Surgery case presentation: A 50 year old lady with a lump in the right breast

A 50 year old lady with a lump in the right breast

1. A 50 year old lady with a lump in the right breast Presented by Lisanul Hasan K71 ,Dhaka Medical College

2. Particulars of the patient : Name of the patient :Mrs. XXX Begum Age: 50 year Sex: Female Occupation: House wife Marital status: Married Address: Present & permanent- Kishorgonj Religion: Islam Date of admission:28 March 2018 Date of examination: 18 April 2018

3. Presenting Complaints : 1.Lump in the right breast for 1 year 2.Weight loss for 6 months

4. History of present illness : According to the statement of the patient she was reasonably well 1 year back. Then she noticed a lump in her right breast located in the lower outer quadrant. It is gradually Increasing in size but painless . There is no associated nipple discharge and axillary swelling. The patient also gives history of anorexia and loss of approximately 10 kg weight by the last 6 months

5. She gives no history of fever . There is no history of chest pain, cough , hemoptysis, breathlessness and jaundice . She is non diabetic , normotensive and non asthmatic . Her bowel and bladder habit is normal.

6. Past history : She has no history of any other medical or surgical illness. Family history : None of her relatives has same type of illness. All her family members are apparently healthy .

7. Menstrual history : Menarche at 14 years of age .Menstrual period was normal with regular flow and duration of cycle was normal .She is menopausal for last 5 months. Obstetric history : Married for 30 years . She has 4 daughters and one son. All are breastfed.

8. Contraceptive history : She did not take any contraceptive method. Drug history : She took calcium and iron tablets. Allergy history : No history of allergy to any known foods or drugs. Immunization history : Partially immunized as per EPI schedule

9. Personal history : She takes regular Bengali diet which usually contains rice , fish, vegetables and sometimes meat .She chews betel leaf and betel nuts. She is non smoker and non alcoholic. Socio-economic history : She comes from a lower middle class family. She lives in a tin shed house , drinks tube-well water and uses sanitary latrine.

10. General examination: Appearance: Ill looking Body built: Below average Co-operation: Co-operative Decubitus: On choice Nutritional status: Cachectic Intelligence: Normal Anemia: Mildly anemic Jaundice: Absent Clubbing: Absent

11. Cyanosis: Absent Koilonychia: Absent Leukonychia: Absent Edema : Absent Dehydration: Absent Blood pressure: 110/70 mmHg Pluse:98 Respiratoy rate: 18 breaths / minute Temperature: Not raised

12. Lymph node : Accessible lymph nodes are not palpable Jugular venous pressure: Not raised Skin condition: Normal Pigmentation : Normal IV cannula: Cannula in situ in the right hand Thyroid gland: Not palpable

13. Local examination of the breast : Left breast : It is normal in position .There is no visible abnormality. Nipple and areola are normal. Right Breast : It is enlarged in comparison to the left breast and there was an intra mammary lump in the lower outer quadrant of the right breast approximately ( 4 into 2) cm in size, oval ,non tender, Hard in consistency. Its surface is irregular, margin is well defined ..

14. It is free from over lying skin but fixed with underlying structure. Overlying skin is normal. There is no ulceration or foul smelling discharge. Nipple & areola is normal

15. Alimentary system: Normal Cardiovascular system: Normal Respiratory system: Normal Nervous system: Normal Musculoskeletal system: Normal Systemic examination

16. Salient feature : Mrs. Dilowara Begum ,50 years old lady hailing from kishorgonj presented with the complaints of a lump in the right breast for 1 year and anorexia and weight loss for last 6 months. According to the statement of the patient she was reasonably well one year back.

17. Then she suddenly noticed a lump in lower outer quadrant of her right breast which was , painless, gradually increasing in size . There is no active nipple discharge and axillary swelling. There was no history of associated fever . The patient gives a history of significant weight loss . She has no history of chest pain , cough ,hemoptysis , breathlessness and jaundice .Her menarche was at 14 years of age

18. Menstrual period was normal with regular flow and duration of cycle was normal .She is menopausal for last 5 months . She is married for 30 years . She has 5 children . All were breastfed. She has no history of taking oral contraceptive. There is no relevant family history of any such disease or any other associated disease.

19. On general examination she was mildly anemic , non icteric , normotensive .All the vital signs are within normal range .There is no lymph node enlargement. On local examination of the right breast it is enlarged and pendulous .

20. A visible and non tender lump is present In the lower outer quadrant of the right breast approximately ( 4 into 2) cm in size, oval ,hard mass which is free from over lying skin but fixed with underlying structure. Nipple areola complex is normal .There is no discharge or ulceration. Examination of other system reveals no abnormality.

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22. A 50 year old lady with a lump in the right breast Presented by Shatabdi Barua Talukder , K-71, Dhaka Medical College

23. Provisional diagnosis : Carcinoma of right breast

24. Differential diagnosis : Fibrocystic disease Fibroadenoma of breast

25. Fibrocystic disease : Points in favor: - commonly occur in 40-55 years. Points against favor : - Associated with pain - Associated with tenderness - Presence of multiple lump

26. Fibroadenoma: Points in favor: - Painless lump Points against favor: - Incidence declines with increasing age - Usually occur upper & outer quadrant - Highly mobile

27. Investigation : For diagnosis : Ultrasonography guided Fine needle aspiration cytology Features are compatible with ductul carcinoma.

28. For staging : Chest X ray P/A view Ultrasonography of the whole abdomen 3. Liver function test : Serum Bilirubin, SGPT,ALP,GGT 4. CT scan chest 5. Bone scan

29. For pre-operative assessment : CBC with ESR Blood Grouping and Rh typing Random blood sugar Serum creatinine, serum urea Urine R/M/E ECG

30. Routine investigations Blood: Hb : 10.3 g/dl RBC : 4.13x 10^6 /uL WBC : 5800 /cumm Platelet : 250000/cumm ESR : 93 mm in 1 st hour Creatinine : 1.13 mg/dl RBS : 8.2 mmol/L

31. Continued…. HBsAg : -ve Anti-HCV: -ve Blood Group: O +ve

32. Pre-operative preparations: Communication and counseling Informed written consent. Optimization of the patient -Correction of Fluid and electrolyte imbalance Gastric lavage

33. Operation note Date : 17.4.18 Start time: 12.30 PM Location of the operation: G-OT 1 Indication of the operation: Ca. breast (right side) Ductul carcinoma Name of the operation: Modified radical mastectomy Type of anaesthesia : G/A

34. Continued…. Findings: Mass found below outer quadrant. Procedure: Excision of breast was done by elliptical incision. Then a single lymph node was excised which was sent for biopsy. Specimen was sent for histopathology.

35. Treatment modality 1.Surgery 2.Radiotherapy 3.Adjuvent systemic therapy-Chemotherapy, hormone therapy, Immunotherapy. 4. Psychological support

36. Thank you