Anda di halaman 1dari 26

Morning Report

Breast Cancer
SKDI : 2
ICD X : C50

Febrima Saputri
Identity
Name : Mrs. S
Gender :
Age : 28 Years old
Occupation : Housewife
Adress : Bagan siapi-api
Status : Married
Chief complain
Lump on the right breast since 3
months before came to the
hospital.
History of Present Illness
2 years ago before came to the hospital, patient felt a
lump on her right breast :
- In the earlier, the lump could be palpated as big as
quail eggs, edges was clear and could be moved.
- the lump felt springy
- pain (-)
- discharge from nipple (-),
- itchiness around the nipple (-)
- fever (-)
1 years ago before came to the hospital, patient felt
again a lump on her surgical scar on right breast :
- The lump continues to expand, could be palpated
as big as quail eggs, felt hard, edges was not clear
and could not be moved.
- pain (+)
- discharge from nipple (-),
- itchiness around the nipple (-)
- fever (-)
- no abnormalities the skin around the lump
3 month ago before came to the hospital, patient
felt a lump on her surgical scar on right breast :
- The lump continues to expand, could be
palpated as big as tomato, felt hard, edges was
not clear and could not be moved.
- pain (-)
- discharge from nipple (-),
- itchiness around the nipple (-)
- fever (-)
- no abnormalities the skin around the lump
The patient didnt complain of a lump in the
armpit and the other place.
The patient admitted breathless (-), chronic
cough (-), felt pain and full in the gut (-),
severe headache (-), bone and join pain (-).
Risk Factor :
Woman
28 years old
Familiy history No body family had cancer.
The age of having first child was 22 years
old.
Has 2 kids and no lactation for both of them.
Got menarche when she was 12 years old.
Used injectable contraception: for 5 years .
No radiation history on the chest, no ovarium
cancer history.
Past Illness History :
(-)

Treatment of History :
2 years ago, patient came to regional
general hospital bagansiapi-api. She was
diagnosed for right breast tumors and has
been treated with surgery.
3 month ago, because felt lump again on
her right breast, patient came to the
hospital again and her oncologist doctor
been doing biopsy. Then the patient was
admitted to regional general hospital Arifin
Ahmad. started her first chemoteraphy .
Untill now, she has gotten 3 times of
chemotheraphy.
Physical Examination

General Status : mild illness


Karnofsky scale : 90
Awarness : composmantis
Vital sign :
BP : 100/80 mmHg
RR : 24 x/minutes
Pulse : 84 x/minutes
T : 37 C
Head and neck : normal limit
Chest : normal limit
Breast and armpit : localized status
Stomach : normal limit
Genitalia : normal limit
Extremity : normal limit
Lymph node : normal limit
Localized Status
Rigt breast area Left breast area
Inspection:
Changing of color skin Inspection:
(-),nipple retraction (-), Changing of color skin(-),
krusta (-), nipple discharge (-), nipple retraction (-),
dimple skin (-),
peau de orange (-), oedem (-). krusta (-),
nipple discharge (-), dimple
Palpation: skin (-), peau de orange (-)
solitery lump on the lower
lateral quadran, hard
consistency, immobile, surface Palpation:
with one lump, edges was not there is no lump, no pain.
clear, size about
8x6 cm, no pain.
v v
Lymph node
Right armpit
Inspection: no visible lump, no changing of skin
color.
Palpation: no lump.

Supraclavicula and infraclavicula


Inspection: no visible lump and changing of skin
color.
Palpation: no lump.
Working Diagnosis
Right breast tumor no extention to regional
lymph nodes suspect Ca mammae T3N0Mx
Examination Planning
Biopsy
Routine blood test and chemical blood test
Chest X-Ray
Breast and Abdominal USG
Biopsy
Breast cancer ductal invasif solid tubular
grade 3
Laboratorium
Hb : 12,03 gr%
HCT : 36,19%
WBC : 6.700 / mm3
Plt : 322.000 / mm3
TNM Classification
T: size of tumor was about 8 x 6 cm T3
N: No regional lymph node metastasis N0
M: No distant metastasis M0
Resume
History:- female 28 years old
- Lump on the right breast
- The lump continues to expand, from as big as
quail egg to as big as tomato and had pain since 3
month ago before came to the hospital, no
changing of color skin, felt hard, edges were not
clear and could not be moved.
- used the injectable contraception for 5 years.
- The patient has history of right breast
tumor
surgery
Resume
Physical examination: - Karnofsky scale 90
- There was a lump
on the lower lateral
quadran, hard
consistency, immobile, edges
was not clear, size about 8x6
cm, no pain
- no enlarged regional
lymph nodes
Final Oncology Diagnosis
Right breast cancer stadium IIB
Management
Radical mastektomy
Chemotherapy ( taxanes-doxorubicin),
Repeated every 3 weeks
Preparation before
surgical
Fasting for about 8 hours
IVFD Ringer Laktat 20 gtt/minute
THANK YOU