A/F/40yo

78.74.93
A, Female, 40 years old, Batakness, live in Tebing Tinggi, North
Sumatera, Married.
Chief complaint : Pain on the left breast
It has been suffered since 2 days before admitted to H. Adam Malik
hospital. Pain was felt intermittently and decreased after taking
painkillers . Pain was not related with menstruation cycles. The pain
got worsen especially at night. There was an ulcer on her left breast
since 2 months ago, that started with a lump since 1 year with diameter
as big as marble and got bigger gradually. Bleeding (+). nipple discharge,
History of loss of weight + 10 kg in 3 months. Patient was able to take
care for herself but unable to do active work.
History of menarche at 12 years old. Patient was married at 18 years old
and had 4 children. Patient delivered her first child at 19 years old.
History of breastfeeding (+) for 6 months each children. No history of
using contraception. History of shortness of breath (-), chronic headache
(-), chronic back pain (-), limb paralysis (-). Patient treated her condition
with traditional medicine. No history of chemotherapy. No history of
family who have the same condition.
 Present State :
Awareness : Alert
BP : 110/70 mmHg
HR : 90x/i
RR : 22x/i
Temp : 36,7 °C
Karnofsky score : 70
VAS :4
BW : 50 kg
 Generalized state :
Head : no abnormality was found
Neck : no abnormality was found
Chest : localized state
Abdomen : no abnormality was found
Extremities : no abnormality was found
Genitalia : female, no abnormality was found
Extremity : no abnormality was found
 Localized state
• Chest
-. I : Asymmetrical
-. P : tactile fremitus equal o/t both Hemitorax
-. P : resonance o/t both hemithorax
-. A : vesicular o/t both hemitorax
Localized state:
• (R) Breast : No Abnormality
was found
• (L) Breast :
– I : Asymetrical, ulcer (+),
irregular border, peau de orange
(-), edema (+), erythema (+),
active bleeding (+), satellite
nodule (-), skin dimpling (-).
- P : mass (+) on the whole
quadrant, solid consitency
irreguler contour, mobile,
unclear border, tenderness (+),
sized 15x10x8 cm, nipple
discharge (-).
 Localized state ;
(L) Clavicle region :
Node (-) o/t supraclavicle and infraclavicle

(L) Axilla region :

Single lymph node palpable on the right axilla, solid
consistency, iregular contour, mobile, clear border,
painless, diameter 2 cm.

(R ) Clavicle and (R) Axilla region in normal limit

 Laboratorium Finding:
Hb / Hct / WBC / PLT : 10,8/ 15/ 9,250/ 324,000
Na / K / Cl : 125/ 3,7/ 105
Random Blood Glucose: 121
Chest X-ray
 Working Diagnosis :
(L) Breast Neoplasm Sugg. Malignant cT4bN1M0 +
Hiponatremia
 Treatment at ER :
• IVFD RL 20 gtt/i
• Paracetamol 3x1000mg
• Sodium Substitution
- (∆Na x BB x 0.6) + Maintenance (2Meq/Kgbb)
- (360) + 120 = 480 Meq  Nacl 3% (7drops/min) + Nacl
0.9% (20drops/min)

Plan :
Hospitalized
Incisional Biopsy and Staging