A5 Chua- Danguilan
SURGERY
August 4, 2010
Dr Ampil
Identifying Data:
Patient M.R.C., is an 18 year old female, housewife and live-in-partner, Filipino, a Born Again
Christian from Sampaloc Manila was admitted for the first time at UERMMMCI on July 24, 2010.
Chief Complaint:
Pain on the right breast of 8 days duration
Source and reliability: Patient with fair reliability
History of Present Illness:
The patient’s condition started 11 days PTA when the patient noticed a small lump on the outer
lower quadrant of her right breast. No other symptom felt. There was no pain.
8 days PTA, the patient felt pain on her right breast, graded as 7/10 and at the same time noticed
redness on the outer lower portion of her right breast. The pain was described as tingling and as if the
skin is being scraped or removed inside her breast. (“parang binabalatan sa loob”) lasting for a few
seconds, felt as many as 4 times on the day. There was no radiation or alleviating factors for pain. The
patient could still sleep and do ordinary household chores but noted that wearing a brassiere aggravates
the pain.
7 days PTA, the pain became worse, now graded 8/10. Pain was noted almost the whole day. The
pain was described as piercing but without radiation. It was alleviated by placing an ice pack over the
breast but pain recurred again after 2-3 minutes. The patient could still do household chores. The
redness over her breast was now more intense.
6 days PTA, the pain was worse, now graded 10/10. Almost a continually occurring pain alleviated
by placing an ice pack on the right breast but only to recur again after 2-3 minutes.
5 days PTA, the pain was now persistent, graded 10/10. She consulted a doctor and was prescribed
with Co-amoxiclav (375 mg,tid, for 5 days) and Paracetamol (Biogesic) 500 mg, q4h. for 5 days. The
patient was compliant with the medications but it did not provide relief for pain.
4 days PTA, the persistent pain was still there, as graded 10/10. The patient also had cough and
colds, undocumented fever and was sweating. She had difficulty of breathing described as she was
drowning (“parang nalulunod. ”).
2 days PTA, aside from the continually occurring breast pain, 10/10, she could no longer do
household chores. She also noted decrease in food intake. The patient could only eat up to 4
tablespoons due to the pain and difficulty of placing food on her mouth. The redness on the lump
increased in intensity and there was no discharge noticed.
1 day PTA, the pain was persistent graded 10/10. The pain radiated to the back and was also
aggravated by lying down. The mass became hard with the overlying skin being smooth and shiny red,
described as ripened tomato. The patient could not sleep due to the pain.
On the day of admission, pain redness on the lower outer portion of the right breast persisted. The
patient was advised by the doctor who prescribed the medications to consult a surgeon if the pain did
not subside.
SOCIO-ENVIRONMENTAL HISTORY
The patient is a highschool graduate, while her live-in partner only finished schooling up to 2nd year
highschool. Her partner works as a messenger, and according to the patient, pays for the hospital bills.
She and her partner have been a couple for about 8 months until they started living-in last May, upon
discovering that she was pregnant. The patient currently lives in her partner’s house located in a
compound at Sampaloc, Manila. A total of 6 people live in their household, including her live-in partner,
his parents, and his siblings. It has two bedrooms and 1 bathroom. Their water and electricity are
supplied by Maynilad and Meralco respectively. The family consumes mineral water for drinking. They
have a pet dog, and two pet birds. The patient does not smoke or drink alcohol.
Family History
Parents still alive with no known morbidities. She has 2 healthy sisters and 1 brother.Her grandfather
(father side) died from a complication of Diabetes Mellitus. The patient has no family history of
Tuberculosis, Hypertension and Malignancies
PAST MEDICAL HISTORY
The patient has no history of prior surgery or confinement. Patient has also no known allergies
to food or medication. She has no asthma, cardiovascular disease and hypertension. She had measles
and mumps when she was a child.
SEXUAL/OBSTETRIC HISTORY
The patient was 13 years old at menarche. Her menstrual cycle is regular and occurs monthly. It typically
lasts for 4 days, with a more or less consistent amount. She consumes about 4 napkins during the first 2
days and about 3 panty liners on the 3rd and 4th day. She has no dysmennorrhea.
According to the patient she developed a urinary tract infection last November 1, 2009. She did not seek
consult for this condition, and was not diagnosed by a doctor. She was only advised by an aunt who has
had UTI with similar symptoms. The patient’s symptoms include intermittent fever, pain in the left lower
back, and difficulty urinating. She was advised by the aunt to drink plenty of fluids. Without any
medications her symptoms resolved after a week.
The patient claims she only started being sexually active when she turned 18 years old, and has had only
1 partner (her current live-in partner) ever since. She denies experiencing any pain during coitus, not
even during their first time. They usually have intercourse once a week until she got pregnant. There
was no documented contraceptive use.
The date of her last menses was December 19, 2009. She took 2 pregnancy tests one last January and
another in February but the results were negative for both. On May 2010 she sought consult because
she still did not have her period, and it was confirmed via ultrasound that she was indeed pregnant. This
is the patient’s first pregnancy. Since discovering she was pregnant she has had regular weekly checkups.
Pertinent subjective findings
1) Small lump on the outer lower quadrant of her right breast
2) Mass became hard with the overlying skin being smooth and shiny red, described as ripened
tomato.
3) Pain on her right breast described as tingling and as if it was being scraped. graded as 7/10
which later on progressed as 10/10
4) Pain on the right arm with Limitation of movement of right arm
5) Pain felt on her right breast radiated to her right arm and back
6) Undocumented fever and sweating
7) Seven months pregnant
Pertinent objective findings:
1) No palpable cervical lymph node.
2) No palpable right axillary lymph node.
3) No masses on left breast. Swollen right breast with dressing.
4) Pregnancy compatible to seven months