Geetha. 54

70 years old female suffering with hard lumps in the left breast 

18 march 2022

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

Chief complaints

A 70 years women daily worker by occupation came to the opd with the chief complaint of pain and swelling at the level of the nipple in the left breast. 

Inverted nipple positive

History of present illness

Pt was asymptomatic 4 months ago when she was noticed a swelling of (4*3) CM under the nipple in the left breast. The patient complains of pain on the moving the mass.the masses are hard. No nipple discharge observed. The nipple appear inverted. 

History of past illness

No history of past illness.No history of past surgery

Personal History

Diet- mixed

Appetite -normal

Bowel movements-regular

Sleep -adequate

Family history

No history 

Drug history 

Patient is not allergic to any known drug

Vitals

Temperature- 98°F

Bp- 110/70 mm hg

Pulse- 76  bpm

Spo2- 98%

General physical examination

The patient is coherent conscious and cooperative

Masses are present on the left breast and no active discharge is present. The nipple retraction is present




Investigations








Ultrasound report


Department of Radiology &Imaging requisition form



Treatment

1) T. PAN  40 mg PO OD
2) T. MVT PO OD
3) T. GTC 500 mg PO OD





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