Zewditu memorial hospital

Addis Ababa, Ethiopia

Identification

Name: Gaddise roba began Age: 42 Sex: female

Occupation: Injera baker Address: Behere tsege, saris

Ethnicity: oromia Marital status: divorced

Date of admission: may29, 2012 Department: surgery Source of history: patient

Ward: bed number: 205/1 Religion: orthodox

Previous admission

None

Chief complaint

Right breast lump of 8 months duration

History of present illness

This is a 24 year old female patient who has been in a relatively good health status until
a year ago, at which time she started to notice swelling of her breasts. The swelling was
symmetrical involving both breasts and was exacerbated in times of cold temperature with no
relationship with her menstruation. Otherwise, there was no associated pain, discharge or color
change noted by the patient. The swelling got relieved in 3 to 4 days without treatment.

Eight months back from now, the patient noticed a small lump in the upper part of her
right breast which caused her pain. After finding the lump, the patient went to “yohannes
tesbel”. In about two weeks time, the lump decreased significantly for which reason she
returned home. But in the next two weeks, the lump started to enlarge. So she restarted
attending tsebel. Nonetheless, the lump was getting enlarged and had associated pain. This
time, the patient also noted swelling of her right axilla. Despite this, she did not seek medical
attention until 2 months back at which time she went to saris health care center. There, she
was given unspecified IM injections for 7 days in success and 10 P.O tablets which were red in
color and taken twice in a day. During and after finishing her medication, the patient was still
feeling pain and hence was not relieved. She then was sent to Arsho for further lab
investigations. There, a needle biopsy from her right breast and axilla was taken and she was
told to have some breast disease and was referred to Zewditu memorial hospital.

The patient has been experiencing menstrual irregularities since ten years back for
which she never sought medical care. She had her menarche by the age of 15 and her
menopause by the age of 41. The patient has been pregnancy 3 times and 3 of them were
successful. She breast fed all of her children until they aged 3. She has no history of
contraception. She has no history of smoking cigarette, alcohol intake, irradiation or trauma to
the chest. She has no history of high fat diet. She has no personal or family history of, DM, HTN,
Asthma, cardiac or breast disease, ovarian, endometrial, or colonic cancer. There is no early
sudden death in the family. She has loss of appetite and unmeasured but significant amount of
weight. She doesn’t have headache, fever, night sweat or anemia. She has no history of
jaundice. There is no color change in her urine and she doesn’t have diarrhea or constipation.
She has no bone pain, abdominal distention, alteration of mental status, confusion or
involuntary movements. She came to the hospital walking by her foot and was fully conscious.

Past illness

None

Functional inquiry (system inquiry)

HEENT

Head: no head injury, headache or dizziness

Ears: no loss of hearing, discharge or tinnitus.

Eyes: good vision, no involuntary lacrimation or photophobia.

Nose: no sinusitis, or eipstaxis.

Mouth and throat: no buccal bleeding, tonsillitis, throat pain or post nasal drip.

GLANDS: there is a mass in the right axilla, no mass in the neck or groins, no heat or cold
intolerance.

RESPIRATORY SYSTEM: no dyspnea, cough or chest pain.

CARDIOVASCULAR SYSTEM: no leg swelling, syncope, palpitation or history of hypertension.

GENITOURINARY SYSTEM: no urgency, hesitancy, dysuria, dribbling or history of STD.

GASTROINTESTINAL SYSTEM: no nausea, vomiting, jaundice or melana. Regular bowel habits.

INTEGUMENTARY SYSTEM: no change in hair color or strength. No abnormal sweating.

ALLERGY: no asthma or drug sensitivity.

LOCOMOTOR SYSTEM: no joint pain or swelling, bony deformity or decreased strength.

CENTRAL NERVOUS SYSTEM: no vertigo, abnormal body movements or loss of consciousness.

PERSONAL HISTORY

Early development: the patient was born and raised in Geda, Oromia region. She was breast fed
and spent a healthy child hood. She grew up helping her family in farming.

Education: the patient never went to school.

Work record: she has worked as a house maid for many years than she could remember and
she is now currently working as an injera baker.

Marital status: she got married by the age of 15. Her marriage came to an end 15 years ago. She
has one son who is 24 years old and two daughters whose age she doesn’t know. They are all
alive and healthy.

FAMILY HISTORY

Father and Mother: her father passed by the age of 73 due to unknown illness but her mother
is still alive and is 70 years old. She is healthy and active.

Siblings: the patient has got 4 brothers and 2 sisters all of whom are healthy.

Family disease: there is no family history of Tb, HTN, DM, Asthma or allergy.

PHYSICAL EXAMINATION

General appearance: the patient whose physical appearance looks appropriate for her stated
age is well nourished woman. She has a healthy looking face. She is not in any form of
respiratory distress. She appears to be alert and fully cooperative.

Vital signs

BP: 110/70 –left arm, in supine position.

PR: 76/min – regular and full volume. No arterial wall thickening.

RR: 20/min

T°: 36.8c° weight: 56 height: 1.60m

HEENT
Head: normal size and shape. No scar, normal hair distribution.
Ears: normal contour of pinnae, clear external ear canal.
Eyes: normal eye brows. Pink conjunctiva, non icteric sclera.
Nose: medial nasal septum, no polyp or unusual discharge.
Mouth and throat: the buccal mucosa and tongue are wet, no post nasal drip.

LYMPHATIC AND GLANDULAR SYSTEM

There are medially located palpable right axillary lymph nodes which are non matted but hard
and fixed. There are palpable non matted hard and fixed lymph nodes on the right
supraclavicular region.
Breast – Inspection
Arms at sides: there are only two breasts with two nipples. The right breasts nipple is
retracted upwards. There is redness, thickening and prominent pore over the right breast. The
right breast is enlarged significantly and has centrally retracted nipple. No rash, ulceration or
discharge. The left nipple points outward and laterally while the right one points centrally.
Arms over head; hands pressed against hips: no retraction, breast is not attached to the chest
wall.
Palpation
Left breast: soft, non tender, no nodularity, thickening or loss of elasticity of the skin.
Right breast: a mass involving the four quadrants is palpated and is hard, non tender,
measuring 14cm by 8cm in size. It has irregular shape but regular surface. There is no warmth
but redness of the overlying skin. The lump is mobile but fixed to the overlying skin. It is well
circumscribed, non pulsatile and non fluctuant. There is no discharge or ulceration.
RESPIRATORY SYSTEM

Inspection: There is no cyanosis or clubbing of the finger nails. The palms are not pale.
Breathing is of regular rate. The chest is symmetrical. There are no flaring of the ala nasi,
deformities, surgical scars, visible pulsation or dilated vessels over the chest.

Palpation: The trachea is central. There is no tenderness over the entire chest. Tactile fremitus
is normal over the entire lung field. Chest expansion is symmetrical.

Percussion: Both the right and left chest are resonant.

Auscultation: The breath sounds are vesicular over the entire lung field.

CARDIOVASCULAR SYSTEM

Arteries: BP and PR see above.

Veins: the JVP observed at an angle of 45 is 2.5cm from the angle of Louis. There are no
distended veins over the neck, chest wall, varices or phlebitis in the legs.

Precordium

Inspection: quiet Precordium. Apical impulse is visible in the left fifth interspace, medial to the
left midclavicular line.

Palpation: the point of maximal impulse is felt where it is visible. It is localized. There is no
parasternal or apical heave. There also is no thrill.

Auscultation: Both heart sounds are heard over the each valvular area. There are no added
heart sounds or murmurs.

GASTROINTESTINAL SYSTEM

Inspection: The abdomen is round, symmetrical and moves with respiration. The flanks are not
full. There are no masses over the abdomen. The umbilicus is inverted. Hernial sites are free.
No visible pulsation or peristalsis. No palmar erythema.

Palpation: The liver was not palpable below the right costal margin. The spleen and kidneys
were also not palpable.

Percussion: Shifting dullness was not present. The total vertical span of the liver along the right
midclavicular line is 10 cm.

Auscultation: The bowel sound is normo-active. There is no bruit over the liver.

GENITOURINARY SYSTEM

There is no costoverteral angle tenderness or mass. The kidneys are not palpable

INTEGUMENTARY SYSTEM

The skin is dry and warm. There is no rash purpura or ulcers. Normal hair distribution. The nails
don’t show spooning.
Locomotor System

There is no muscle tenderness or spasm. There is no bone deformity or tenderness. There is no

tenderness of the joints. There is no edema.

NERVOUS SYSTEM

Mental status: the patient is well oriented in person, place and time. She has normal speech.
She has good cognition, memory and mood.

Cranial nerves: all are functioning normally

Motor: limbs are symmetrically positioned, no spontaneous or induced fasciculation. Tone is

normal and power is grade 5.

Sensory: both superficial and deep sensations are intact.

Others: no nuchal rigidity, brudzneski’s or kernig’s sign.

Reflexes: both superficial and deep reflexes are normal and intact. No clonus.

Summary

Subjective: this is a 42 year old female patient who presented with a right breast lump of 8
months duration. It progressively enlarged to attain its size today. She has loss of appetite and
weight.

Objective: the patient has right breast lump measuring 14cm by 8cm. it is irregular in shape but
has regular surface. It is non tender and hard. It is mobile but fixed to the overlying skin, well
circumscribed, non pulsatile, non fluctuating. There is no discharge, rash or ulcer but has a peau
d’orange appearance.

List differential diagnosis

1. Breast cancer

2. Fibroadenoma
Discussion of differentials

2. Fibroadenoma:

For- Sex of the patient. Single, mobile, non-tender and size of the lump.

Against- Retraction of the nipple, hard consistency, irregularity in shape and, fixity to overlying
skin and poorly delineated lump.

Investigation: Routine laboratory investigations like CBC, urinalysis and serum electrolytes.
Diagnostic tests like ultrasonography (because below 40), mammography and FNAC should be
done. On ultrasonography and mammography, there will be a well circumscribed lesion. FNAC
of the lump can confirm the diagnosis.

1. Left Breast Cancer

For- Sex of the patient, duration and progress of the lump, single, non-tender, retraction of the
nipple, hard consistency, irregularity in shape, fixity to overlying skin and poorly delineated
lump, presence of d’orange appearance.

Against- the absence of risk factors, mobility of the lump and absence of nipple discharge.

Investigation: Routine laboratory investigations like CBC (Hb may be decreased, increased ALP
suggests bone metastasis), urinalysis and serum electrolytes. Diagnostic tests like
mammography, ultrasonography and FNAC should be done. On mammography, there will be
microcalcifications. On ultrasonography, there will be irregular walls. FNAC of the lump and
axillary lymph nodes can confirm the diagnosis. Steroid hormone receptors (ER/PR) should also
be assessed for indication of therapy.

Abdominal ultrasonography along with liver function tests are done to rule out secondaries in
the liver and ascites, bone scan for bone metastasis, chest x-ray for lung secondaries and
CT/MRI if brain secondaries.

TNM Staging: T4bN3Mx- Stage III-B Final Diagnosis : Right Breast Cancer.