2. D.B. D.B. 45 years old 45 years old Female Female Married Married Housewife Housewife Kapasigan, Pasig City Kapasigan, Pasig City

3. Breast mass, right Breast mass, right

4. 1 year PTA 4 months PTA Enlargement of breast mass Enlargement of breast mass 25 centavo coin 25 centavo coin Unrecalled antibiotics w/o relief Unrecalled antibiotics w/o relief

5. 1 month PTA Admission

6. General: (+) anorexia, (-) weight loss, fever, weakness, fatigue General: (+) anorexia, (-) weight loss, fever, weakness, fatigue HEENT: (+) headache, (-) dizziness, enlarged LN HEENT: (+) headache, (-) dizziness, enlarged LN Pulmonary: (-) dyspnea, hemoptysis, cough, wheezing Pulmonary: (-) dyspnea, hemoptysis, cough, wheezing Cardiovascular: (-) palpitations, chest pains, orthopnea Cardiovascular: (-) palpitations, chest pains, orthopnea Gastrointestinal: (-) jaundice, abdominal pain, nausea, vomiting, changes in bowel movement, tea-colored urine Gastrointestinal: (-) jaundice, abdominal pain, nausea, vomiting, changes in bowel movement, tea-colored urine Genitourinary: (-) nocturia, dysuria, frequency, hematuria Genitourinary: (-) nocturia, dysuria, frequency, hematuria Musculoskeletal/Dermatologic: (+) myalgia, (-) back pain, arthralgia, rashes, pruritus Musculoskeletal/Dermatologic: (+) myalgia, (-) back pain, arthralgia, rashes, pruritus Endocrine: (-) excessive sweating, heat/cold intolerance, polyuria, excessive thirst Endocrine: (-) excessive sweating, heat/cold intolerance, polyuria, excessive thirst

7. No hypertension, diabetes mellitus, asthma No hypertension, diabetes mellitus, asthma No allergies No allergies No previous hospitalizations No previous hospitalizations Removal of “pugita,” left eye (2003) Removal of “pugita,” left eye (2003)

8. G4P3 (3,0,1,3) G4P3 (3,0,1,3) Menarche at 13 years old Menarche at 13 years old ~28-30 day cycle ~28-30 day cycle Regularly menstruating Regularly menstruating 3 days, consuming 3 regular pads/day 3 days, consuming 3 regular pads/day (-) dysmenorrhea (-) dysmenorrhea LMP: February 13, 2012 (PMP: January 15, 2012) LMP: February 13, 2012 (PMP: January 15, 2012) Oral contraceptive pills (1986-2000) Oral contraceptive pills (1986-2000) Injectables (2009-2011) Injectables (2009-2011)

9. Hypertension- mother, father Hypertension- mother, father Asthma- siblings Asthma- siblings Cancer Cancer Bone cancer- uncle Bone cancer- uncle Unrecalled cancer- aunt Unrecalled cancer- aunt No diabetes mellitus, PTB No diabetes mellitus, PTB

10. Housewife, mother Housewife, mother Married to an electrician, OFW Married to an electrician, OFW Lives with husband and youngest child Lives with husband and youngest child Nonsmoker Nonsmoker Occasional alcoholic beverage drinker Occasional alcoholic beverage drinker No history of illicit drug use No history of illicit drug use

11. Conscious, coherent, cooperative Conscious, coherent, cooperative Vital signs Vital signs 120/80 mmHg 120/80 mmHg 86 beats/ min 86 beats/ min 20 breaths/min 20 breaths/min 36.5C 36.5C VAS 0/10 VAS 0/10 Weight 59 kilos, Height 153 cm Weight 59 kilos, Height 153 cm BMI 25.2 kg/m 2 (overweight) BMI 25.2 kg/m 2 (overweight)

12. Anicteric sclerae, pinkish conjunctivae, no Anicteric sclerae, pinkish conjunctivae, no No tragal swelling or tenderness No tragal swelling or tenderness No nasal discharge No nasal discharge Pinkish lips, moist oral mucosa, no lesions or sores, no tonsillopharyngeal congestion Pinkish lips, moist oral mucosa, no lesions or sores, no tonsillopharyngeal congestion No cervical lymphadenopathies, non-palpable thyroid gland No cervical lymphadenopathies, non-palpable thyroid gland

13. No lesions or scars on the chest No lesions or scars on the chest Symmetrical breasts Symmetrical breasts Pinkish-brownish nipple, no skin dimpling/ retractions Pinkish-brownish nipple, no skin dimpling/ retractions 7 cm x 5 cm mass on the upper outer area of the right breast 7 cm x 5 cm mass on the upper outer area of the right breast Hard, non-tender Hard, non-tender Well-circumscribed Well-circumscribed Movable Movable Smooth borders Smooth borders 11 to 2 o’clock position 11 to 2 o’clock position No enlarged axillary or supraclavicular lymph nodes No enlarged axillary or supraclavicular lymph nodes No nipple discharge No nipple discharge

14. Symmetric chest expansion, no retractions Symmetric chest expansion, no retractions Equal tactile fremiti Equal tactile fremiti No dullness on percussion No dullness on percussion Good air entry, clear breath sounds Good air entry, clear breath sounds

15. Adynamic precordium Adynamic precordium PMI at 5 th ICS, left MCL PMI at 5 th ICS, left MCL Normal rate and regular rhythm, distinct S1/S2, no murmurs Normal rate and regular rhythm, distinct S1/S2, no murmurs No carotid bruits No carotid bruits

16. Soft, flabby abdomen without scars Soft, flabby abdomen without scars Normoactive bowel sounds Normoactive bowel sounds Tympanitic Tympanitic No tenderness No tenderness Non-palpable liver edge Non-palpable liver edge No masses No masses (-) CVA tenderness (-) CVA tenderness

17. No rashes/ skin lesions No rashes/ skin lesions Warm extremities Warm extremities Good skin turgor Good skin turgor Full and equal pulses Full and equal pulses No cyanosis, no clubbing No cyanosis, no clubbing CRT < 2 seconds CRT < 2 seconds

18. Awake, alert, well-groomed Awake, alert, well-groomed Oriented to 3 spheres Oriented to 3 spheres GCS 15 GCS 15 No cranial nerve deficits No cranial nerve deficits MMT: 5/5 MMT: 5/5 DTRs: 2+ DTRs: 2+

19. 7x5 cm hard, nontender movable, well-circumscribed breast mass, (-) nipple discharge (-) enlarged lymph nodes Rapidly enlarging BREAST MASS; Cyclic BREAST PAIN Family history of CANCER; Long history of OCP use 45/ F, G4P3, housewife

20. Breast cancer, right Breast cancer, right

21. Breast cyst Breast cyst Common in those in their 40s, perimenopausal Common in those in their 40s, perimenopausal Cyclic breast pain Cyclic breast pain Breast mass Breast mass Firm Firm Well-demarcated Well-demarcated Mobile Mobile

22. Fibroadenoma Fibroadenoma Common in the those <30 years Common in the those <30 years Breast mass Breast mass Usually solitary Usually solitary Rubbery Rubbery Round or lobulated Round or lobulated Nontender Nontender Mobile Mobile

23. Ultrasound of the breast Ultrasound of the breast Solid vs. cystic Solid vs. cystic Fine needle aspiration Fine needle aspiration Diagnostic and therapeutic for breast cysts Diagnostic and therapeutic for breast cysts If suspected cyst proves to be a solid lesion, then material for biopsy may be obtained instead. If suspected cyst proves to be a solid lesion, then material for biopsy may be obtained instead.

24. Solid breast mass Clinically benign Excisional biopsy Mammogram Clinically suspicious Mammogram + FNA/ Core Operation Management of solid breast masses. (Harris et. al., 2000. Diseases of the Breast. p.43)

25. Invasive ductal carcinoma, Nottingham combined histologic grade III Invasive ductal carcinoma, Nottingham combined histologic grade III

30. Invasive ductal carcinoma, Stage IIB, T3 N0 M0 Invasive ductal carcinoma, Stage IIB, T3 N0 M0

31. Most common malignant tumor (80%) Most common malignant tumor (80%) Most often present as a palpable mass or mammographic abnormality Most often present as a palpable mass or mammographic abnormality Feel like a hard, bumpy, movable, irregularly-shaped lump beneath the areola Feel like a hard, bumpy, movable, irregularly-shaped lump beneath the areola

33. Reproductive factors Reproductive factors Age at menarche Age at menarche Menstrual cycle characteristics Menstrual cycle characteristics Pregnancy and age at first full-term pregnancy Pregnancy and age at first full-term pregnancy Nulliparous Nulliparous Late age at first full-term pregnancy Late age at first full-term pregnancy Number and spacing of births Number and spacing of births Lactation/ breastfeeding Lactation/ breastfeeding Age at menopause Age at menopause

34. Oral contraceptives Oral contraceptives Duration of use Duration of use Use before a first full-term pregnancy or at an early age Use before a first full-term pregnancy or at an early age Postmenopausal hormone use Postmenopausal hormone use Dietary factors Dietary factors Dietary fat intake Dietary fat intake Obesity Obesity Dietary fiber Dietary fiber Vitamin A Vitamin A Alcohol: >1 drink/day Alcohol: >1 drink/day

35. Physical activity: >3 hours/week Physical activity: >3 hours/week Ionizing radiation Ionizing radiation Environmental pollution Environmental pollution Organochlorines Organochlorines Active and passive smoking Active and passive smoking Silicone breast implants Silicone breast implants Family history (mother and sister, first degree relative) Family history (mother and sister, first degree relative) Jewish heritage Jewish heritage Benign breast disease Benign breast disease

36. Has a tendency to metastasize via lymphatics Has a tendency to metastasize via lymphatics Lymph nodes Lymph nodes Contralateral breast Contralateral breast Liver Liver Lungs Lungs Bones (vertebra) Bones (vertebra) Brain Brain

38. CBC and blood typing Hemoglobin133 g/L Hematocrit0.4 WBC5.1 x 10 9 /L Neut0.60 Lymph0.37 Eos0.03 PlateletAdequate Blood typeA + Urinalysis ColorYellow TurbiditySlightly turbid pH5.5 Sp. Gr.1.025 AlbuminNegative SugarNegative Pus4-8/hpf RBC0-2/hpf Epithelial cellsFew BacteriaOccasional UratesFew MucusMany

39. Chest x-ray Chest x-ray Normal chest findings Normal chest findings ECG ECG Non-specific ST-T wave changes Non-specific ST-T wave changes

41. To avoid ay chance of local/regional recurrence To avoid ay chance of local/regional recurrence To maximize options for breast reconstruction To maximize options for breast reconstruction Most widely used surgical procedure to treat operable breast cancer Most widely used surgical procedure to treat operable breast cancer Removes the breast, surrounding tissue and nearby lymph nodes Removes the breast, surrounding tissue and nearby lymph nodes Leaves the pectoralis major intact Leaves the pectoralis major intact Avoids disfiguring hollow defect below the clavicle Avoids disfiguring hollow defect below the clavicle

45. Five-year survival rates are highly correlated with tumor stage: Five-year survival rates are highly correlated with tumor stage: Stage 0: 99-100% Stage 0: 99-100% Stage I: 95-100% Stage I: 95-100% Stage II: 86% Stage II: 86% Stage III: 57% Stage III: 57% Stage IV: 20% Stage IV: 20%