DEMOGRAPHIC DETAILS

Name : Rosnarliza MRN : 88363

Age : 33 years old Date of admission : 27 October 2010

Gender : Female Occupation :

Housewife

Ethnic group : Malay Marital status : Married

CHIEF COMPLAINT

Rosnarliza, 33 years old Malay housewife with no known medical illness or drug
allergies presented to Selayang Hospital with complaint of left breast swelling and pain 5
days prior to admission.

HISTORY OF PRESENTING ILLNESS.

She was previously well until 5 days prior to admission when she started to notice a
lump in her left breast 5 days prior to admission when she was taking shower. It was about
the size of an egg and she had dragging sensation. The lump was not progressively increase
in size and painless initially. However, she started to experienced pain and noticed redness
and warm on the skin over the lump on the next day. She also noted yellowish discharge
from nipple which was minimal in amount, not foul smelling or blood stained. Patient denied
any punctum or sudden increase in size of swelling.

The pain was gradual in onset, throbbing in nature, only on the swelling, intermittent,
non radiating and aggravated by doing housework especially when she used her left arm.
The pain was partially relieved by taking painkillers. It was progressively worsen until the
day of admission.

The left breast swelling and pain was associated with one day history of continuous
fever but no night sweats, chills or rigors. There was no recorded temperature at home
however patient claimed it was low grade fever.

On further questioning, she denied history of recent trauma to the left breast,
lactation, no feeling of lump over the armpit, swelling of the arm, previous history of similar
problem, loss of weight or loss of appetite.

She did seek medical attention at health clinic however was discharged with
antibiotic and painkillers.
SYSTEMIC REVIEW

CNS : no headache, blurring of vision, syncope or dizziness

RESP : no cough, hemoptysis or breathlessness

CVS : no chest pain or palpitation

MSK : no muscle, joint or bone pain, swelling or neurological deficit such as

hemiparesis or hemiplegia

GIT : no abdominal pain, vomiting or altered bowel habit

GUT : no bladder incontinence, dysuria or hematuria

PAST MEDICAL / SURGICAL HISTORY

She has no known medical illness such as asthma, hypertension or diabetes mellitus.

DRUG HISTORY

She is not on any regular medication or traditional herbs consumption.

ALLERGIC HISTORY

She has no allergy towards food and medication.

MENSTRUAL HISTORY

The first day of her last normal menstrual period was on 15 October 2010. She
attained her menarche at the age of 12. She has regular menses with 28 to 30 day cycle.
She usually bleeds for 6 days. The flow was normal and she usually wore 3-4 pads per day.

PAST GYNAECOLOGICAL HISTORY

She has no previous gynaecological problems. She had done Pap smear test
screening in 2005 and was told that result was normal.

PAST OBSTETRICS HISTORY

She gave birth to 3 children; first was via Emergency Lower Segment Cesarean
Section for fetal distress, second and third via Spontaneous Vaginal Delivery. Last child birth
was 3 years ago when she last breastfed her daughter until 8 months old.
CONTRACEPTIVE HISTORY

She never consumes oral contraceptive pills or hormone replacement therapy.

FAMILY HISTORY

She is the eldest from 4 siblings; all other siblings are alive and healthy. Her mother
has Type 2 Diabetes Mellitus and asthma while she was unsure about her father’s health
status as her parents were divorced long time ago. She denied family history of malignancy,
breast disease or thyroid disorders.

SOCIAL HISTORY

She is married with 3 children. Her husband works as a technician. Her husband and
children are well and healthy. She is a non-smoker and does not consume alcohol however
husband is a smoker but he usually smokes outside the house. They live in Kg. Laksamana
with good basic amenities.

PHYSICAL EXAMINATION

General Examination

Pn. Rosnarliza, a medium built lady was sitting comfortably on bed. She was
conscious, alert and oriented to time, place and person. Generally she was not in respiratory
distress or in pain. Her hydration status was adequate.

Vital signs

1) Temperature : 37.0°C
2) Blood Pressure : 105/62 mmHg
3) Pulse Rate : 96 beats per minute
4) Respiratory Rate : 20 breaths per minute

Impression: Vital signs were stable.

Face, head and neck, limbs

She was not jaundice or pale. There was no presence of thyroid enlargement or
lymphadenopathy. Her hands were warm and dry. There were no central or peripheral
cyanosis, clubbing or pitting edema.
Back

Shape and structure of spine were normal. No rashes, scar, lesion or no sacral oedema
detected.

Lymph nodes

No lymph nodes were palpable over the pre and post auricular, occipital, cervical, axillary
and inguinal area.

Breast examination

Inspection

The left breast appeared more swollen as compared to the right side. There was a visible
swelling at the lower half of the left breast and erythematous skin overlying it. There was no
other skin changes such as skin dimpling or puckering, peau d’ orange, nodules or
ulceration. The areolae and nipples looked normal. There was no evidence of discharge from
nipple. There was also no dilated veins or previous surgical scar.

On raising arms above head level, there was o abnormality detected.

Palpation

The right breast was normal with no palpable mass, discharge from nipple or areola.

There was a single swelling felt at the lower half of the left breast. The swelling was oval in
shape, with well defined margin measuring about 10cm x 8cm. The swelling was firm in
consistency, warm and tender. The skin overlying it was smooth however appeared
erythematous. The swelling was mobile within the breast tissue and not fixed to the skin,
non fluctuant or transilluminate. On pressing the areola and nipple, there was minimal
amount of yellowish discharge expressed. It was not foul smelling and no blood stained.

Axillary lymph nodes were not palpable.

Systemic examination

Abdominal examination

i. Inspection
The abdomen was flat. All the four abdominal quadrants moved symmetrically
with respiration. The umbilicus was centrally located and inverted. There was
no surgical scar, superficial dilated vein, visible swelling, peristalsis or
pulsation. The hernial orifices were intact.

ii. Palpation
On light palpation, the abdomen was soft with no area of tenderness,
guarding or rebound tenderness and no palpable mass. On deep palpation,
there was no tenderness as well. The liver and spleen were not palpable. The
kidneys were not bimanually palpable.

iii. Percussion
On percussion the abdomen was tympanitic generally with no fluid detected.
Shifting dullness was negative.

iv. Auscultation
Bowel sound was present with normal frequency and intensity.

Respiratory examination

i. Inspection
The chest shape was normal and the chest wall moved symmetrically with
respiration. There was no surgical scar or superficial dilated veins.

ii. Palpation
The trachea was centrally located. The chest expansion was symmetrical
bilaterally. Apex beat was palpable at the fifth intercostal space within
midclavicular line.

iii. Percussion
The lung areas were resonant with normal cardiac and liver dullness.
 iv. Auscultation
The air entry was equal bilaterally and vesicular breath sound heard with no
added sound such as rhonchi, stridor or crepitation.

Cardiovascular examination

i. Inspection
The chest shape was normal with no deformity, cardiac bulging, scar,
superficial dilated vein or visible pulsation.

ii. Palpation
The apex beat was palpable at the fifth intercostal space within midclavicular
line. There was no parasternal thrill or heave.

iii. Auscultation
The first and second heart sounds were heard with normal intensity and
frequency. There were no additional heart sound or murmur and no carotid
bruit.

CLINICAL SUMMARY

Pn. Rosnarliza is a 33 year old housewife with no known medical illness and drug
allergies presented with 5 day history of left breast swelling and throbbing pain associated
with low grade fever. On further questioning, she denied history of recent trauma to the left
breast, lactation, no feeling of lump over the armpit, swelling of the arm, previous history of
similar problem, loss of weight or loss of appetite. On examination, the left breast appeared
swollen with evidenced of inflammation such as warm, tender, erythematous. In addition
there was nipple discharge upon pressing on areola and nipple.

PROVISIONAL DIAGNOSIS

Left breast abscess

Points for:

a. Acute onset

b. Pain and swelling of unilateral breast, with yellowish discharge from nipple
 c. Associated with fever

Points against:

a. Non lactating

b. No recent history of trauma to breast

DIFFERENTIAL DIAGNOSIS

Left breast carcinoma

Points for:

Points against:

Left breast fibroadenoma

Points for:

Points against:

Fat necrosis of left breast

Points for:

Points against:

Chronic granulomatous mastitis of the left breast

Points for:

Points against:

Left phylloides tumor

Points for:
Points against:

INVESTIGATIONS

Full blood count

Parameter Result Normal range Interpretation

WBC(x 103/uL) 13.36 4.0-11.0 Increased
RBC(x 103/uL) 4.92 4.2-5.4 Normal
Hb (g/dl) 13.1 11.8-16.5 Normal
Hct (%) 40.7 36.0-46.0 Normal
MCV(fl) 89 77.0-96.0 Normal
MCH(pg) 29 27.0-32.0 Normal
MCHC(g/dL) 33 30.0-35.0 Normal
PLT(x 103/uL) 237 150.0-400.0 Normal

Impression: Results showed….

Automated differential

White blood cell Result Normal range Interpretation

Neutrophil(x 103/uL) 11.1 2.9-7.9 Increased
Eosinophil (x 103/uL) 0.4 0.1-2.1 Normal
Lymphocyte (x 103/uL) 2.2 1.8-4.0 Normal
Monocyte (x 103/uL) 0.6 0.0-1.6 Normal
Basophil (x 103/uL) 0.0 0.0-0.2 Normal
Neutrophil (%) 82.8 40.0-75.0 Increased
Eosinophil(%) 4.2 0.0-5.0 Normal
Lymphocyte (%) 20.9 20.0-45.0 Normal
Monocyte(%) 5.3 0.0-8.0 Normal
Basophil(%) 0.3 0.0-2.0 Normal

Impression: Results showed….

Renal Profile

Electrolytes Test value Normal range Interpretation

Urea (mmol/L) 1.9 1.7-8.3 Normal
Sodium (mmol/L) 135 135-150 Normal
Potassium(mmol/L) 4.0 3.5-5.0 Normal
Creatinine (umol/L) 47 44-88 Normal
Impression: All were normal.

Liver Profile

Parameters Value Normal Range State

Total Protein 75 66-87 g/L Normal
Albumin 36 35-50 g/L Normal
Total Bilirubin 18 <20 umol/L Normal
Alkaline Phosphatase 126 53-128 U/L Normal
Alkaline 22 < 43 U/ L Normal
aminotransferase

Impression: Normal liver profile

Ultrasound of Left Breast

Findings: There is a large area of inflammatory soft tissues predominantly in lateral aspectof
the breast. There are large areas of loculated abscess seen in between the lobules. These
mainly seen near areola region.

Histopathology Examination

Fragments of inflamed and congested breast tissue, diffusely infiltrated by neutrophils with
microabscess formation. The breast acini show reactive cellular changes. Some of the acini
are slightly dilated and contain inflammatory cells No granuloma noted. No malignancy is
evident.

FINAL DIAGNOSIS

Left breast abscess

PRINCIPLE OF MANAGEMENT

Antibiotic

Intravenous Cloxacillin then changed to Tablet Cloxacillin1g qid

Analgesia

Intravenous Tramal then changed to Tablet Tramal 50mg tds then discharged with Tablet
Paracetamol 1g prn

Ultrasound guided aspiration

The ultrasound guided aspiration was deferred due to multiple locules and predominantly
non-liquified area.

Despite antibiotics and aspiration, the swelling got worse.

Incision and drainage

Area cleaned and draped

Incision made over middle area of swelling

Findings: 3cm x 3cm left breast abscess on the left outer quadrant, multiloculated cavity
3cm deep 2cm x 2cm, 10 ml pus with unhealthy tissue drained.

Septation are broken.

Area washed and cavity packed with gauze.

Daily dressing at nearest health clinic

TCA at specialist clinic for review

DISCUSSIO