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    Responsi Breast Cancer in English

    Uploaded by

    Rick van Dew
    This case report describes a 45-year-old woman diagnosed with grade IIIb mammarian carcinoma of the right breast. She underwent a radical mastectomy and 6 cycles of neoadjuvant chemotherapy. During her hospital stay from January 24th to 31st, she was monitored daily and experienced symptoms of headache, nausea and pain, which improved with treatment. Her vital signs remained stable and local examination showed healing of the mastectomy site with no bleeding or pus. She was discharged on the 31st in stable condition to continue chemotherapy as an outpatient.

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    © All Rights Reserved
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    Responsi Breast Cancer in English

    Uploaded by

    Rick van Dew
    19 views14 pages
    This case report describes a 45-year-old woman diagnosed with grade IIIb mammarian carcinoma of the right breast. She underwent a radical mastectomy and 6 cycles of neoadjuvant chemotherapy. During her hospital stay from January 24th to 31st, she was monitored daily and experienced symptoms of headache, nausea and pain, which improved with treatment. Her vital signs remained stable and local examination showed healing of the mastectomy site with no bleeding or pus. She was discharged on the 31st in stable condition to continue chemotherapy as an outpatient.

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    This case report describes a 45-year-old woman diagnosed with grade IIIb mammarian carcinoma of the right breast. She underwent a radical mastectomy and 6 cycles of neoadjuvant chemotherapy. During her hospital stay from January 24th to 31st, she was monitored daily and experienced symptoms of headache, nausea and pain, which improved with treatment. Her vital signs remained stable and local examination showed healing of the mastectomy site with no bleeding or pus. She was discharged on the 31st in stable condition to continue chemotherapy as an outpatient.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    19 views14 pages

    Responsi Breast Cancer in English

    Uploaded by

    Rick van Dew
    This case report describes a 45-year-old woman diagnosed with grade IIIb mammarian carcinoma of the right breast. She underwent a radical mastectomy and 6 cycles of neoadjuvant chemotherapy. During her hospital stay from January 24th to 31st, she was monitored daily and experienced symptoms of headache, nausea and pain, which improved with treatment. Her vital signs remained stable and local examination showed healing of the mastectomy site with no bleeding or pus. She was discharged on the 31st in stable condition to continue chemotherapy as an outpatient.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    of 14

    BREAST CANCER CASE REPORT 201

    4
    CASE REPORT
    Preceptor : dr. Bambang Arianto, Sp.B FINACS
    A. PATIENT IDENTITY
    Name
    Age
    Address
    MRS
    Registry number

    : Mrs. Eko Retno


    : 45 Years Old
    : Kedung Asem 102 Surabaya
    : 24th January 2014 31st January 2014
    : 666828

    B. SUBJECTIVE
    PRIMARY SURVEY
    Airway :
    Additional breath sounds (-)
    Gaps (-)
    Breathing :

    I : Normochest, symmetric, retraction (-), RR: 20x/minute


    P: Movement of the chestwalls symmetric, Krepitasi (-),
    Trachea deviasi (-), ICS widen (-)
    P : Resonant/ resonant
    A : Vesicular +/+, Ronkhi -/-, Whizing -/-

    Circulatiom : HR : 84x/mnt reguler


    Blood pressure : 120/80mmHg
    Warm akral (+,+,+,+)
    CRT < 2 detik
    Disability :
    Exposure :

    GCS : 456
    Round pupil isokor 3mm/3mm
    (-)

    SECONDARY SURVEY
    Chief complaint :
    Lump in the right breast.
    HISTORY OF PRESENT ILLNESS :
    Patient was hospitalized at RS Haji Surabaya since 24 th January 2014
    and diagnosed as breast cancer or mammarian carcinoma. Since 10
    years ago, her menstruation cycle was irregular sometimes once in six
    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    months. Her first time menstruate when she was 11 years old. Patient
    didnt have a child so she was never breast feeding. Firstly it was
    began feeling hurt at left breast and then the right breast has a lump.
    Besides lump, there was a blood, pus, and nipple erotion. Patient was

    never have any breast tumor in younger age.


    HISTORY OF PAST ILLNESS:
    Patient was diagnosed with breast cancer since 15 th august 2013 and
    resulted of FNAB at 12th September 2013 was infiltrating ductal
    carcinoma with first complaint lump in the right breast since 2 years
    ago and was found bleeding from nipple and darkness skin One and
    half month before she came to RS Haji. She has received 5 times

    chemotheraphy
    SOCIAL HISTORY : ALLERGIES HISTORY : Denied
    C. GENERAL STATUS :
    General state : Good
    Blood pressure :120/80 mmHg
    HR
    : 84 x/minute
    RR
    : 24x/ minute
    Tax
    : 37 oC
    Head/Neck : A-/I-/C-/D- enlargement lymphnode (-)
    Thorak
    I

    : Normochest, symmetric, retraction (-) mass 9x9x4 cm in the

    right breast
    P

    : Movement of the chestwalls symmetric, Krepitasi (-),deviated


    trachea (-), widened intercostals space (-)

    : Resonant/ resonant

    : Vesicular +/+, Ronkhi -/-, Wheezing -/-

    : Ictus does not seem

    : Ictus no palpable, thrill (-)

    COR

    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    P

    : heart border normal

    : S1S2 single, Gallop (-), Murmur (-)

    Abdomen
    I

    : Flat simetris

    : Soepel , tenderness (-), H/L/R no palpable,

    : Meteorismus (+)

    : bowel sounds (+) normal

    Extremity

    o Warm akral
    +
    +
    o Oedema

    +
    +

    o Cyanosis

    o CRT < 2 dtk


    D. LOCALISE STATUS

    Regio mammae dextra


    Mass 9x9x4 cm, not evaluated margin, irregular shape, attach at breast

    skin.
    Pus (+)
    Bleeding (+)
    Edema (+)
    Redness (+)
    Nipple retracted (+)

    peau dorange (+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4

    I. Laboratory Examination
    Complete Blood Count :
    Hb

    : 12,8 g/dL

    Leukosit

    : 7,360 /mm3

    Hematokrit

    : 37 %

    Trombosit

    : 339.000 /mm3

    Liver Function Test, Renal Function Test


    SGOT

    : 20 U/L

    SGPT

    : 23 U/L

    Bun

    : 7 Mg/dl

    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    Creatinin

    : 0,6 Mg/dl

    Tumor Marker :

    CEA

    : 1 ng/ml

    Ca-125

    : <4 U/ml

    Ca 15-3

    : 13,37 U/ml

    Imuno-Serologis
    HbsAg

    : -0,02 mIU/ml

    Faal Hemostasis
    PTT

    : 9,1 detik

    INR

    : 0,81

    APTT

    : 23,1 detik

    Urinal Analysis
    BJ :1,010
    pH : 6,0
    Nitrit : (-)
    Protein : (-)
    Glukosa : N
    Keton : (-)
    Urobilin : N
    Bilirubin : (-)
    Sedimen eri : 0- 1
    Leuko : 0-1
    Cylind : (-)
    Epitel : 0-1
    Bact : (-)
    Cryst silinder (-);Lain :(-)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    Foto Thorax PA 09-01-2014:
    Cor

    : Besar dan bentuk normal

    Pulmo

    : Tak tampak Kelainan

    Sinus Phrenicocostalis

    : Kanan kiri tajam

    Tulang dan soft tissue normal


    E. DIAGNOSIS
    Mammarian carcinoma grade IIIb (T4N1M0) dextra at regio central
    PLANNING THERAPY
    - Neoadjuvant chemotheraphy for 6th cycle
    F. PLANNING MONITORING
    - General state
    - Vital sign.
    - Patient complaints.

    DAILY SOAP
    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    Date
    24/1/14

    Subjective

    Objective

    Headache

    General
    state:
    enough
    VS:
    Blood pressure :
    120/80mmHg
    HR:84x/m
    RR:24x/m
    Tax:37C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Assesment

    Planning

    Mammarian Planning diagnosis:


    carcinoma
    grade IIIb
    (T4N1M0)
    Planning therapy:
    Neoadjuvant
    chemotheraphy for
    6th cycle
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Mass 9x9x4 cm,
    not
    evaluated
    margin, irregular
    shape, appatch at
    breast skin.Pus
    (+)Bleeding
    (+)Edema
    (+)Redness
    (+)Nipple
    retracted (+)peau
    dorange (+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    25/1/14

    General
    state:
    enough

    Headache

    VS:
    Blood pressure :
    110/70mmHg
    HR:72x/m
    RR:24x/m
    Tax:36,2C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Mammarian Planning diagnosis:


    carcinoma
    grade IIIb
    (T4N1M0)
    Planning therapy:
    Neoadjuvant
    chemotheraphy for
    6th cycle
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Mass 9x9x4 cm,
    not evaluated
    margin, irregular
    shape, appatch at
    breast skin.Pus
    (+)Bleeding
    (+)Edema
    (+)Redness
    (+)Nipple
    retracted (+)peau
    dorange (+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    General
    state:
    enough

    26/1/14

    VS:
    Blood pressure :
    120/80mmHg
    HR:88x/m
    RR:20x/m
    Tax:36C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Mammarian Planning diagnosis:


    carcinoma
    grade IIIb
    (T4N1M0)
    Planning therapy:
    Neoadjuvant
    chemotheraphy for
    6th cycle
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Mass 9x9x4 cm,
    not evaluated
    margin, irregular
    shape, appatch at
    breast skin.Pus
    (+)Bleeding
    (+)Edema
    (+)Redness
    (+)Nipple
    retracted (+)peau
    dorange (+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    BREAST CANCER CASE REPORT 201


    4
    27/1/14

    General
    state:
    enough
    VS:
    Blood pressure :
    120/80mmHg
    HR:84x/m
    RR:20x/m
    Tax:36,2C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Mammarian Planning diagnosis:


    carcinoma
    grade IIIb
    (T4N1M0)
    Planning therapy:
    Neoadjuvant
    chemotheraphy for
    6th cycle today
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Mass 9x9x4 cm,
    not evaluated
    margin, irregular
    shape, appatch at
    breast skin.Pus
    (+)Bleeding
    (+)Edema
    (+)Redness
    (+)Nipple
    retracted (+)peau
    dorange (+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    10

    BREAST CANCER CASE REPORT 201


    4
    28/1/14

    General
    state:
    enough

    Headache,
    nausea,
    vomit

    VS:
    Blood pressure :
    110/70mmHg
    HR:72x/m
    RR:24x/m
    Tax:36,7C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Post op
    radical
    mastectomy
    Mammarian
    carcinoma
    grade IIIb
    (T4N1M0)
    H-I

    Planning diagnosis:
    Hb
    Planning therapy:
    Infus RL 16 tpm
    Ceftriakson 2x1 g
    Ketorolac 3x10mg
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Bleeding(-)pus(-)
    bau(-)
    tenderness(+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    11

    BREAST CANCER CASE REPORT 201


    4
    29/1/14

    General
    state:
    enough

    Headache,
    pain at

    VS:
    Blood pressure :
    120/80mmHg
    HR:84x/m
    RR:32x/m
    Tax:35,4C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Post op
    radical
    mastectomy
    Mammarian
    carcinoma
    grade IIIb
    (T4N1M0)
    H-II

    Planning diagnosis:
    Hb
    Planning therapy:
    Infus RL 16 tpm
    Infuse fultrolit
    1500cc/24 jam
    Terfacef 2x1
    Ketorolac 3x1
    Sanmol 3x1
    Kalnex 3x500 mg
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Bleeding(-)pus(-)
    bau(-)
    tenderness(+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    12

    BREAST CANCER CASE REPORT 201


    4
    30/1/14

    General
    state:
    enough

    Headache

    VS:
    Blood pressure :
    110/80mmHg
    HR:88x/m
    RR:28x/m
    Tax:37C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Post op
    radical
    mastectomy
    Mammarian
    carcinoma
    grade IIIb
    (T4N1M0)
    H-III

    Planning diagnosis:
    Planning therapy:
    Cefixim 2x100 po
    Asam mefenamat
    3x500 po
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Bleeding(-)pus(-)
    bau(-)
    tenderness(+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    13

    BREAST CANCER CASE REPORT 201


    4
    31/1/14

    General
    state:
    enough

    KRS today

    VS:
    Blood pressure :
    120/80mmHg
    HR:80x/m
    RR:20x/m
    Tax:36,3C

    Head/Neck:
    A/I/C/D (-)

    Thorax:
    cor/pulmo:
    normal

    Abdomen:flat
    , symmetric,
    tenderness (-)
    , H/L/R no
    palpable,
    tympani,
    bowel sounds
    (+) N

    Ext: normal

    Post op
    radical
    mastectomy
    Mammarian
    carcinoma
    grade IIIb
    (T4N1M0)
    H-IV

    Planning diagnosis:
    Planning therapy:
    Cefixim 2x100 po
    Asam mefenamat
    3x500 po
    Planning monitoring
    :
    General state
    Vital sign
    Complaints

    Status lokalis:
    Regio mammae
    dextra
    Bleeding(-)pus(-)
    bau(-)
    tenderness(+)

    UNIVERSITY OF MUHAMMADIYAH MALANG

    14

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