M/F/40yo

Chief complaint : Pain on lump on the right breast

It has been suffered since 1 week before admitted to

Pirngadi hospital. This condition starts with a lump on
the right breast with diameter as big as quail egg and
gets bigger in last 6 months. Bleeding (-), and loss of
weight + 10 kg in 3 months. No history of family who
have the same condition. History of menarche at 12
years old. Patient was married at 20 years old and had 3
childrens. Patient delivered her first child at 23 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 (-), jaundice (-). History of chemoradiation
(-).
Present State :
Awareness : Alert
BP : 110/80 mmHg
HR : 88x/i
RR : 20x/i
Temp : 36,6 °C
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 : asymmetrical,
- P : tactile fremitus equal o/t both hemithorax
- P : resonance o/t both hemithorax
- A : vesicular o/t both hemithorax
Localized state:
• (L) Breast : no abnormality was found
• (R) Breast:
L : mass at right breast, peau d’orange (+), ulcer (-),
satellite nodule (-)
P : mass (+) at right breast, size 9,8 x 7,5 x 5,2 cm ,
solid consistency, iregular contour, mobile, clear
border, pain (+)
Localized state:
• (R) Clavicle region :
Multiple lymph node (+) o/t supraclavicle and
infraclavicle, mobile, conglumeration, pain (+)
• (R) Axilla :
Multiple lymph node palpable on the right axilla, solid
consistency, conglumeration, iregular contour,
mobile, clear border, pain (+).
• Abdomen :
– I : symetric
– P: smooth and flat; spleen and liver not palpable
– P : tympani
– A: peristaltic (+) Normal
Clinical Picture
Laboratorium finding:
Hb / Hct / WBC / PLT : 10.3/ 32/ 9,380/ 433,000
Na / K / Cl : 136/ 4.2/ 93
Random Blood Glucose : 112
Chest X-ray
Working Diagnose :
(R) Breast neoplasm sugg malignant cT4bN3cM0
Treatment at ER :
_ Analgesic oral
– patient was ambulatory