Surgery long case presentation on Breast cancer for mbbs 4th year students.

1. CLINICAL CASE PRESENTATION
Dr. Kishan Rao B

2. Patient Particulars
• Name - Mrs. X
• Age - 55 years
• Gender - Female
• Address - Ansari nagar, New Delhi, 1100608
• Educational status - Higher secondary
• Occupation - Home maker
• Date of Admission - 13/04/2020
• Date of Examination - 13/04/2020

3. Chief Complaints
• Lump in left breast for 5 months
• Retraction of left nipple for 1 month
• Discharge from left nipple for 10 days

4. History of Presenting Complaints
• Lump in left breast
- for 5 months
- first noticed while bathing
- insidious in onset
- initially about 2*2cm
progressed to 3*3cm
- no associated pain

5. • Retraction of left nipple
- for 1 month
• Discharge from left nipple
- for 10 days
- spontaneous oozing
- blood stained

6. • No history of swelling in right breast, arm pit or
elsewhere in body
• No history of fever
• No history of trauma to breast
• No history of loss of appetite ,weight
• No history of bone pain
• No history of cough, breathlessness
• No history of jaundice
• No history of headache,vomiting,convulsions

7. Past History
• No history of similar complaints in the past
• No history suggestive of benign breast diseases
• No history of Diabetes Mellitus, Hypertension,
Bronchial Asthma, Tuberculosis, Epilepsy or other
chronic diseases.
• No history of surgery, breast biopsy.
• No history of irradiation.

8. Personal History
• Appetite - normal
• Diet - predominantly non vegetarian , oily food
• Sleep - adequate
• Bowel habits - regular
• Bladder habits - regular
• Addictions - chews betel nut, tobacco since 30 years

9. Menstrual History
• Age at menarche - 12 years
• Regular cycles of 28 ± 2 days
• Age at menopause - 51 years

10. Marital and Obstetric History
• Married at the age of 22 years
• 2 children
• Age of first pregnancy - 24 years
• Age of last child birth - 30 years
• No history of abortion
• Normal vaginal deliveries
• Breast fed each child up to 1 year of age

11. Family History
• No history of breast, ovarian, colorectal,
pancreatic, prostate cancer in family
• No history of any chronic disease in family

12. • Pedigree Chart

13. Treatment History
Initially consulted a nearby Physician ,who
referred to a Surgeon for needful
Allergy History
No drug allergy till date
Socio-Economic History
Lower Middle Class

14. Physical Examination
• Adult female
• Conscious, oriented to time , place & person
• Cooperative
• Average built (155cm)
• Obese [BMI - 31kg/m²]
• Sitting comfortably on bed while examining
• Performance score - Karnofsky Scale 80

15. General Survey
• Eyes - pallor present , no icterus
• Oral cavity - betel nut stains on teeth
• Neck - normal
• Upper limbs - normal
• Lower Limbs - normal
• Back - normal

16. • Pulse – 78 beats per minute
• Blood Pressure – 136/80 mm Hg
• Respiration – 14 cycles per minute
• Temperature – 98.8 ° F

17. Local Examination
Examination of Both Breasts :
Inspection with patient’s arms by side of the body
• Both breasts symmetrical
• Both breasts almost of equal size
• Shape - similar

18. • Nipples -
same level
left nipple retracted – circumferentially
no active discharge

19. • Areola
- normal size
- no cracks, fissure , ulcer, eczema
- no discharge
• Skin over breast – normal

20. Inspection of breasts with arms raised over
the head
- Left nipple level higher than right nipple
- No dimpling of skin

22. • On leaning forward ,breasts fall equally
on both sides
• Axilla , Supraclavicular fossa , Upper limb
- normal

23. Palpation
• No local rise of temperature
• Non tender
• Left nipple 1.5cm higher and 1 cm deviated
outwards than right nipple.
• Left nipple circumferentially retracted and could
not be corrected by pressing on base
• Areola - normal

24. • A lump of 4*4 cm palpable
- in left upper outer and lower outer quadrants,
2cm lateral to left nipple, 16cm below midclavicle
- non tender
- margins well defined , irregular
- uneven surface
- hard in consistency
- fixed to breast tissue
lump moves along with breast tissue
but not independent of breast tissue
- no tethering of skin
- not fixed to skin , muscles

25. • Contra lateral breast - normal
• Upper limbs - normal

26. Examination of Regional Lymph nodes
No palpable lymph nodes in either axilla or
in supra clavicular fossa

27. Skeletal System
No bony tenderness, evidence of fracture
Respiratory System
Bilateral vesicular breath sounds heard, no added sounds
Per abdomen
Soft, non tender, no organomegaly
Cardiovascular System
S1 S2 heard
Central Nervous System
No focal neurological deficits

28. Summary
• Post menopausal woman aged 55 years presented
with Swelling in left breast since 5 months,
Retraction of left nipple since 1 month and blood
stained discharge since 10 days
• On examination , nipple circumferentially retracted,
a 4*4 cm lump palpable in left outer upper and
lower quadrants of breast, non tender, hard in
consistency, moving with breast tissue ,without
involving skin or muscle and no palpable lymph
nodes in axilla.

29. Provisional Diagnosis
Carcinoma Left Breast in a
Post menopausal woman
Stage Ⅱ A [cT2 cN0 cM0]
4*4