Breast Ca

54/F LJP

Chief Complaint: Breast Mass

History:
• 2 months PTA, patient palpated a small non-painful mass about 2cm in largest diameter,
firm, non-moveable. Consult done with a local clinic and was advised biopsy vs excision
of the mass. Patient was undecided at that time hence did not push thru with the
procedure. No medications taken.
• 1 month PTA, patient noted an increase in the size of mass now about 3-4cm led to
consult at another physician. This time, she was already decided and opted to undergo
excision (partial mastectomy) under general anesthesia. Specimen was sent for biopsy
yielded Invasive Ductal Carcinoma.
• Patient was then advised surgical intervention to which patient agreed and was then
admitted.

PMH – hypertensive, non-diabetic

FH – HTN, no DM, no history of cancer

PE
Awake, afebrile
With a visible postop scar at the right breast spanning from the outer lower to the inner lower
quadrant, no nipple inversion, no peau du orange, no erythema, no palpable masses, with a
palpable lymph node at the right axillary region, non tender, moveable
BP 120/90
PR 72
RR 19

Laboratories/Imaging

COVID-19 RT PCR Test - Negative

Biopsy: Invasive Ductal Carcinoma with 80% intraductal carcinoma (comedocarcinoma); tumor
size 2.8cm in greatest dimension, positive for tumor: lymphovascular spaces

Liver ultrasound – unremarkable

Chest x-ray – unremarkable

12L ECG - unremarkable

CBC
Hgb 11.7
Hct 0.34
Wbc 6.6
Seg 0.55
Lympho 0.40
Mono 0.03
Eosino 0.02
Plt 250

Na 137.80
K 3.64

Crea 0.75

Admitting diagnosis – Invasive Ductal Carcinoma, right s/p partial mastectomy Clinical Stage
T2N1M0
For Modified Radical Mastectomy