T/F/45yo

78.24.86
T, Female, 45 years old, Javanese, live in Medan, North Sumatera,
Married

Chief complaint : Pain on the left breast

It has been suffered since 3 months before admitted to H. Adam Malik hospital,
but worsen in 1 week ago. Pain was felt intermittently and was not related to
menstruation cycles. There was ulcer on her left breast since 2 years ago that
started with a lump with diameter as big as marble and got bigger gradually
and pops 3 months ago. Bleeding (-). History of loss of weight + 10 kg in 4
months. Patient was able to take care for herself and able to do active work.

History of menarche at 12 years old. Patient was married at 25 years old and
has 2 children. Patient delivered her first child at 26 years old. History of
breastfeeding (-). History of hormonal contraception use (-). History of
shortness of breath (-), chronic headache (-), chronic back pain (-), limb
paralysis (-). Patient treated her condition with traditional medicine. No history
of chemotherapy. No history of family who have the same condition. History of
previous breast surgery (-), history of benign breast tumor (-). History of
smoking and alcohol consumption (-)
 Present State :
Awareness : alert
BP : 120/70 mmHg
HR : 88x/i
RR : 22x/i
Temp : 36,7 °C
Karnofsky score : 90
VAS :3
BW : 55 kg
 Generalized state :
Head : no abnormality was found
Neck : no abnormality was found
Chest : localized state
Abdomen : no abnormality was found
Extremities : no abnormality was found
Genitalia : female, no abnormality was
found
Extremity : no abnormality was found
 Localized state
• Chest
-I : Asymmetrical
-P : tactile fremitus equal o/t both Hemitorax
-P : resonance o/t both hemithorax
-A : vesicular o/t both hemitorax
Localized state: Breast

• (R) Breast : No Abnormality

was found
• (L) Breast :
– I : mass (+) on lateral inferior
quadrant, ulcer (+), irregular
border, peau de orange (-),
pus (-), active bleeding (-),
satellite nodule (-), erythema
(+), skin dimpling (-).
- P : mass (+), size 8x6x2.5cm,
solid consitency mobile,
irreguler contour, unclear
border.
 Localized State
(R) Axilla region : node (-)

(R) Clavicle : Node (-) o/t supraclavicle and infraclavicle

(L) Axilla Region : lymph nodes was palpated on the left

axilla region, fixated, solid consistency,
conglomerated, irregular contour, well
circumscribed.

(L) Clavicle : Node (-) o/t supraclavicle and infraclavicle

 Laboratorium finding:
Hb / Hct / WBC / PLT : 12,4/ 21/ 13,680/
343,000
Na / K / Cl : 136/ 5.9/ 101
Random Blood Glucose: 96
Chest X-ray
 Working Diagnosis :
(L) Breast Neoplasm Sugg. Malignant cT4bN2M0
 Treatment at ER :
• IVFD RL 20 gtt/i
• Antibiotic --> Cefadroxil 500mg/12h
• Analgesic --> Paracetamol 1.000mg/8h

Plan :
• Staging and Incisional Biopsy from Outpatient
Department