Wednesday, December 21, 2016

Oncology Case Study

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
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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