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    Carcinoma of Breast Case Sheet

    Uploaded by

    Hanisha Vasireddy
    This document contains a case sheet for carcinoma of the breast, outlining the information to be collected from a patient presenting with a breast lump or pain, including their history of present illness, past medical history, family history, social history, examination findings of the breasts, lymph nodes, and systemic review of symptoms. A provisional diagnosis of carcinoma of the right or left breast with a TNM stage is to be given, along with differential diagnoses to consider.

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    © All Rights Reserved
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    Carcinoma of Breast Case Sheet

    Uploaded by

    Hanisha Vasireddy
    538 views7 pages
    This document contains a case sheet for carcinoma of the breast, outlining the information to be collected from a patient presenting with a breast lump or pain, including their history of present illness, past medical history, family history, social history, examination findings of the breasts, lymph nodes, and systemic review of symptoms. A provisional diagnosis of carcinoma of the right or left breast with a TNM stage is to be given, along with differential diagnoses to consider.

    Original Description:

    Clinical case taking

    Original Title

    CARCINOMA OF BREAST CASE SHEET

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    This document contains a case sheet for carcinoma of the breast, outlining the information to be collected from a patient presenting with a breast lump or pain, including their history of present illness, past medical history, family history, social history, examination findings of the breasts, lymph nodes, and systemic review of symptoms. A provisional diagnosis of carcinoma of the right or left breast with a TNM stage is to be given, along with differential diagnoses to consider.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    538 views7 pages

    Carcinoma of Breast Case Sheet

    Uploaded by

    Hanisha Vasireddy
    This document contains a case sheet for carcinoma of the breast, outlining the information to be collected from a patient presenting with a breast lump or pain, including their history of present illness, past medical history, family history, social history, examination findings of the breasts, lymph nodes, and systemic review of symptoms. A provisional diagnosis of carcinoma of the right or left breast with a TNM stage is to be given, along with differential diagnoses to consider.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7

    SURGERY

    CARCINOMA OF BREAST CASE SHEET


    NAME OF THE PATIENT :

    SEX :

    AGE:

    OCCUPATION :

    ADDRESS :

    CHIEF COMPLAINT:

    Patient presented with chief complaint of lump in the breast since__ or pain in the breast since___or
    nipple retraction

    H/O PRESENT ILLNESS :

    The present history started as the patient noticed a small lump in the right or left breast while bathing

    duration of the swelling ,

    exact size at the time of onset,

    exact site at the time of onset,

    progression,

    sudden increase in size of the swelling or sudden decrease in size of the swelling,

    h/o trauma

    h/o pain--duration,site,nature,radiating or not,aggreviating and relieving factors,

    h/o discharge from nipple

    h/o fever , cough , breathlessness ( to rule out metastasis to lungs)


    h/o loss of weight (malignant tumors )

    h/o of loss of appetite

    h/o bony pain ,back pain (metastasis to bones)

    any other swellings

    PAST HISTORY :

    similar complaint in the past

    h/o HTN

    h/o DIABETIS MELLITUS

    h/o TB,

    h/o asthma ,

    h/o previous exposure to radiation

    h/o previous surgeries

    MARITAL HISTORY : as carcinoma breast is more common in nulliparous women

    DRUG HISTORY : h/o intake of oral contraceptives

    FAMILY HISTORY : carcinoma of the breast and thyroid in the family

    PERSONAL HISTORY :

    h/o smoking

    h/o alcholism,

    sleep disturbances

    bowel and bladder disturbances ,


    GENERAL EXAMINATION :

    palor, icterus , cyanosis , clubbing , lymphadenopathy ,edema

    VITALS :

    pulse rate

    temperature ,

    blood pressure ,

    respiratory rate

    INSPECTION :

    examining the patient in sitting position and arms by the side with breast exposed upto waist

    examination of both the breasts:

    position(same level or at different levels),

    shape(hemispherical or not)

    size

    dimpling

    puckering (infiltration into ligaments of cooper)

    mnemonic : remember the sequence—LUMP—NIPPLE—AREOLA—AXILLA-—ARM & THORAX---


    SUPRACLAVICULAR FOSSA

    RIGHT BREAST

    for lump – Upper outer Upper inner

    draw the diagram in which quadrant the lump is located


    Lower outer Lower inner
    (upper & outer quadrant is most common )

    number ,

    situation ,

    size ,

    shape

    borders -well defined or not

    extension ,

    skin over the swelling –peudeau orange appearance or ulcer or red or shiny or any other
    changes ,

    surface of the swelling(smooth or nodular),

    any engorged veins

    any visible pulsations,

    NIPPLE –

    present on the both sides or not

    single or multiple

    size

    surface (for cracks and fissures)

    discharge

    drawn towards lump or not

    AREOLA –

    Normal or deformed

    Color – dark or not

    Size
    Surface

    AXILLA – visible swellings or not (lymph node metastasis)

    ARM & THORAX –

    normal or not

    any cutaneous nodules

    SUPRACLAVICULAR FOSSA:

    Check for enlargement of supraclavicular nodes(indicates the advanced stage of


    ca. of breast
    Raising the arms above the head – check for lower mammary surfaces of both breasts at same
    level or not)

    Check for shoulder movements

    PALPATION :
    Examination of breast in sitting position with arms by the side

    Normal breast is to be palpated first and next the effected breast

    Effected breast examination :

    temperature over the swelling

    tenderness over the swelling ,

    all inspectory findings are confirmed ,

    mobility ,

    consistency

    fixity to the skin –skin pinchable or not

    swelling moves along with breast or not (malignant tumor) (whereas fibroadenoma moves
    with in the breast)

    fixity to muscles –
    pectoralis major –ask the patient to put her hands on her hip and now move the tumor
    perpendicular to the plane of attachment )

    serratus anterior –ask the patient to push hands against the wall and now move the lump

    NIPPLE :

    Any swelling beneath the nipple or not

    Can be everted or not

    Any discharge on pressure

    PERKUSSION :

    Not much significant here

    AUSCAULTATION :

    Any bruit heard or not

    Systemic examination –

    CVS,

    RESPIRATORY,

    ABDOMINAL(for hepatomegaly or spleenomegaly

    CNS

    EXAMINATION OF REGIONAL LYMPH NODES :

    PROVISIONAL DIAGNOSIS :
    Probably this is a case of carcinoma of right or left breast and mention the TNM staging

    DIFFERENTIAL DIAGNOSIS :

    Giant fibroadenoma
    Chronic mastitis

    Recurrent breast abscess

    Tuberculosis of breast

    NOTE : THESE CASE SHEETS MAY DIFFER FROM ONE PROFESSOR TO ANOTHER

    THANK YOU

    FOR ANY CORRECTIONS & SUGGESTIONS :

    : bandaruprudhvi@gmail.com or 8121314003

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