Left Breast Cancer

General Information:

Name: Wang ××

Occupation: Retired Nurse

Sex: Female

Native place: Nanjing

Age: 68

Address: 78 Yongfu Road, Nanjing

Nationality: Han

Admission Date: 2008/9/23

Marital Status: Married

Record Date: 2008/9/23

Chief complaints: a lump in the left breast for about three weeks.

History of present illness:

The patient noted a solitary lump in superior outer quadrant of her left breast three weeks ago. The lump is fixed and is about 2×2 cm large without mastalgia. The nipples aren’t distracted and no blood or fluid is secreted. Now the patient comes to our clinic for the treatment. The patient has no cough or jaundice. She sleeps and eats well without any weight loss. Her urination and defecation function normally.

Past medical history: Hypertension has been detected for 3 years (160/110 mmHg). Her blood pressure is now in good control as she takes captopril 5 mg qd. She denies having had hepatitis, tuberculosis or diabetes. She is not allergic to any known drugs or food. She hasn’t received any operations or blood transfusion before.

Personal history: Born and lived in Nanjing and she hasn’t been to the areas of epidemic diseases, like malaria, schistosomiasis. No alcohol or drug abuse. Denying having had any venereal diseases.

Marital history: married at 24. Her husband is in good health.

Childbearing history: G2P2, both are male and healthy.

Menstrual history: no menses after 51.

Family history: Her family members don’t have any diseases of this kind. No psychological problems have been found.

Physical examination

T: 36.5C HR: 80 bpm    Bp: 130/86 mmHg    R: 20 tpm    Wt: 52 kg

The mind is clear and she is in good nutrition. No jaundice, rash or hemorrhage is found. Superficial lymph nodes are not palpable. Skull is normal. Sclera is not yellow. The pupils are round and equally big with light reflex positive. No ulcer or hemorrhage is found on oral mucosa. The neck is soft and the thyroid can’t be palpated. The trachea is located in the midline and the chest wall is normal. Lungs are clear without any moist or rhonchi. No eminence is found in the precordial region. Heart rate is 80 bpm and its rhythm is regular. No murmur is auscultated. Abdomen is flat and soft without any tenderness or rebound tenderness. Liver and spleen can’t be palpated in sub costal region and Murphy’s sign is negative. Shifting dullness is negative and gurgling sound is 4 tpm. Anus and external genital are normal. No abnormality is found in the spine and extremities. Physiologic reflexes are positive while pathologic reflexes are negative.

Specialized examinations: the two breasts are symmetrical and no discharge is secreted from the nipples. There is no lump or tenderness in the right breast. A solid mass is found in the superior outer quadrant and is 2×2 cm large. Its shape is irregular with poor mobility. No superficial lymph nodes are palpated in bilateral axillary and supraclavicular regions.

Auxiliary Examinations:

B-ultrasound (08-9-20): A solid mass is detected in the superior outer quadrant of left breast. It’s of 16.7 mm×19.8 mm large and its margin is not clear. Its elastic scoring is 4 and it’s considered to be breast cancer. No mass is detested in the right breast and no enlarged lymph nodes are detected in bilateral axillary regions.

Impression: Left breast cancer

Signature: Li Dehai