clinical breast exam BY AGE 50 Annual mammography

56. MANAGEMENT 04

57. MANAGEMENT Upon ADMISSION, > TPR Q SHIFT > NPO > IVF: PNSS 1L * 8 HRS > DX: CBC TYPING, BUN, CREA, NA, K, PT INR, APTT, HBAIC, CHEST X RAY, 12L ECG > MEDS: AMPICILLIN + SULBACTAM 2G IV Q12 CLINDAMYCIN 600MG IV Q8 PARACETAMOL 600MG IV Q6 RTC OMEPRAZOLE 40MG IV Q8 PRN FOR PAIN TRAMADOL 50MG IV Q8 PRN FOR PAIN > OR PLAN : “E” WOUND DEBRIDEMENT, DRAINAGE OF ABCESS > SECURE CONSENT > REFER TO IM-ENDO & IM GEN MED AT ER LEVEL FOR CLEARANCE & CO-MANAGEMENT > MVS Q4 > I & O Q SHIFT > REFER

58. SUR GICAL MANAGEMENT FOR WOUND DEBRIDEMENT & DRAINAGE OF ABSCESS

59. PRE-OP MANAGEMENT > Start Insulin Isophane 12 U SC in AM , 6U SC in PM > Hold Metformin 24 he PTOR > Hold Losartan on the day of OR > Increase CBG monitoring to Q4 once on NPO > Shift IVF to D5NSS 1L * 10 Hours once on NPO

60. ADVANTAGES OF SURGICAL INTERVENTION INFECTION CONTROL DRAINAGE : Remove pus & infected material from the abcess, reducing bacterial load & helping to control infection DEBRIDEMENT : Removes dead or necrotic tissue, which can Harbor bacteria & impede healing PAIN RELIEF : Alleviates pressure & pain caused by accumulation of plus within the ABCESS REDUCED REOCCURRENCE RISK : Properly managing & resolving the Abcess reduce likelihood of reoccurence MINIMIZES SCARRING : Prompt & effective treatment can minimize tissue damage & subsequent scarring

61. COMPLICATIONS Scarring Breast Asymmetry Retraction of Nipple Areola Skin Necrosis Recurrent infection Septicemia

62. PREVENTION BREAST CARE Keep nipples clean & dry. Use nipple cream if noted any crack or sore nipples to promote healing PROMPT TREATMENT OF MASTITIS Treat any signs such as breast pain, redness, warmth promptly with rest, fluids, continued breastfeeding or pumping GOOD HYGIENE Wash hands before breastfeeding MONITORING Regularly check your breasts for lumps Redness or other signs of infection & seek medical advice

63. PREVENTION Self breast examination monthly 10-14 days after menstruation Annual mammography Smoking cessation