OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF SURGERY
Name: Andres, Julieta S. Age/Sex: 49/F Address: 1423 Kalimbas St., Sta. Cruz, Manila Date of admission: January 27, 2009 Admitting Diagnosis: Breast Cancer, Stage IV (Lung Metastasis) Pleural Effusion, Left S/P CTT S/P Chemotherapy 6 cycles Residents in charge: Drs. Estonilo/Velasquez/Peralta/Arriola
Hospital #: 1943841
Clinical Abstract This is a case of a 49 year old female from Sta. Cruz, Manila who came in due to difficulty in breathing. History of Present Illness Three years prior to admission, patient noted sudden rupture of breast mass, right, with difficulty of breathing. She consult ed at UST where Incisional of the breast mass was done and revealed Metastatic Carci noma. Chemotherapy was done, 6 cycles. She was lost to follow-up until Three months prior to admission, there was sudden onset of dyspnea. Consult was made at UST, where thoracostomy, left, was done after CXR abd revealed malignant effusion. Few hours prior to admission, patient again experienced sudden onset of difficulty of breathing. Patient sought consult at UST where CTT on the left was done and revealed pleural effusion, left. Due to financial constraints, patient decided to transfer to hospital of choice hence consult and subsequent admission at OMMC. Past Medical History (-) Hypertension, DM, Bronchial Asthma, PTB, thyroid problem Family History No known heredofamiial diseases Personal and Social History nonsmoker, nonalcoholic beverage drinker Review of Systems General: With weight loss, with anorexia, no fever, no chills HEENT: no blurring of vision, no tinnitus, no dysphagia, no gum/nose bleeding Respi: no colds, no hemoptysis Cardio: no chest pain, no easy fatigability GU: no dysuria, no oliguria, no hematuria Endocrine: no polyuria, no polyphagia, no polydipsia Neuro: no seizures, no headache. Physical Examination: Conscious, coherent, in respiratory distress Vital Signs: BP: 110/80 HR: 100 RR: 28 Temp: 36.7’C HEENT: Anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no tonsillopharngeal congestion, no cervical lymphadenopathy, no neck vein distention, CHEST AND LUNGS: symmetrical chest expansion, no retractions, decreased breath sounds on the left lung field BREAST: ulcerated lesion on the right upper outer quadrant HEART: adynamic precordium, no thrills, PMI at the 5th ICS LMCL, no murmur, tachycardic, regular rhythm, good S1. ABDOMEN: flabby, normoactive bowel sounds, no tenderness. EXTREMITIES: No cyanosis. No edema, no cyanosis, full and equal pulses Assessment: Breast Cancer Stage IV (Lung metastasis) Pleural Effusion, left S/P CTT S/P Chemotherapy 6 cycles Plan: For admission The patient was admitted to the Surgery Ward Room 303 under the service of Drs. Penserga/Devesa/Estonillo/Velasquez/Peralta/Arriola after securing consent for admission and management. Patient was initially put on NPO temporarily and was hooked to D5LR 1 L to keep vein open. CXR-PA and psot CXR-PA were done. She was started on Tramadol drip to run for 24 hours. TT 0.5 ml was given TIM. Multivitamins was also gven once daily. She was advised for blow bottle exercises. Daily thora bottle care was ordered. Vital signs were measured every hour.