MORNING

REPORT
CA. MAMMAE
 Name : Mrs. R
Age : 49 years old
Sex : female
IDENTITY Address
Admmision
: Anawoi Street
: November, 29th 2018 (09.10)

Doctor in charge :
dr. Mochammad Saiful, Sp.B (K) Onk
 • Chief complain : wound In breast

• Anamnesis : Patient complaint about her breast, it’s pain

and has a wound, firstly this condition happened when 1
years ago, in the right breast growth the lump like a bean.
And then 5 month ago appeared a wound at the right
breast.

History
• Patient
Patient use herbal for her treatment but the wound is more
worst.

Taking
3
 Blood
Pulse
Pressure

PHYSICAL 170/100 mmHg 100 x /minute

EXAMINATION Regular
strong
The patient was conscious with moderate ill
Temperature
Respiration
Rate

36𝑜 𝐶
28x/minute
Iregular 4
 GENERAL STATUS
Thorax :
I : Not simmetry, lump at right breast
P : tenderness (+) in right breast,
P : Sonor (+/+) Head : Normally
A : Vesiculer (+/+) Face : Normally
Eyes : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Mammae Region : Neck : Normally
I : lump and consistency solid, Chest : Normally
hard and iregular surface. Peau Extremity
Superior : Normally
d’orange Inferior : Normally
P : tenderness (+) in right breast,
P : Sonor (+/+)
A : Vesiculer (+/+)

5
CLINICAL
FINDING

6
 Ca. Mamma
DIAGNOSIS
HYPERTENSION GRADE II

7
 • Blood Routine
Planning
• USG Mammae
MANAGEMENT
O2 ANALGESIK
IVFD H2 RA

Consul a Onkology surgeon

9
THANK YOU
COASS BEDAH FAKULTAS KEDOKTERAN
UNIVERSITAS HALU OLEO