SCENARIO: MM, a 54-year old female presents to the Family Medicine Clinic due to a 2-week history of increasing shortness of breath and cough and mild/moderate pain in left side. She was diagnosed with infiltrating intraductal adenocarcinoma of the left breast 5 years ago; at that time, ER(-)/ PR(-); her-2/neu(+); p53(+); staged as having T3N1M0, stage IIIA, high-risk breast cancer. She underwent a modified radical mastectomy with axillary node dissection followed by 6 cycles of CMF chemotherapy. Her mother and sister also had a history of breast cancer. Past Medical History Gravida 4, para 4; menses onset age 13; HTN x 10 years; Type 2 DM x 8 years; breast CA described above; remained disease free until present follow up. Past Surgical History: Left modified radical mastectomy 5 years ago; cholecystectomy 14 years ago. Medications: Glyburide, 5mg PO BID Verapamil SR, 240mg PO daily Furosemide, 40mg PO daily Allergies: NKDA Physical Examination: GEN: Well-developed, obese woman in no acute distress VS: BP 120/88, HR 80, RR 20, T 370C, Ht167.6 cm, Wt 92 kg HEENT: PERRLA, no JVD, no lymphadenopathy COR: Normal S1 and S2, no murmurs, rubs, or gallops CHEST: Well-healed scar left breast area; dullness of percussion over left lung bases, decreased breath sounds ABD: Obese, soft, nontender, no masses or organomegaly GU: WNL RECT: External hemorrhoids noted EXT: No clubbing, cyanosis, or edema NEURO: A and O X 3; cranial nerves intact, normal deep tendon reflexes Laboratory Examination Results in SI units (Conventional unit): Na 143 (143) Lkcs 6.8 x 109 Plts 372 x 109 K 4.5 (4.5) LDH 204 (204) Glu 7.7 (138) Cl 100 (100) Alk Phos 1.5 (90) Ca 2.35 (9.4) HCO3 22 (22) AST 0.62 (37) Mg 1.1 (2.2) BUN 3.9 (11) ALT 0.5 (30) Uric Acid 286 (4.8) Cr 106 (1.2) PO4 1.32 (4.1) T Bili 5.1 (0.5) Hct 0.426 (42.6) Alb 40 (4.0) PTT 22.0 Hgb 130 (13) T Prot 68 (6.8) INR 1.0 Differential test: Neut 0.7 (70%}, lymph 0.20 (20%), mono 0.055 (6.5%), baso 0.013 (1.3%), eos 0.022 (2.2%) Urinalysis: WNL ECG: Normal sinus rhythm CXR: Effusion in left lower lobe. Fluid layers out on lateral x-ray Bone scan: Multiple metastases to left lower ribs. Pleural fluid: Thoracentesis: Glucose 5.3 (95), LDH 234 (234), pH 7.5, specific gravity 1.025, protein 50 g/L (5.0 g/dl), Lkcs 2.6 x 109, RBC 110 x 1012 (110 x 106); cytology: adenocarcinoma breast Question: 1.Is the patient qualified for total mastectomy? Why?
SCENARIO:
MM, a 54-year old female presents to the Family Medicine Clinic due to a 2-week history of increasing shortness of breath and cough and mild/moderate pain in left side.
She was diagnosed with infiltrating intraductal adenocarcinoma of the left breast 5 years ago; at that time, ER(-)/ PR(-); her-2/neu(+); p53(+); staged as having T3N1M0, stage IIIA, high-risk breast cancer. She underwent a modified radical mastectomy with axillary node dissection followed by 6 cycles of CMF chemotherapy. Her mother and sister also had a history of breast cancer.
Past Medical History
Gravida 4, para 4; menses onset age 13; HTN x 10 years; Type 2 DM x 8 years; breast CA described above; remained disease free until present follow up.
Past Surgical History:
Left modified radical mastectomy 5 years ago; cholecystectomy 14 years ago.
Medications:
Glyburide, 5mg PO BID
Verapamil SR, 240mg PO daily
Furosemide, 40mg PO daily
Allergies: NKDA
Physical Examination:
GEN: Well-developed, obese woman in no acute distress
VS: BP 120/88, HR 80, RR 20, T 370C, Ht167.6 cm, Wt 92 kg
HEENT: PERRLA, no JVD, no lymphadenopathy
COR: Normal S1 and S2, no murmurs, rubs, or gallops
CHEST: Well-healed scar left breast area; dullness of percussion over left lung bases, decreased breath sounds
ABD: Obese, soft, nontender, no masses or organomegaly
GU: WNL
RECT: External hemorrhoids noted
EXT: No clubbing, cyanosis, or edema
NEURO: A and O X 3; cranial nerves intact, normal deep tendon reflexes
Laboratory Examination Results in SI units (Conventional unit):
|
Na |
143 (143) |
Lkcs |
6.8 x 109 |
Plts |
372 x 109 |
|
K |
4.5 (4.5) |
LDH |
204 (204) |
Glu |
7.7 (138) |
|
Cl |
100 (100) |
Alk Phos |
1.5 (90) |
Ca |
2.35 (9.4) |
|
HCO3 |
22 (22) |
AST |
0.62 (37) |
Mg |
1.1 (2.2) |
|
BUN |
3.9 (11) |
ALT |
0.5 (30) |
Uric Acid |
286 (4.8) |
|
Cr |
106 (1.2) |
PO4 |
1.32 (4.1) |
T Bili |
5.1 (0.5) |
|
Hct |
0.426 (42.6) |
Alb |
40 (4.0) |
PTT |
22.0 |
|
Hgb |
130 (13) |
T Prot |
68 (6.8) |
INR |
1.0 |
Differential test: Neut 0.7 (70%}, lymph 0.20 (20%), mono 0.055 (6.5%), baso 0.013 (1.3%), eos 0.022 (2.2%)
Urinalysis: WNL
ECG: Normal sinus rhythm
CXR: Effusion in left lower lobe. Fluid layers out on lateral x-ray
Bone scan: Multiple metastases to left lower ribs.
Pleural fluid: Thoracentesis: Glucose 5.3 (95), LDH 234 (234), pH 7.5, specific gravity 1.025, protein 50 g/L (5.0 g/dl), Lkcs 2.6 x 109, RBC 110 x 1012 (110 x 106); cytology: adenocarcinoma breast
Question:
1.Is the patient qualified for total mastectomy? Why?
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