Mrs. Fatmawati/ 53 y.

Chief Complain : Nausea and vomiting

History :
She complained nausea and vomiting since 1 day before admission. He had vomiting more than 5 times especially after
eating and drinking therefore she felt weakness and couldn’t do activity.
He had lump in the right breast since 1 year before admission. The lump size like a marble for the first and increased
became like a takraw ball in one year (TDT : 72 days). Beside that, she complained other lumps in the armpit in the last 3
months. Lump in the armpit was felt hard, immobile and painless.
He didn’t complained shortness of breath, full in the abdomen or right upper abdominal pain, headache and pain in the
bone, but in the last year he lost of apetite and lost of weight more than 10 kg in the last 6 month.
Risk Factor :
Her first menstruation when she aged 13 years old, and she still menstruation. She had 3 children and she breastfeed
all children. She had history of IUD for contraception for more than 1 year.
History of Past Illness : HT (-), DM (+)
History of Family Illness : Tumour (-), DM (-)
 Vital Sign
• BP : 130/80 mmHg
• HR : 121 bpm (regular, strong)
• RR : 20 tpm
• Tax : 37.10C
• Karnofsky Score : 50-60%
• SpO2 : 98% without O2 supply
Physical
Examination • Head : pale conjunctiva (+/+), sclera icteric (-/-), pupil equal 3 mm|3 mm, light reflex +|+
Head • Mouth : moist mucous membrane
• Neck : enlargement of the lymph node supraclavicular dexter, increase jugular vein pressure (-)

• I : symmetrical respiratory movement, retraction (-)

Chest • P : sonor +|+
• A : vesicular breath sound, no ronchi , no wheezing

• I : distension (-), venectation (-)

• A : bowel sound (+) 4-5x /minute
Abdomen • P : soft, tenderness a/r epigastric, liver / spleen / mass not palpable
• P : tympany

Extremities • warm extremities, parese -|-, edema -|-

 Local Status

a/r mammae dx :
• I : mass (-), peau d orange (-), skin dimpling (-), nipple
retraction (-)
• P : mass (-)
a/r mammae sx :
• I : mass (+), peau d orange (+), skin dimpling (-), nipple
retraction (+),
• P : mass (+), hard consistency, irregular border,
mobile, tenderness (-)
a/r axilla sx
• I : mass (+), regular border, ulcer (-)
• P : mass (+), hard, conglomeration, painless, mobile
Clinical Picture
X-Ray Thorax
26 June 2018
Metastasis Intrapulmonal (-)
USG Abdomen
26 June 2018
Metastasis intrahepatal (-)
FNA-B (July 26th
2018)
Ductal Carcinoma with Lymph
Node Metastasis
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
Hemoglobin 8.2 12,00-16,00 g/dl
Leukosit 1.0 4,0-10,5 ribu/ul
Eritrosit 3.6 3,90-5,50 juta/ul
Hematokrit 27.6 37,00-47,00 vol%
Trombosit 149 150-450 ribu/ul
RDW-CV 13.1 11,5-14,7 %
MCV 76.7 80,0-97,0 fl
MCH 25.5 27,0-32,0 pg
MCHC 33.3 32,0- 38,0 %
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan
SGOT 15 0-46 U/l
SGPT 9 0-45 U/l
GDS 280 <200
Ureum 39 10-50 mg/dl
Creatinin 1.15 0.6-1.2 mg/dl
Na 123 136-145
K 3.6 3.5-5.1
Cl 86 98-107
 Working Diagnosis
Ca Mammae Sinistra T4CN3M0 On Chemotherapy + Anemia +
Leukopenia + Cachexia

Karnofsky Score 50-60%

 Management
• IVFD NS Loading 500 cc  20 dpm Consult to Oncology Surgery
• Inj. Metoclopramid 10 mg • Hospitalized
• Inj. Ranitidine 50 mg • Transfusion PRC 2 kolf/day up to Hb
> 10 gr/dL
• Inj. Leucogen 300 mcg