A / F / 39 yo

77.58.90
Chief complaint : Pain on the Left breast
It has been suffered by the patient since 2 days before admitted to Adam Malik
Hospital. Patient has never been treated before. History of weight loss + 5 kg in 3
months, frequent coughing (-) low back pain (-). Patient is able to care for her daily
needs with help.
Patient had her first child at the age of 27. She has 3 children and breastfeed both
of them for 6 months. Her menarche was at 12 years old. History of using oral
hormonal contraception (+), family who has the same condition (-)radiation history
(-), history of benign surgery(-)
Present State :
Awareness : Alert
BP : 130/80 mmHg
HR : 78 bpm
RR : 19 times/min
Temp : 36,7 °C
VAS :4
Karnofsky : 70
Generalized state :
Head : no abnormality was found
Neck : no abnormality was found
Axilla : no abnormality was found
Chest : localized state
Abdomen : no abnormality was found
Extremity : no abnormality was found
Genitalia : female, no abnormality was found
Localized state:
Chest
• I : Asymmetrical,ulcer o/t (L) breast
• P : tactile fremitus o/t both hemithorax
• P : resonance o/t both hemithorax
• A: vesicular o/t both hemithorax

• L) Breast
• I: Ulcer (+) o/t Left breast 6x4cm, irregular
surface, eritema (+), p’eau d’orange (-), nipple
retraction (-)

• P: upper outer quadran, solid consistency,

tenderness (+), imobile, not well circumscribed,
Pain (+), Mass (+) size 5 x 7 cm.
• (R) Axilla region
-. No palpable node

• (R) clavicle region

- No palpable node

• (L) Axilla and clavicle region

- No palpable node
Laboratory finding:
Hb / Hct / WBC / PLT : 12.3 / 37 / 10.130 / 243.000
Na / K / Cl : 136 / 4.2 / 91
Random Blood Glucose : 106
Chest X-Ray
Working Diagnosis:
(L) Breast neoplasm sugg. malignant cT4bN0M0
Treatment at ER :
Ambulatory
paracetamol 3x1000mg
Plan for incisional biopsy and staging from outpatient department
(OPD)