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S/F/47yo

77.99.94
S, Female, 47 years old. Bataknese, Live in P.Siantar,
North Sumatera, married, menarche at age 15 yo.
Chief complaint : Ulcer on the right breast
It has been suffered since 6 months before admitted to Adam
Malik Hospital. The pain was felt constantly. It started as a
lump with size of an egg and got bigger progressively in the
last 1 year. Patient has never been treated before. Patient can
do normal activity, but need some effort.
History of menarche at 15 years old. Patient was married at 26
years old and had 3 childrens. Patient delivered her first child
at the age of 28. History of breastfeeding (+) for less than 6
months each children. History of using oral hormonal
contraception (+). History of weight loss + 10 kg in 4 months.
History of chronic headache (-), chronic back pain (-), limb
paralysis (-), jaundice (-), frequent coughing (-).
• History family who has the same condition (-).
History of using traditional medication (-). History of
previous breast surgery (-). History of benign breast
disease (-). History of smoking (-). History of alcohol
consumption (-).
Present State

Awareness : Alert
BP : 110/70 mmHg
HR : 98 bpm
RR : 20 times/min
Temp : 37,2 °C
Karnofsky score : 80
VAS :4
Generalized state

Head : no abnormality was found


Neck : no abnormality was found
Axilla : localized state
Chest : localized state
Abdomen : no abnormality was found
Genitalia : female, no abnormality was found
Extremity : no abnormality was found
Localized State

Chest
I : Asymmetrical,ulcer o/t (R) breast (+)
P : tactile fremitus o/t both hemithorax
P : resonance o/t both hemithorax
A : vesicular o/t both hemithorax
Localized state:
• (L) Breast : no abnormality was found
• (R) Breast :
– I: Right breast is bigger in size
compare to the left breast. Mass on all
quadran of right breast, skin colour o/t
breast was different from surrounding
tissue. Ulcer o/t right breast, irregular
edge, erythema (+), p’eau d’orange (-),
skin dimpling (-), satelite nodule (+),
active bleeding (-).
– P: Mass o/t right breast, size 10,3 x 6 x
4,5 cm, solid consistency, irregular
contour, mobile, unclear border.
• (R) Axilla region
- single lymph node palpable, with size 1x1cm, solid
consistency, conglomeration (-), irregular contour,
mobile, pain (+)

• (R) clavicle region


- No palpable node

• (L) Axilla and clavicle region


- No palpable node
Laboratory finding:
Hb / Hct / WBC / PLT : 11,1 / 18 / 11.500 / 266.000
Na/K/CL : 131/3.1/102
Random Blood Glucose : 97
Chest X-Ray
Working Diagnosis :
(R) Breast Neoplasm Sugg. Malignant cT4bN1M0
Treatment at ER :
- Analgesic oral Paracetamol 1000 mg

Plan:
- Ambulatory
- Staging and Incisional biopsy from outpatient
department

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