Addis Ababa University

Faculty of Medicine

Department of Surgery
Surgery Case Report I

Name: Aelaf Aseged

ID: MDR/9030/02

Submitted to: Dr. Daniel

Date of Submission: June 18, 2012

Saint Paulo’ Hospital Hospital No.

Addis Ababa

Name: W/O Sembe Gemechu Age: 42 Sex: F Occupation: House Wife Religion: Orthodox

Address: Sululta, Oromia Zone Date of Admission: June 4 2012 Date of Clerking: June 6 2012

Marital Status: Married Ethnicity: Oromo Department: Surgery Ward: 4th, East

Bed No: 406/18 Historian: The Patient

Previous Admission

None

Chief Complaint

Right breast lump, 5 months

History of Present Illness

The patient was relatively healthy until 5 months ago at which time she notice a bean shaped hard lump on
the right breast while taking a shower. The swelling increased in size gradually in the following months. It
was associated with intermittent aching pain of the lump. The pain was exacerbated by movement of the
right arm. There was no accompanied discharge.

The patient also complains of easy fatigability, anorexia, weight loss and global headache accompanied by
vertigo and ringing sensation of the right ear. She also has right upper quadrant abdominal aching pain
radiating to the lower right extremity. It was exacerbated by cold environment and fatty foods. It was
accompanied by vomiting of ingested food and diarrhea.

Following these she went to a traditional healer who gave her a topical traditional remedy to rub on the
breast lump. She was doing so as instructed for 4 months but showed no positive improvement. This led
the patient to seek medical attention at local health center where the doctors were unable to treat her and
referred her to Tikur Anbessa Hospital.

The patient has 6 children. She breast fed them all for an average of 8 months. The patient has been
amenorrhic for the past 2 months. Her age at menarche was 16. Otherwise,

No history of trauma to the breast, radiation to the chest

No history of cough, chest pain, fever, chills or night sweats
No history of swelling of other sites
No history of bone pain, urinary complaints
No history of abdominal distension, yellowish discoloration of the eye, tarry or clay colored stool
No use of oral contraceptive pills or other medications
No history of abortion
No history of alteration of mental status, confusion, involuntary movement.
No history of smoking, drinking alcohol or Chat abuse. Her Diet mainly contains of injera and shiro wott.
No family or personal history of similar illness, hypertension, diabetes mellitus, tuberculosis, cardiac illness
or allergy.

There was no color change noticed by the patient. She came here by herself unsupported.

Past Illnesses

No chicken pox, mumps, small pox or any other childhood diseases.

Functional Inquiry

H.E.E.N.T

Head: SEE HPI. No trauma

Ears: SEE HPI. No loss of hearing, discharge or earache

Eyes: No pain, strain, lacrimation, photophobia or itching

Nose: No epistaxis or discharge

Mouse and throat: No dental pain, bleeding from the gums or sore throat. Intact tonsils.

Glands: SEE HPI. No heat or cold intolerance.

Respiratory System: SEE HPI. No expectoration, hemoptysis, shortness of breath, wheezing or stridor.

Cardiovascular system: No dyspnea, palpitation, orthopnea or syncope.

Gastrointestinal system: SEE HPI. No dysphagia.

Genitourinary system: SEE HPI.

Integumentary system: Moist skin, no rashes or ulcers, no changes in hair distribution or pigmentation.

Allergy: SEE HPI.

Locomotory system: No bony deformities, no joint pain.

Central nervous system: SEE HPI.

Personal History

Early development: She was born and raised in Sululta where she lived all her life.

Education: Like her parents she never went to school but she is able to read and write numbers.

Habits: SEE HPI.

Diet: SEE HPI.

Marital Status: She is married and has 6 children. Two of her children died to unspecified disease at age 11
month and 10 year respectively.

Family History

Father and mother: Both her parents are dead due to unspecified disease.

Siblings: He has three sisters. All are healthy.

Family Diseases: SEE HPI.

Physical Examination

General Appearance

The patient is chronically ill looking. She is sitting on her bed and doesn’t seem to be in cardio respiratory
distress.

Vital signs

BP: 100/70mmHg, right arm, supine Pulse: 82/min., radial artery, regular, full volume

RR: 19/min shallow, regular rhythm T0: 36.80c, axillary

H.E.E.N.T

Head: Normal size, shape and hair distribution, No scar.

Ears: Normal contour of pinna. Clear external ear canal.

Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus. The conjunctivae are
pink. The sclerae are not icteric. No funduscopic examination was done.

Nose: The nasal septum is not deviated. There is no polyp or unusual discharge.

Mouse and throat: The lips show no fissure, ulceration or herpes. The gums are intact and show no
ulceration. There are no carious teeth. There are no extractions, dentures or filling. The tongue is pink,
doesn’t show any atrophy. The tonsils aren’t inflamed and the uvula is intact.

Lymphatic and glandular system

There are no enlarged lymph nodes over the occipital, posterior and pre auricular, anterior and posterior
cervical, sub-mandibular, sub-mental, supra-clavicular, axillary, inguinal and epithrochlear areas. The
thyroid is not enlarged. No tremor or lid lag.

The Breast- Inspection:

Arms at sides: There are only two breasts with two nipples. The nipples are equal in size and shape, have no
ulceration, rashes or discharge. There is no redness, thickening of the skin and prominent pores. There is a
visible mass over the upper outer quadrant area of the right breast. There are dilated vessels over the
upper part of the right breast. The breasts are asymmetric and their size is not similar with the right breast
being bigger and slightly elevated as compared to the left breast.

Arms over head; there is slight elevation of the mass (fixed to the skin)

Palpation:

Left breast: Soft, non-tender with no nodularity, thickening or loss of elasticity of the skin.

Right breast: Upper outer quadrant mass, firm, tender, 6cm by 5cm in size, oval shaped, irregular surface,
well circumscribed, warm, mobile, not pulsatile and doesn’t fluctuate. The nipples have no discharge or
thickening and are elastic.

Hands pressed against hips: there is decreased mobility of the mass (fixed to the pectoralis muscle)
 Respiratory System

Inspection: There is no cyanosis or clubbing or the finger nails. The palms are not pale. Breathing is deep
and is of regular rate. The chest is symmetrical. There are no deformities, surgical scars, visible
pulsation or dilated vessels.

Palpation: The trachea is central. There is no tenderness over the entire chest. The total circumferential
chest expansion is 3 cm along the nipple line on deep inspiration. Tactile fremitus is normal over
the entire lung field. Chest expansion is symmetrical.

Percussion: Both the right and left chest are resonant. Diaphragmatic excursion is 3cm.

Auscultation: The breath sounds are vesicular over the entire lung field. No wheezing, stridor crepitation or
pleural friction rub.

Cardiovascular system

Arteries: BP and pulse (see under vital signs). The pulse volume is normal, the rhythm is regular and there
was no abnormal character or unusual condition of vessel wall. Pulse volume can be tabulated as follow:

Carotid Axillary Brachial Radial Femoral popliteal PT DP

Right +++ ++ ++ ++ +++ ++ ++ ++
Left +++ ++ ++ ++ +++ ++ ++ ++

No radio-femoral delay detected.

Veins: There are no distended veins over the neck, chest wall, or leg.

The JVP at an inclination of 450 is 2 cm above the angle of louis.

No hepato-jugular reflex.

Precordium

Inspection: There is no abnormality in shape (no precordial bulge). The precordium is Quiet. The apical
impulse is visible at the fifth intercostal space along the mid clavicular line.

Palpation: The point of maximum impulse is felt where it is visible. There is also no parasternal or apical
heave. There is also no thrill.
Auscultation: The heart sounds are normal over the valvular areas. There is no gallop or murmur.

Abdomen

Inspection: The abdomen is scaphoid, symmetrical and moves with respiration. There is no flank fullness.
There are no dilated veins, scars or masses. The umbilicus is inverted. Hernia sites are free. No visible
pulsation or peristalsis.

Auscultation: The bowel sound is normo-active. There is no bruit over renal artery, abdominal aorta or liver
areas.

Palpation:

 Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was
tenderness.
 Deep palpation: The liver was not palpable below the right costal margin. The spleen was also not
palpable.

Percussion: No shifting dullness or fluid thrill. No flank dullness. The total vertical span of the liver along the
right mid-clavicular line is 7 cm.

Integumentary System

The skin is warm with no rash or ulcers. There is normal hair distribution. The nails don’t show spooning but
clubbing (grade II) is present.

Locomotory System

There’s no muscle or bone tenderness. The joints are normal and there’s no bony deformity. But there is
muscles wasting.

Nervous system

Mental Status:

The patient is conscious with a GCS of 15/15. She is fully cooperative and doesn’t seem to be depressed.

She knows what day it is, where she is and what her name is. Orientation

She remembers what she ate for breakfast. She also remembers where she used to live. Memory
She speaks in a low voice tone. There is no hesitancy and gap in the flow and rhythm of her words. Speech

She denies any hallucinations or delusions.

Cranial Nerves:

N-I: Smells mango via each nostril.

N-II: She can differentiate 2 fingers at about 5 meters by both eyes. (Visual Acuity)

She sees waggling of finger approximately 1000 from axis of the eye. (Visual Fields)

She differentiates green and red colors. (Color Appreciation)

N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia. The pupils are round,
regular in outline and equal in size. They react to light directly and consensually.

N-V: She identifies light touch and pin prick over the mandibular, maxillary and ophthalmic areas of the
face. She closes her eyes at the touch of the cornea with a cotton swab. Contraction of the temporal and
masseter muscles is symmetrical and strong.

N-VII: The face is symmetrical at rest and during voluntary movements (smiling, raising the eye brows). She
can close both eyes equally and forcefully.

N-VIII: She hears rubbing of the fingers on both ears.

N-IX & X: The soft palate rises in the midline when saying ‘ah!’

N-XI: The Sternocleidomastoid and trapezius muscles contract on turning the head and on shrugging the
shoulder against resistance, respectively.

N-XII: The tongue protrudes in the midline and shows no fasciculation or atrophy.

Motor:

 Muscle bulk: There is no muscle bulk reduction in all extremities and there is also no bulk
difference between the left and the right sides. There is no spontaneous as well as induced
fasciculation.
 Muscle tone and power.
 TONE POWER
Upper Lower Upper Lower
Right Normo-tonic Normo-tonic 5 5
Left Normo-tonic Normo-tonic 5 5
0 – no active contraction 1 - flickering movements 2 - movement in horizontal axis
3 - movement against gravity only 4 - movement against gravity + mild resistance 5 - normal power

Coordination:

Finger to nose, heal to shin and rapid alternating movement of the arm were done without any
abnormalities.

Pronator Drift test was negative.

Reflexes:

 Superficial reflexes: Abdominal reflex is present both in upper and lower quadrants. Corneal reflex
is intact in both eyes .Plantar reflex is down going on both sides.
 Deep tendon reflexes:

Biceps Triceps Supinator Patellar Ankle

Right ++ ++ + ++ +
Left ++ ++ + ++ +

 Clonus: No clonus

Sensory:

 She identifies light touch and pin prick over the extremities and trunk.
 She appreciates the form of a key by means of only touch (Stereognosis)
 She recognizes writings of different numbers on his palm (Graphesthesia)
 She is able to differentiate 2 pin pricks upto 4 mm apart over the finger tips (2 pt discrimination).
 She is able to recognize different movements of the toes with his eyes closed. (Position sense)
 Vibration sense was not assessed due to lack of Tuning Fork.

Meningeal Sign:

 There is no neck stiffness.

 Kernig's Sign is negative.
 Brudzinski's Sign is negative.

Summary of problems
  Subjective summary

This is a 42 year old multiparous female patient who presented with right breast lump of 5 month duration.
It showed gradual increment and was associated with aching pain with no discharge. She also complains of
easy fatigability, anorexia, weight loss, global headache, tinnitus, vertigo and abdominal pain.

 Objective Summary

The patient is chronically ill looking. The vital signs are within normal range.

Breast – No nipple retraction or discharge. No peau d’orange. There is visible mass at the upper outer
quadrant of the right breast. It’s firm, oval, 6x5 cm, tender, warm, irregular surface and fixed to the skin
and pectoralis muscle. No palpable lymph nodes.

There is RUQ abdominal tenderness but no hepatosplenomegally or ascites.

Differential diagnosis
 Phylloides Tumor
 Fibrocystic breast disease
 Breast Cancer
 Fibroadenoma

Discussion of the differential diagnosis

 Phylloides Tumor

For: Sex of the patient, growth rate, irregular surface, warmth, dilated veins over surface, no involvement
of lymph nodes, and no nipple retraction

Against: Fixity to the skin and pectoralis, absence of serous discharge

Investigation: Routine laboratory investigations like CBC, urinalysis and serum electrolytes. Diagnostic tests
like mammography (because above 40), and FNAC should be done. On mammography, there will be a well
circumscribed lesion with or without calcification.

 Fibrocystic breast disease

For: Sex and age of the patient, firm consistency, shape, size, tenderness, absence of retraction
Against: Irregular surface, fixity to the skin and pectoralis, absence of discharge

Investigation: Routine laboratory investigations like CBC, urinalysis and serum electrolytes. Diagnostic tests
like ultrasonography (investigation of choice), mammography and FNAC should be done.

 Breast Cancer

For: Sex of the patient, Age of the patient, duration and progress of the lump, single, firm consistency,
irregularity in surface, site of the lump, fixity to overlying skin and pectoralis muscle.

Against: Tender, regularity in shape, absence of retraction or dimpling of the overlying skin, the absence of
risk factors and absence of nipple discharge.

Investigation: Routine laboratory investigations like CBC (Hb may be decreased, increased ALP suggests
bone metastasis), urinalysis and serum electrolytes. Diagnostic tests like mammography, ultrasonography
and FNAC should be done. On mammography, there will be microcalcifications. On ultrasonography, there
will be irregular walls. FNAC of the lump and axillary lymph nodes can confirm the diagnosis. Steroid
hormone receptors (ER/PR) should also be assessed for indication of therapy.

Abdominal ultrasonography along with liver function tests are done to rule out secondaries in the liver and
ascites, bone scan for bone metastasis, chest x-ray for lung secondaries and CT/MRI if brain secondaries.

TNM Staging: T3N0Mx- Stage II-B

 Fibroadenoma

For: Sex of the patient, single, oval shape, firm consistency, site and size of the lump.

Against: Age of the patient, non- tender, irregularity in surface, fixity to overlying skin and pectoralis
muscle.

Investigation: Routine laboratory investigations like CBC, urinalysis and serum electrolytes. Diagnostic tests
like mammography and FNAC should be done. On mammography, there will be a well circumscribed lesion.
FNAC of the lump can confirm the diagnosis.