4. History of Present Illness
2 YEARS PTC
(+) 2X2CM MASS PALPATED ON THE RIGHT PERIUMBILICAL
AREA ,FIRM,ROUND,MOVABLE,NON TENDER
(-)ABDOMINAL PAIN (-)WEIGHT LOSS (-) VOMITING (-)FEVER
WT: 50 KG
1 YEAR PTC
(+) 4X4CM MASS PALPATED ON THE RIGHT PERIUMBILICAL
AREA ,FIRM,ROUND,MOVABLE,NON TENDER
(+)3/10 COLICKY ABDOMINAL PAIN (+)VOMITING (+)WEIGHT LOSS
(+) DYSPHAGIA ON SOLID FOODS (-)FEVER
WT: 44 KG
5. History of Present Illness
- Sought consult in Qatar
- EGD was done: gastric mass involving body and antrum
- Colonoscopy: infiltration of gastric malignancy in the ascending
colon
- CT scan was done : gastric mass with local infiltration and
peritoneal disease T4N3M1. Adnexal mass with dermoid.Liver
cyst for MRI to rule out avascular mets.Right ureteric infiltration
with ureteric hydroureteronephrosis
- Biopsy done: (+) cytokeratin staining AE1/AE3.
6. History of Present Illness
4 MONTHS PTC
PERSISTENCE OF THE SYMPTOMS PROMPTED CONSULT.
7. Past Medical History
(-) Hypertension
(-) Diabetes
(-)ALLERGIES
Family History
(+) Hypertension
(-) Diabetes
(-) Thyroid disease
(-) Bronchial asthma
(-) Cancer
Personal-Social
History
Non-smoker
Non-alcoholic beverage
drinker
Denies Illicit drug use
Domestic Helper
8. OB-Gynecologic History
OB Score: G2P2 (2002)
LMP: December 17, 2020
M: 13 years old
I: Regular, monthly
D: 5 days
A: 3 moderately soaked
pads per day
S: (-) Dysmenorrhea
9. Physical Examination
BREASTS
Symmetrical
RIGHT
Noted a 3cm wound scar with
granulation tissue, non tender non
inflammation. No palpable mass
noted, No palpable axillary lymph
nodes. No nipple retraction or nipple
discharge
11. Mammogram: 10/14/20 (Non Institutional)
Mediolateral oblique and craniocaudal views of the breast.
History of Lumpectomy, right upper inner quadrant
Findings:
- There is heterogeneously dense fibroglandular density
- No suspicious discrete masses, abnormal microcalcifications,
architectural distortion, skin thickening or other indirect evidence of
malignancy identified on the left
- There is architectural distortion in the right upper inner quadrant
corresponding with the surgical site however another architectural
distortion is seen in the right upper outer quadrant
12. Mammogram: 10/14/20 (Non Institutional)
Unenlarged lymph nodes are noted in both axillary regions.
IMPRESSION:
BI RADS 0 – need additional evaluation
13. CT SCAN of CHEST and UPPER ABDOMEN:
10/30/20
CHEST:
Findings
Examination shows minimal fibrotic densities in the apical
segment of the right upper lobe and apicoposterior segment of
the left upper lobe
Short linear opacities are seen in the medial segment of the
right middle lobe and lateral basal segment of the left lower lobe
No evident ground glass densities, consolidation or nodules in
both lungs
14. CT SCAN of CHEST and UPPER ABDOMEN:
10/30/20
Trachea and proximal airways are patent and clear
There are no enlarged lymph nodes in the hilar, mediastinal and
supraclavicular regions
The heart and great vessels appear normal in size and
configuration
There is no evidence of pleural and pericardial effusion
There is no irregularly shaped soft tissue density in the upper
inner quadrant of the right breast with overlying skin thickening.
The left breast is unremarkable.
15. CT SCAN of CHEST and UPPER ABDOMEN:
10/30/20
Osseous structures show no evidence of disease. No gross lytic
or blastic lesions
IMPRESSION
Minimal biapical fibrosis
Subsegmental atelectasis or fibrosis, right middle lobe and left lower
lobe
Irregular-shaped soft tissue density in the upper inner quadrant of the
right breast with overlying skin thickening, likely post surgical changes.
Correlation with mammogram and ultrasound is suggested
16. CT SCAN of CHEST and UPPER ABDOMEN:
10/30/20
ABDOMEN
The liver is normal in size and configuration with smooth marginal
contour. No evident parenchymal abnormalities are detected.
The intrahepatic and extrahepatic bile ducts are not dilated.
The gallbladder surgically absent. The gallbladder bed is
unremarkable
Pancreas, spleen and both adrenal glands are unremarkable
Stomach and intestinal segments are collapsed precluding
optimal evaluation. No demonstrable abnormality is appreciated.
The appendix is unremarkable
17. CT SCAN of CHEST and UPPER ABDOMEN:
10/30/20
ABDOMEN
There are no enlarged intra – and retroperitoneal lymph node. No
ascites is seen
There is a small calcific focus in the right femoral head measuring 0.8
cm likely representing a bone island. Osseous structures appear intact.
No gross lytic or blastic lesions
IMPRESSION:
No evidence of metastasis
Surgically absent gallbladder
22. Plan
● RT PCR
● Modified Radical Mastectomy with Axillary node Dissection
● Adjuvant Chemotherapy
Editor's Notes
Lim, Jovie
09175079174
History of Present Illness:
2 months ptc noted palpable mass at right breast, around 1.5 x1.5 cm non tender, no discharge noted. No nipple retraction, no erythema
Sought consult at local clinic and patient was advised for removal of breast mass.
Patient underwent lumpectomy and biopsy of the mass was done revealing invasive ductal carcinoma.
Patient then sought consult and was advised for imaging of which mammogram was performed. Noted fibroglandular density.
Sought consult for further management
History of Present Illness:
2 months ptc noted palpable mass at right breast, around 1.5 x1.5 cm non tender, no discharge noted. No nipple retraction, no erythema
Sought consult at local clinic and patient was advised for removal of breast mass.
Patient underwent lumpectomy and biopsy of the mass was done revealing invasive ductal carcinoma.
Patient then sought consult and was advised for imaging of which mammogram was performed. Noted fibroglandular density.
Sought consult for further management
