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1. 49 yo women

2. lump in her left brest

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1. 49 yo women - late fourtys, risk in breast cancer due to menopause

2. lump could be cyst , inflammation or cancer

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1. breast cancer

2. breast cyst

3. body acne

4. fibroadenoma

5. galactocele

6. trauma cause fat necrosis

7. lyphoma

8. mastitis

9. breast feed

further questioning

1. site - which quadrant(upper quadrant more prone site of carcinoma), any other site (axila)

2. onset - sudden(cyst) or gradually(malagnancies), during menstruation

3. characteristic - pain, soft or hard, nipple dischare or skin changes( maignancies likely to have discharge)( bloody malignant , milky is hormonal change), ( size of the lump)( pain), mobility

4. radiation - is it radiate to any site like axila

5. associated sx - is it come with fever(mastitis or abscess), unintentional weight lose( nmalignancies)

6. time - how long the lump persist, is it change size by time

7. exacerbatinh factor - any postion or medication causing the lump tp appear

8. severity - scale 1 - 10

past medical history

1. any surgery before on breast

2. diagnosed with any breast condition

3. on any medication (OCP), long term use

4. having any infection, any pus

5. infection to pancrease, lymphatic

pregnancy and menstrual related histrory

1. how many pregnancies, breast feed, how many children,

2. last menstruation, or menopause, regular or irregular

family history

1. any family memper have same lump or any family history with same presentation

social history

1. any trauma to breast area

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menarche - the first period

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1. Further questioning revealed that the patient first noticed a painless lump in

the upper outer quadrant of the left breast two weeks ago on self-

examination. - painless indicate malignancy, left side breat more breast tissue so greter risk

She hadn't noticed any nipple discharge, skin changes or

alteration in the lump's size. -tumour might nort infiltrate duct sytem , bole rule out mastitis and trauma for skin chnages, maignant slow progress in size

Past medical history. The patient’s history included a diagnosis of

fibrocystic disease of the breast, based on a biopsy performed five years

ago. - non cancerous , oestrogen high proges low so hyperproliferation, ER pos ,

No treatment was done, and subsequently, she was lost to follow-up. -nsaid to reduce breast pain

The rest of her past medical history was unremarkable. - no surgery , trauma , infection of pancreas

The patient had no

history of surgery, breast trauma or radiation exposure. - no spreading cancer

Menstrual and reproductive history: The patient was in the peri-

menopausal period. - hormonal fluctutation during this period can affect the breast

She had two pregnancies after the age of 30, both of

which resulted in live births.

The patient did not breastfeed the infants. She had her menarche before the age of 10. -early menarchy and late pregnancy without breast feeed increase oestrogen exposure and can lead to cancer - prolactin high, oestrogen low (the moa behind it ), delay pregancy tisssue remain undiffrentiated, inproliferative state increase risk of cancer

Family history. Her mother died at the age of 45 years from "a breast

disease”. - genetic high risk

Medications. The patient did not take oral contraceptives pills, nor was

she treated with hormone replacement therapy (HRT).

Social history. The patient had a history of moderate smoking and alcohol

consumption. -increase risk

She worked as a senior lawyer at a finance law firm. -stress increase risk

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1. breast cancer

2. breast cyst

3. body acne

4. fibroadenoma

5. galactocele

6. trauma cause fat necrosis

7. lyphoma

8. mastitis

vital sign

PE

-lymph node palpate , tender or not, mobility, consistency, margin

biopsy

imaging

tumour marker all BRCA 1 2

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vital sign normal

anxious- sebab dia malu, takut , risau

on palpation, a non-tender, slightly moveable, 2.0-cm mass in the upper

outer quadrant of her left breast was revealed. - postive of breast cancer , cyst pun bole jadi , cancer bole jadi mobile , larger lump rise more concern

Also, several smaller

nodules and ill-defined firm areas were present in both breasts. -indicate multifocal and bilateral disease, sugget malignancy rather than benign condition , ill defined border not clear, nodule indicate metastasis

The

nipple and skin appeared normal. A 1.5 cm moveable nodule was

palpable in the left axilla. takde visible changes like ulcer, metastatic lymph noe

The rest of the examination was normal

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Liver function tests (LFTs) – within the reference range. - liver enlargement canindicate metastasis

Imaging studies: A mammogram and ultrasound showed a 25mm irregular

mass with stippled calcifications in the upper outer quadrant of the left breast. -stipple calcification means dotted calcificafication in breast tissue

Surgical management and histopathological examination: A core biopsy

revealed moderately differentiated invasive ductal carcinoma. - diagnosis

The patient

underwent a lumpectomy of the left breast with sentinel lymph node

evaluation. - lymph node first which kene dari tumour

Gross examination of the lumpectomy specimen showed a 20 mm,

grey, scirrhous mass in the central portion of the specimen.

The margins of the

lumpectomy specimen were free of a tumour.

Histopathology of the sentinel

lymph node revealed metastatic ductal carcinoma.

Therefore, a completion

axillary lymph node clearance (ALNC) was performed a week later, showing

two additional positive lymph nodes out of 15. -

Laboratory investigations

revealed the tumour to be oestrogen and progesterone receptors positive with

a high proliferative rate and a diploid DNA content.

The tumour was HER2

positive.

Adjuvant therapy. The patient was given chemotherapy, radiotherapy and

immunotherapy.