Oncology Case Study
Adenocarcinoma of right breast, Total right mastectomy
History of Present
Illness
50-year-old female with known carcinoma of the
left breast with widespread right pulmonary and bone metastases. No further
treatment since mastectomy. Patient has completed her third round of
chemotherapy for the lung and bone metastases. The patient was now admitted for
treatment of lumps of the lower-outer quadrant of the right breast.
Past Medical History
History of Left breast carcinoma
Bone and lung metastases
History of Left breast mastectomy
Pertinent Physical
Exam
Temperature temp 36.2, HR 102, RR 18 B/P 126/88
Neuro: AAOX3, PEARL
Resp: Bilateral Breath Sounds, decrease on right side
Cardiac: pulses strong and equal, positive
Extremities: Trace edema in upper extremities, lower extremities
with evidence of chronic insufficiency
ABD: round and soft to palpation with positive
bowel sounds.
Impression and Plan
The patient was now admitted for treatment of
lumps of the lower-outer quadrant of the right breast. A right mastectomy has
been recommended as treatment for the lumps of the right breast due to the
patient’s history of right breast carcinoma with metastases. The patient has
agreed to the recommended treatment.
Course in Hospital
Percutaneous needle biopsy of
upper quadrant of right breast. Biopsy specimen was sent for frozen
section with adenocarcinoma of right breast being diagnosed. An open
total right mastectomy was then performed.
D24.2 Benign neoplasm of
right breast
C79.51 Secondary malignant
neoplasm of bone
C78.01 Secondary malignant
neoplasm of right lung
Z85.3 Personal history of
malignant neoplasm of breast
Z90.12 Acquired absence of
left breast and nipple
0HTT0ZZ Resection of Right
Breast, Open Approach
0HBT3ZX Excision of Right
Breast, Percutaneous Approach, Diagnostic
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