R/F/43yo

74.71.14
Chief complaint : Ulcer on the right breast

It has been suffered since 5 months before admitted to Adam

Malik hospital. This condition starts with a lump on the right
breast since 1 year ago with diameter as big as marble and gets
bigger in last 5 months. Bleeding (-), and loss of weight + 10 kg in
3 months. No history of family who has the same condition.
Patient occasionally requires assistance in daily activity, but able
to care most of her needs. Patient is feeling weak.
History of menarche at 12 years old. Patient married at 18 years
old and had 3 children. Patient delivered her first child at 20
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 (-). History of traditional medicine (+).
Present State :
Awareness : Alert
BP : 120/80 mmHg
HR : 88x/i
RR : 23x/i
Temp : 36,6 °C
Karnofsky score : 60
VAS :4
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 : symmetrical,
- P : tactile fremitus o/t both
hemithorax
- P: resonance o/t both hemithorax
- A: vesicular o/t both hemithorax

Right Breast
- L : ulcer and mass at right breast,
retracted nipple (+), peau d’orange (+),
- P : mass at right breast, solid
consistency,irregular contour, clear
border,painless, size 12x8x4 cm,
mobile
Localized state:
• (R) Clavicle region :
node (-) o/t supraclavicle and infraclavicle
• (R) Axilla :
Single lymph node palpable on the right axilla, solid
consistency, iregular contour, mobile, clear border,
painless, diameter 2x2 cm.
Laboratorium finding:
Hb / Hct / WBC / PLT : 6.9/ 23/ 12,960/ 485,000
Na / K / Cl : 133/3.1/95
Random Blood Glucose : 96
Chest X-ray
Working Diagnose :
(R) Breast Neoplasm Sugg Malignant cT4bN1M0
+ Anemia
Treatment at ER :
–IVFD Crystalloid
–Inj. Antibiotic
–Inj. Analgesic
–Blood Transfusion

Plan :
•Hospitalized
•Incisional biopsy
•Staging