A/F/59yo

72.14.53
Chief complaint : Lump on the right breast
It has been suffered since 1 year ago with diameter as big
as marble and gets bigger in last 3 months. Pain was felt on
the right breast since 2 days ago. Bleeding (+) on the right
breast, and loss of weight + 10 kg in 3 months. No history of
family who have the same condition. Patient occasionally
requires assistance in daily activity, but able to care most of
her needs.
History of menarche at 13 years old. Patient was married at
25 years old and had 4 childrens. Patient delivered her first
child at 28 years old. History of breast feeding (+) for 6
months each children. Used hormonal contraception (-).
History of shortness of breath (-), chronic headache (-),
chronic back pain (-), limb paralysis (-). History of traditional
medicine (+).
Present State :
Awareness : Alert
BP : 110/80 mmHg
HR : 88x/i
RR : 20x/i
Temp : 36,6 °C
Karnofsky score : 80
VAS :3
Generalized state :
Head : no abnormality was found
Neck : no abnormality was found
Chest : localized state
Axilla : localized state
Abdomen : no abnormality was found
Extremity : no abnormality was found
Genitalia : female, no abnormality was found
Localized state:
• Chest
- I : asymmetrical
- P : tactile fremitus equal o/t both hemithorax
- P : resonance o/t both hemithorax
- A : vesicular o/t both hemithorax
Localized state:
(R) Breast:
L : mass at right breast, peau
d’orange (+), ulcer (+),
bleeding (+), satellite
nodule (+)
P : mass (+) at right breast,
size 12x8x4 cm, solid
consistency, irregular
contour, fixated (+),
unclear border, pain (+)
(L) Breast:
No abnormality was found
Localized state :
Axilla:
• (R) : Single lymph node palpable on the left axilla,
with diameter 2x2 cm, mobile, solid consistency
• (L) : no abnormality was found

Infraclavicle & supraclavicle : No palpable nodes

• Abdomen :
–I : symetric
–P: smooth and flat; spleen and liver not palpable
–P : tympani
–A: peristaltic (+) Normal
Laboratorium finding :
Hb / Hct / WBC / PLT : 12,3/ 33/ 13.450/ 571,000
Na / K / Cl : 141/ 3,3/ 99
Random Blood Glucose : 119
Chest X-ray
Working Diagnose :
(R) Breast Neoplasm Sugg Malignant cT4bN1M0
Treatment at ER :
• Pain Management
– Analgetic Oral  Paracetamol 3x1000mg
• Patient was ambulatory

– Plan
– Staging in the outpatient
– 1. USG Liver
– 2. Incisional biopsy