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Case Personal CA MAMMAE

Case Personal CA MAMMAE

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Published by: Adhitya Soewadji Martodimuljo on May 02, 2012
Copyright:Attribution Non-commercial

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05/09/2013

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Compiled by
:
 Aria Adhitya S1102003035
Mentor:Dr. H. Herry Setya Yudha Utama, Sp.B, MHKes, FInaCs
 
SURGERY DEPARTMENT RSUD ARJAWINANGUN  PERIOD 30 January 
7 April 2012
PERSONALCASE
 
CARCINOMA MAMMAE
 
 
2
BAB ICa Mamae case
STATUS OF PATIENTS :
A. PATIENT IDENTITY
Name : Mrs. S LAge : 42 yearsSex : FemaleJob : HousewifeReligion : MoslemAddress : Arjawinangun
B. ANAMNESA
 
Main complaint :Lump in left breast
 
Additional complaints : -
 
History of present illness :
Mrs N, 42 years old, comes to Arjawinangun Hospital complains there’s a lamp in
left breast that she had since 4 years ago. At first, it is a mobile sized, but in several mounth
it becomes bigger than before. On palpable, it feels pain. There’s no discharg
e comes fromnipple, It is immobile / fixed, There is no lumps on the right breast. Mrs S L said that this
lump doesn’t affect patient’s breath. Patient said that her mother had the same illness.
 
Past medical history :
There’s no same medical history in
the past
 
3
 
Family history of disease:Her mother had the same illness.
C. PHYSICAL EXAMINATION
 
Status PresentGeneral condition : Moderate ill appearanceConsciousness : compost mentisvital sign :Blood pressure : 120/80 mmHgPulse : 80x/mntrespiratory rate : 24x/mnttemperature : 36.6 °C
 
Generalis StatusSkin : Skin color is black, no jaundice, enough turgorHead : Symmetrical, normochepal, equitable distribution of hairEyes : conjunctiva anemis (- / -), sclera jaundice (- / -), light reflex (+ / +) normalNose : Deviation of the septum (-), discharge (-)Ears : symmetrical, cerumen right-left (+)Mouth and throat :Lips : not dry, and no cyanosisTonsils : T1/T1Pharing : not hiperemisNeck : Not deviasi, No enlargement of lymph glandsThoracic :Inspection : hemithorak symmetrical right and left in a state of static and dynamicPalpation : tactile fremitus symmetrical right and leftPercussion : sonor to the hemithorax

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