MRS. D , 37 yo.

Carcinoma Mammae Dekstra

 Identity
Name : Mrs. S
Age : 37 y.o
Occupation :-
Address : Teluk Gong
Religion : Moslem
Date of admission : 20-07-2017(2 pm)
 History of recent complaints
Chief complaints : Multiple mass on the right breast
Additional complaints : Pain on the right breast
 History of recent complaints
Patient came with mass on the right breast and pain since 7
month ago followed by persistent pain 3 days ago (VAS 3).
Tenderness (+), discharge (-), bleeding (-). Patient also reported
that she has been diagnosed with carcinoma of the right breast
since february but was too afraid to proceed to the surgery
room.
 History of past illness and habits
Allergy : drugs (-), food (-) others (-)
Medication : diabetes mellitus medication (patient forget the name, consumed
daily, once a day)
Past illness : Hypertension (-), diabetes mellitus (+), heart disease (-), liver disease (-),
asthma (-), TB (-)
Family illness : cancer/malignancy (-)
Habits : smoking (-) , alcohol consumption (-),
 Physical examination
Arousal : compos mentis (GCS 15)
Vital sign : 120 / 80 mmHg, 80 x/minute, 22 x/minute, 36C (axilla)
Head to toe examination
Head : normocephaly, other lesions (-)
ENT : mucosa within normal limit, rhinorrhea (-), nasal obstruction (-),
dysphagia (-), odynophagia (-), teeth complete within normal limit
Thorax : simetrical expansion, lesion (-), sonor +/+, vesicular +/+, wheezing -/-,
rhonki -/-
Abdomen : lesion/mass (-), pressure pain (-), bowel sound 10x/minute
Extrimity : motoric 5/5/5/5, sensoric function normal, CRT <2 seconds
Genitalia : within normal limit
 Status Localis

Multiple mass found a/r mammae dekstra with hard

consistency, regular edge. immobile to skin and
mobile to underlying tissue, tenderness (+),the
biggest size around 1,5 cm x 1 cm, no fluid thrill,
discharge or pulsatility. Total of the palpable mass
were 4 with axillary right node enlargement.
USG 14/02
 Diagnosis
Working diagnosis :
Malignant multiple right breast mass

Differential diagnosis :
Multiple cystic on the right breast mass
 Initial Workup
Chest X ray 18/07
Normal no metastases
Laboratory check up 18/07
Complete blood count, Blood Glucose, Kidney Function
All within normal limits
 Management plan
Inpatient care
Operative management (Modified Radical Mastectomy):
21/07/2017
 Modified Radical Mastectomy
Indication: Removing the entire breast including the skin,a reola, nipple, and
most axillary lymph nodes but the pectoralis major muscle is spared.
Technique:
Patient in supine position and being generalized anesthesia
Drapping was done to minimalize area of operation followed by antiseptic procedure
Incision was done
Identification of mass
Mass was excisised and taken to pathologic anatomy for further analysis
Wound of incision is then be sewed back
Operation finished
Complication:
Hematoma, infection, chronic seroma, skin necrosis.
 Care before the operation
IVFD RL 1500cc/24 hr Diet: no specific diet
IV drugs:
Ceftriaxone 1 gr IV with skin test (1 hour before the operation)

Observe for vital sign

 Care after of operation
IVFD RL 1500cc/24 hr Diet: no specific diet
IV drugs:
Ceftriaxone 1 gr 2 IV
Ketorolak 30 mg x 2 IV
Kallnek 500 mg x 3 IV
Pantoprazole 40 mg x 2 IV Drip
Observe for vital sign
 Patient follow up
Date 21/07/2017(POD 0)

Subjective Tenderness on operation site vas 3(+), nausea (-),

headache (-), sleep well, drink 1 glass of water,
havent eaten anything and pee yet since the
operation, Flatus +.
Objective a/r mammae dekstra post operation site was
covered with drain attachment. Production of the
drain + and
Assessment Post modified radical mastectomy on the right
breast POD 1
Planning If condition is stable, patient may be discharged and
followed up 1 week after post operation
Patient is also educated how to do wound toilet
 Discharge criteria
Normal vital sign
Minimal bleeding in operation site < 5 cc
 Outpatient care
Take home medications : -

Control dates : 1 week after post operation