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Case Protocol - Mucinous.
Case Protocol - Mucinous.
DEPARTMENT OF SURGERY
Prepared by:
Shereen S. Lucman
OBJECTIVE
Present a case of M.O, 56 yrs. old female with Mucinous Carcinoma of the
breast, right; S/P Modified Radical Mastectomy, Right; Drain (7/14/21,
APMC); S/P Excision Biopsy (6/25/21, APMC)
MEDICAL HISTORY
IDENTIFYING DATA
Patient, 90%
CHIEF COMPLAINT
PHYSICAL EXAMINATION
Neurologic GCS 15
PRIMARY IMPRESSION
Mucinous Carcinoma, right breast, Stage IIA (cT2N0M0)
S/P Excision Biopsy (6/25/2021, MCH)
DIAGNOSTICS
URINALYSIS
7/13/21 Normal
Values
Color Yellow Yellow
Transparency Clear Clear
Reaction (pH) 6.0 5.5-6.5
Sp. Gravity 1.015 1.010-1.030
Sugar Negative Negative
Protein Negative Negative
RBC 19 0-2/hpf
Pus cells 3 0-5/hpf
Epithelial Cells 7 Few
Bacteria 262 Few
COAGULATION
7/05/2021 ER
PROTHROMBIN TIME
PATIENT CONTROL Normal Values
RESULT 11.2 12.1 10 – 14
seconds
% ACTIVITY 105.9 93.3 >70%
INR 0.95 1.03 <1.16
APTT
RESULT 34.9 33.1 24 – 39
ROUTINE CHEMISTRY
IMMUNOLOGY -SEROLOGY
HbsAg- Nonreactive
CARDIAC 7/13/21 Normal Values
MARKER
D-Dimer 0.62 mg/L 0-1.35 mg/dl
PRE-OPERATIVE DIAGNOSIS
Mucinous Carcinoma, right breast, Stage IIA (cT2N0M0)
S/P Excision Biopsy (6/25/2021, MCH)
CONTEMPLATED PROCEDURE
OPERATION PERFORMED
FINAL DIAGNOSIS
POST-OPERATIVE PLAN
Adjuvant Chemotherapy