BREAST CANCER CASE REPORT 201

4
CASE REPORT
Preceptor : dr. Bambang Arianto, Sp.B FINACS
A. PATIENT IDENTITY
Name
Age
Address
MRS
Registry number

: Mrs. Eko Retno

: 45 Years Old
: Kedung Asem 102 Surabaya
: 24th January 2014 31st January 2014
: 666828

B. SUBJECTIVE
PRIMARY SURVEY
Airway :
Additional breath sounds (-)
Gaps (-)
Breathing :

I : Normochest, symmetric, retraction (-), RR: 20x/minute

P: Movement of the chestwalls symmetric, Krepitasi (-),
Trachea deviasi (-), ICS widen (-)
P : Resonant/ resonant
A : Vesicular +/+, Ronkhi -/-, Whizing -/-

Circulatiom : HR : 84x/mnt reguler

Blood pressure : 120/80mmHg
Warm akral (+,+,+,+)
CRT < 2 detik
Disability :
Exposure :

GCS : 456
Round pupil isokor 3mm/3mm
(-)

SECONDARY SURVEY
Chief complaint :
Lump in the right breast.
HISTORY OF PRESENT ILLNESS :
Patient was hospitalized at RS Haji Surabaya since 24 th January 2014
and diagnosed as breast cancer or mammarian carcinoma. Since 10
years ago, her menstruation cycle was irregular sometimes once in six
UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
months. Her first time menstruate when she was 11 years old. Patient
didnt have a child so she was never breast feeding. Firstly it was
began feeling hurt at left breast and then the right breast has a lump.
Besides lump, there was a blood, pus, and nipple erotion. Patient was

never have any breast tumor in younger age.

HISTORY OF PAST ILLNESS:
Patient was diagnosed with breast cancer since 15 th august 2013 and
resulted of FNAB at 12th September 2013 was infiltrating ductal
carcinoma with first complaint lump in the right breast since 2 years
ago and was found bleeding from nipple and darkness skin One and
half month before she came to RS Haji. She has received 5 times

chemotheraphy
SOCIAL HISTORY : ALLERGIES HISTORY : Denied
C. GENERAL STATUS :
General state : Good
Blood pressure :120/80 mmHg
HR
: 84 x/minute
RR
: 24x/ minute
Tax
: 37 oC
Head/Neck : A-/I-/C-/D- enlargement lymphnode (-)
Thorak
I

: Normochest, symmetric, retraction (-) mass 9x9x4 cm in the

right breast
P

: Movement of the chestwalls symmetric, Krepitasi (-),deviated

trachea (-), widened intercostals space (-)

: Resonant/ resonant

: Vesicular +/+, Ronkhi -/-, Wheezing -/-

: Ictus does not seem

: Ictus no palpable, thrill (-)

COR

UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
P

: heart border normal

: S1S2 single, Gallop (-), Murmur (-)

Abdomen
I

: Flat simetris

: Soepel , tenderness (-), H/L/R no palpable,

: Meteorismus (+)

: bowel sounds (+) normal

Extremity

o Warm akral
+
+
o Oedema

+
+

o Cyanosis

o CRT < 2 dtk

D. LOCALISE STATUS

Regio mammae dextra

Mass 9x9x4 cm, not evaluated margin, irregular shape, attach at breast

skin.
Pus (+)
Bleeding (+)
Edema (+)
Redness (+)
Nipple retracted (+)

peau dorange (+)

UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4

I. Laboratory Examination
Complete Blood Count :
Hb

: 12,8 g/dL

Leukosit

: 7,360 /mm3

Hematokrit

: 37 %

Trombosit

: 339.000 /mm3

Liver Function Test, Renal Function Test

SGOT

: 20 U/L

SGPT

: 23 U/L

Bun

: 7 Mg/dl

UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
Creatinin

: 0,6 Mg/dl

Tumor Marker :

CEA

: 1 ng/ml

Ca-125

: <4 U/ml

Ca 15-3

: 13,37 U/ml

Imuno-Serologis
HbsAg

: -0,02 mIU/ml

Faal Hemostasis
PTT

: 9,1 detik

INR

: 0,81

APTT

: 23,1 detik

Urinal Analysis
BJ :1,010
pH : 6,0
Nitrit : (-)
Protein : (-)
Glukosa : N
Keton : (-)
Urobilin : N
Bilirubin : (-)
Sedimen eri : 0- 1
Leuko : 0-1
Cylind : (-)
Epitel : 0-1
Bact : (-)
Cryst silinder (-);Lain :(-)

UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
Foto Thorax PA 09-01-2014:
Cor

: Besar dan bentuk normal

Pulmo

: Tak tampak Kelainan

Sinus Phrenicocostalis

: Kanan kiri tajam

Tulang dan soft tissue normal

E. DIAGNOSIS
Mammarian carcinoma grade IIIb (T4N1M0) dextra at regio central
PLANNING THERAPY
- Neoadjuvant chemotheraphy for 6th cycle
F. PLANNING MONITORING
- General state
- Vital sign.
- Patient complaints.

DAILY SOAP
UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
Date
24/1/14

Subjective

Objective

Headache

General
state:
enough
VS:
Blood pressure :
120/80mmHg
HR:84x/m
RR:24x/m
Tax:37C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Assesment

Planning

Mammarian Planning diagnosis:

carcinoma
grade IIIb
(T4N1M0)
Planning therapy:
Neoadjuvant
chemotheraphy for
6th cycle
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Mass 9x9x4 cm,
not
evaluated
margin, irregular
shape, appatch at
breast skin.Pus
(+)Bleeding
(+)Edema
(+)Redness
(+)Nipple
retracted (+)peau
dorange (+)

UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
25/1/14

General
state:
enough

Headache

VS:
Blood pressure :
110/70mmHg
HR:72x/m
RR:24x/m
Tax:36,2C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Mammarian Planning diagnosis:

carcinoma
grade IIIb
(T4N1M0)
Planning therapy:
Neoadjuvant
chemotheraphy for
6th cycle
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Mass 9x9x4 cm,
not evaluated
margin, irregular
shape, appatch at
breast skin.Pus
(+)Bleeding
(+)Edema
(+)Redness
(+)Nipple
retracted (+)peau
dorange (+)

UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
General
state:
enough

26/1/14

VS:
Blood pressure :
120/80mmHg
HR:88x/m
RR:20x/m
Tax:36C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Mammarian Planning diagnosis:

carcinoma
grade IIIb
(T4N1M0)
Planning therapy:
Neoadjuvant
chemotheraphy for
6th cycle
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Mass 9x9x4 cm,
not evaluated
margin, irregular
shape, appatch at
breast skin.Pus
(+)Bleeding
(+)Edema
(+)Redness
(+)Nipple
retracted (+)peau
dorange (+)

UNIVERSITY OF MUHAMMADIYAH MALANG

BREAST CANCER CASE REPORT 201

4
27/1/14

General
state:
enough
VS:
Blood pressure :
120/80mmHg
HR:84x/m
RR:20x/m
Tax:36,2C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Mammarian Planning diagnosis:

carcinoma
grade IIIb
(T4N1M0)
Planning therapy:
Neoadjuvant
chemotheraphy for
6th cycle today
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Mass 9x9x4 cm,
not evaluated
margin, irregular
shape, appatch at
breast skin.Pus
(+)Bleeding
(+)Edema
(+)Redness
(+)Nipple
retracted (+)peau
dorange (+)

UNIVERSITY OF MUHAMMADIYAH MALANG

10

BREAST CANCER CASE REPORT 201

4
28/1/14

General
state:
enough

Headache,
nausea,
vomit

VS:
Blood pressure :
110/70mmHg
HR:72x/m
RR:24x/m
Tax:36,7C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Post op
radical
mastectomy
Mammarian
carcinoma
grade IIIb
(T4N1M0)
H-I

Planning diagnosis:
Hb
Planning therapy:
Infus RL 16 tpm
Ceftriakson 2x1 g
Ketorolac 3x10mg
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Bleeding(-)pus(-)
bau(-)
tenderness(+)

UNIVERSITY OF MUHAMMADIYAH MALANG

11

BREAST CANCER CASE REPORT 201

4
29/1/14

General
state:
enough

Headache,
pain at

VS:
Blood pressure :
120/80mmHg
HR:84x/m
RR:32x/m
Tax:35,4C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Post op
radical
mastectomy
Mammarian
carcinoma
grade IIIb
(T4N1M0)
H-II

Planning diagnosis:
Hb
Planning therapy:
Infus RL 16 tpm
Infuse fultrolit
1500cc/24 jam
Terfacef 2x1
Ketorolac 3x1
Sanmol 3x1
Kalnex 3x500 mg
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Bleeding(-)pus(-)
bau(-)
tenderness(+)

UNIVERSITY OF MUHAMMADIYAH MALANG

12

BREAST CANCER CASE REPORT 201

4
30/1/14

General
state:
enough

Headache

VS:
Blood pressure :
110/80mmHg
HR:88x/m
RR:28x/m
Tax:37C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Post op
radical
mastectomy
Mammarian
carcinoma
grade IIIb
(T4N1M0)
H-III

Planning diagnosis:
Planning therapy:
Cefixim 2x100 po
Asam mefenamat
3x500 po
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Bleeding(-)pus(-)
bau(-)
tenderness(+)

UNIVERSITY OF MUHAMMADIYAH MALANG

13

BREAST CANCER CASE REPORT 201

4
31/1/14

General
state:
enough

KRS today

VS:
Blood pressure :
120/80mmHg
HR:80x/m
RR:20x/m
Tax:36,3C

Head/Neck:
A/I/C/D (-)

Thorax:
cor/pulmo:
normal

Abdomen:flat
, symmetric,
tenderness (-)
, H/L/R no
palpable,
tympani,
bowel sounds
(+) N

Ext: normal

Post op
radical
mastectomy
Mammarian
carcinoma
grade IIIb
(T4N1M0)
H-IV

Planning diagnosis:
Planning therapy:
Cefixim 2x100 po
Asam mefenamat
3x500 po
Planning monitoring
:
General state
Vital sign
Complaints

Status lokalis:
Regio mammae
dextra
Bleeding(-)pus(-)
bau(-)
tenderness(+)

UNIVERSITY OF MUHAMMADIYAH MALANG

14