1. History

2. General Data 33/F G4P2 (2012) Roman Catholic From Quezon City Admitted: August 13, 2009 CC: L breast mass

3. History of Present Illness 11 months PTA: -~2x2cm breast mass, (L) -(+) slight tenderness -(-) accompanying skin changes/nipple discharge/weight loss -(-) consults done/medications taken

4. History of Present Illness 8 months PTA: -(+) gradual enlargement of mass -consult at a local hospital -CNB: results showed fibrocystic changes -No medications/interventions -advised observation.

5. History of Present Illness 1 month PTA: -Mass continued to enlarge; noted to triple in size -(+) nipple retraction -consult at BCC -Slide review of previous CNB slide: invasive ductal CA

6. History of Present Illness 1 month PTA: -(+) missed menses for 4 weeks -(-) nausea/vomiting -(+) slight dizziness -pregnancy test: positive -(-) consults / medications

7. Review of Systems (-) fever (-) weight loss (-) rashes (-) headache/dizziness (-) nasal discharge (-) difficulty of breathing / dyspnea (-) chest pain (-) urinary complaints (-) bowel disturbance

8. Past Medical History (-) DM / HPN / PTB / allergies / asthma No comorbidities

9. Family Medical History (-) CA, breast mass (-) Hypertension, DM, asthma, thyroid disorder, epilepsy

10. Menstrual History Menarche: 12 yrs. Old interval of 30 days lasting for 3-5 days consumes 3 pads per day, fully soaked (-) dysmenorrhea LMP: May 23, 2009

11. Sexual History First coitus 26 y/o (current partner, nonpromiscuous) (-) dyspareunia (-) post coital bleeding (-) family planning method

12. Obstetric History GYearAOGViac/oFMC 12001FTSVDTondo General (-) 22004FTSVDFabella(-) 32008; abortion c/o hilot 42009; abortion

13. Personal/Social History housewife Non-smoker Non-alcoholic beverage drinker Denies illicit drug use

14. Physical Examination

15. Conscious, coherent, ambulates with assistance, not in cardiorespiratory distress Vitals: BP 120/80 HR 82 RR 20 T 36.8

16. Physical Examination HEENT: Pink palpebral conjunctivae, anicteric sclerae, pupils ERTL Supple neck, no palpable cervical lymph nodes, Thyroid gland not enlarged

17. Physical Examination Chest/Lungs: No retractions, Symmetrical chest expansion, clear breath sounds CVS: Adynamic precordium, AB at 5 th LICS MCL, no murmur

18. Physical Examination Abdomen: Globular, NABS Skin/Extremities: Warm, moist skin, no active dermatosis Full and equal pulses, no clubbing or cyanosis of extremities, no edema

19. Physical Examination Breast 10x10 cm mass- hard, slightly tender, non movable mass L breast, (+) nipple retraction (-) skin changes/nipple discharge Essentially normal R breast (-) palpable axillary/cervical nodes

20. Physical Examination Genitourinary: Normal external genitalia, no vaginal discharge, no external lesion Internal Examination: Cervix- soft, long, closed; Uterus- enlarged to approximately 12 weeks, no adnexal mass/tenderness

21. Physical Examination Neurologic Examination Awake, alert, oriented to 3 spheres pupils 2-3 mm ERTL, no visual field cuts, (+) ROR – OU full and equal EOM’s, V1-3 intact, can clench teeth, Can smile, can raise eyebrows, can close both eyes, no asymmetry, Intact gross hearing, no lateralization on Weber’s, AC > BC on Rinne, tongue midline on protrusion, can raise shoulders

22. Physical Examination Neurologic Examination - Motor: (-) spasticity, rigidity, fasciculation, MMT 5/5 on all extremities ++ DTR’s on all extremities (-) sensory deficit (-) Babinski, (-) nuchal rigidity

23. Course in the Wards

24. 8/13/09 (1 st hospital day) –Admitted to W4B29 8/14/09 (2 nd hospital day) –Referred to OB-GYN

25. Course in the Wards 8/15/09 (3 rd hospital day) –OB-Gyn: TV-UTZ done, showing early fetal demise; suggest cervical ripening with laminaria x 24h then reassessment of cervix. – presented with possibility of D&C after MRM if Sx is amenable

26. Course in the Wards 8/16/09 (4 th hospital day) –GS1: Noted OB entries –For OR scheduling: MRM, L –NPO –IVF: D5NR 1L x 8h –Cefazolin 1g IV LD ( ) ANST to be given at OR –OB may do D&C or insert laminaria –Anesthesiology: plan – GETA –pre-op meds – nalbuphine 5mg + promethazine 25mg as cocktail

27. Course in the Wards 8/16/09 (4 th hospital day) –OB-Gyn: will do D&C after MRM –Anesthesiology: plan – GETA –pre-op meds – nalbuphine 5mg + promethazine 25mg as cocktail –IVF: D5NR x 8h + K50 ext tubing on RUE (IV Cannula g18)

28. Laboratory Examinations

29. Blood Type: A+ CBC Hgb 122, Hct 0.394, WBC 9.78, RBC 4.33, Plt 302, N 0.660, L 0.272 PT 12.9/12.4/0.98/1.19 aPTT 36.9/33.0 BUN 2.68, Crea 50(L), Na 140, K 3.7, Cl 104

30. Ethical Considerations

31. 1 st Trimester – MRM (procedure of choice), in spite of increased risk spontaneous abortion following anesthesia – Chemotherapy - 12% risk of birth defects and risk for spontaneous abortion 2 nd Trimester – MRM (procedure of choice) – Chemotherapy – no evidence of teratogenicity

32. Ethical Considerations 3 rd Trimester – Lumpectomy with axillary node dissection if adjuvent radiation therapy if deferred until delivery – Chemotherapy: no evidence of teratogenicity Prognosis is similar, stage by stage, to that of nonpregnant Breast CA patients

33. Ethical Considerations Upon questioning, the patient was willing to undergo chemotherapy and surgery in spite of the risk of spontaneous abortion to the fetus According to her and her family, it is more important to have her cured She finds herself unable to continue the pregnancy if she still has cancer

34. Ethical Considerations Philippine Constitution Article 2, Sec 12: – The State recognizes the sanctity of family life and shall protect and strengthen the family as a basic autonomous social institution. It shall equally protect the life of the mother and the life of the unborn from conception. The natural and primary right and duty of parents in the rearing of the youth for civic efficiency and the development of moral character shall receive the support of the Government.

35. Ethical Considerations Grounds on which abortion is permitted in the Philippines: – To save the life of a womanYES – To preserve physical healthNO – To preserve mental healthNO – Rape/incestNO – Fetal impairmentNO – Economic/social reasonsNO – Available on requestNO

36. Ethical Considerations Authorization of an abortion requires consultation with a panel of professionals

37. Source Brunicardi,et. Al. (2005). Schwartz’s Principles of Surgery. 8 th Ed. McGraw-Hill, USA. Philippine Constitution UN Abortion Policies: A Global Review (2002) http://www.un.org/esa/population/publicatio ns/abortion/profiles.htm. accessed on 8/17/09 http://www.un.org/esa/population/publicatio ns/abortion/profiles.htm