Transcript
OS 217: 217: Systemic Systemic Diseases Diseases Oncology Oncology LEC 0X:LECTURE TITLE Exam 02| Lecturer | Date OUTLINE
PART 1: GRAND ROUNDS CASE I. History II. Physical Examination III. Differential Diagnosis IV. Labs and other Diagnostics V. Final Diagnosis
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B. Physical Exam Findings
PART 1: GRAND ROUNDS CASE
I. HISTORY A. General Data AM 58 year old female from Calamba, Laguna
Lump in right breast
B. Chief Complaint
C. History of Present Illness
4 mos PTA: patient palpated a small lump on her right breast without any associated pain or skin changes. No consult was done at that time 2 mos PTA: patient noted an increase in the size of the breast mass. She consulted at the local clinic. She was advised to consult at PGH Breast Clinic with impression of a possible breast tumor. Date of Admission: at the breast clinic, biopsy and other labs were done. D. Review of Systems
(-) headaches, seizures, nausea and vomiting, blurring of vision (-) difficulty of breathing, cough, chest pain (-) abdominal pain, changes in bowel habits, GI bleeding, dysuria (-) weakness or musculoskeletal pains E. Past Medical History
Controlled hypertension for 5 years maintained on Losartan (100mg PO 1x a day) Myomectomy (at 42 y/o) No known allergies to food or drugs F. Family History
Father died of acute MI at 56y/o No other disease noted in family Has three children, all adults G. Personal Social History
No vices reported High school teacher since she was 25 years old Only one sexual partner (-) history of STD Menopause at age 56 H. Additional Info to be Asked Other symptoms o Nipple discharge o Weight loss o Location of mass o Menstrual and menopausal history o Tenderness, warmth, signs of inflammation Previous history of benign breast disease Gynecologic/Obstetric History o Age at menarche o Age at full term pregnancy o Use of oral contraceptives Personal/Social History o Diet and physical activity o Exposure to radiation
II. PHYSICAL EXAMINATION A. Vital Signs Awake, not in distress HR 88, RR 20 Temp 36.7C, BP130/70
Pink conjunctivae, anicteric sclera, no tonsillopharyngeal congestion or exudates, no CLAD Symmetric chest expansion, clear breath sounds, distinct heart sounds, regular rhythm, no murmurs (+) 3x2cm movable hard mass on the right breast, no nipple and skin changes noted (+) 1x1 cm movable nodule on the right axilla. No other nodes palpated in left axilla and supraclavicular areas.
III. DIFFERENTIAL DIAGNOSIS A. Primary Working Impression Table 1. PWI of Patient Breast Cancer Rule In: Rule Out: (+) firm movable mass Need biopsy (+) movable nodules (+) rapid increase in size age B. Differential Diagnoses Table 2. DDx of Patient Fibroadenoma Rule in: Rule Out: (+) firm movable mass Usually in younger patients (-) nipple or skin changes To rule out using biopsy Fibrocystic Breast Disease Rule In: Rule Out: (+) firm movable mass Menopause (-) nipple or skin changes To rule out With biopsy Benign Phyllodes Tumor Rule in: Rule Out: (+) firm movable mass (+) palpable lymph nodes Age of the patient To rule out With biopsy Intraductal Papilloma Rule in: Rule Out: (+) firm movable mass (+) palpable lymph nodes Age of the patient (-) nipple discharge To rule out With biopsy
IV. LABS and DIAGNOSTICS A. Laboratory Tests Table 3. Lab Tests done on the patient Diagnostic Test Result Interpretation CBC Hgb: 120 (NV 120-160) Low hematocrit Hct: 0.3 (NV 0.36-0.4) All else within WBC: 9 (NV 4.5-11) normal range Plt: 350 (NV 150-400) Blood Chem Na: 142 All within normal K: 3.6 range Crea: 71 Alb: 38 Ca: 2.34 PT/PTT PT: 99% activity Normal INR1.4, PTT normal B. Diagnostics Used Table 4. Diagnostics done on the patient Diagnostic Test Result Chest X-ray (-) cardiomegaly (-) pulmonary opacities Mammography BI-RADS 1 Left Breast
Core Needle Biopsy
Patti, Leonard, Jasper Jer
Interpretation unremarkable
Routine screening recommended
Invasive Ductal Carcinoma, Right Breast
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IV. FINAL DIAGNOSIS Biopsy revealed Invasive Ductal Carcinoma of the Right Breast, Stage IIB (cT2N1M0) Patient was then admitted and prepared for surgery
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Table X. Table Title COLUMN 1 COLUMN 2 ROW 1 Field Field ROW 2 Field Field ROW 3 Field Field ROW 4 Field Field ROW 5 Field Field Note: Additional Information or explanation
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