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Breast Cancer
SKDI : 2
ICD X : C50
Febrima Saputri
Identity
Name : Mrs. S
Gender :
Age : 28 Years old
Occupation : Housewife
Adress : Bagan siapi-api
Status : Married
Chief complain
Lump on the right breast since 3
months before came to the
hospital.
History of Present Illness
2 years ago before came to the hospital, patient felt a
lump on her right breast :
- In the earlier, the lump could be palpated as big as
quail eggs, edges was clear and could be moved.
- the lump felt springy
- pain (-)
- discharge from nipple (-),
- itchiness around the nipple (-)
- fever (-)
1 years ago before came to the hospital, patient felt
again a lump on her surgical scar on right breast :
- The lump continues to expand, could be palpated
as big as quail eggs, felt hard, edges was not clear
and could not be moved.
- pain (+)
- discharge from nipple (-),
- itchiness around the nipple (-)
- fever (-)
- no abnormalities the skin around the lump
3 month ago before came to the hospital, patient
felt a lump on her surgical scar on right breast :
- The lump continues to expand, could be
palpated as big as tomato, felt hard, edges was
not clear and could not be moved.
- pain (-)
- discharge from nipple (-),
- itchiness around the nipple (-)
- fever (-)
- no abnormalities the skin around the lump
The patient didnt complain of a lump in the
armpit and the other place.
The patient admitted breathless (-), chronic
cough (-), felt pain and full in the gut (-),
severe headache (-), bone and join pain (-).
Risk Factor :
Woman
28 years old
Familiy history No body family had cancer.
The age of having first child was 22 years
old.
Has 2 kids and no lactation for both of them.
Got menarche when she was 12 years old.
Used injectable contraception: for 5 years .
No radiation history on the chest, no ovarium
cancer history.
Past Illness History :
(-)
Treatment of History :
2 years ago, patient came to regional
general hospital bagansiapi-api. She was
diagnosed for right breast tumors and has
been treated with surgery.
3 month ago, because felt lump again on
her right breast, patient came to the
hospital again and her oncologist doctor
been doing biopsy. Then the patient was
admitted to regional general hospital Arifin
Ahmad. started her first chemoteraphy .
Untill now, she has gotten 3 times of
chemotheraphy.
Physical Examination