Patient Encounter 2 (Jan 15, 2025)

A. Demographic Data
Patient VB is a 49 year old woman who lives in Caloocan City. Her religion is Iglesia ni
Cristo and she is currently married.​

B. Chief Complaint
​ Patient VB palpated a mass on her left breast.

C. History of Present Illness

​ The mass was first noticed by the patient 1 year PTC during a breast self-examination.
She described the mass as a peso-coin in diameter, bumpy, soft, and diffuse. She did not notice
an increase in size since she first palpated the mass. No change in skin color, nipple discharge,
or tenderness during palpation was noted by the patient. She also felt occasional stabbing pain
on the lateral side of her left breast. She does not remember when the pain started, but noted
that the pain usually did not last longer than 3 minutes. A painful episode occurs around once a
week at sporadic times, with a pain rating of 4/10 that does not interfere with daily activities. No
aggravating causes were noted by the patient and she did not do anything to alleviate the pain
due to its short duration. Since the onset of pain, she has not noticed a change in
characteristics. She was prompted to seek a consult due to the palpated mass for her own
self-assurance.

D. Past Medical History

The patient has had chickenpox, measles, and mumps during her childhood. She had a
BCG vaccine, tetanus, pneumonia, HPV, and COVID (3 doses of Pfizer) but other
immunizations are unrecalled.

She was diagnosed with hypertension in her 30s and diabetes in 2023. She is currently
maintained on Metformin (500 mg) 3x/day and Amlodipine (5 mg) 1x/day. Her usual blood
pressure is 135/90 mmHg.

In 2019, VB had surgery on her left ovary to remove a 13 cm cyst. However, the cysts
returned and now affected both her ovaries in 2020. She was advised to have bilateral
oophorectomy, but her surgery was delayed because she caught COVID. 3 months later in
2020, her transvaginal ultrasound discovered that her cysts resolved on their own and surgery
was no longer indicated. Instead, she was injected with an unrecalled medication monthly right
after her COVID infection to stop menstruation and prevent ovarian cyst regrowth. The injection
intervals were slowly tapered to every 3 months.

E. Obstetric and Gynecologic History

​ The patient had her menarche at 11 years old. Her cycle usually lasted around 30 days
with her menstruation lasting for 4 days. She consumed around 1 pad a day and had no
associated diarrhea or constipation but did have occasional dysmenorrhea during menstruation.
Her OB score is 11(1001) with a son who is currently 23 years old.

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​ Her coitarche occurred when she was 25 years old. She has had only one partner, he
current husband who she is married to for 23 years. She has no history of STDs. She is
amenorrheic since last year, but was not tagged as menopausal.

F. Family History
​ Her sister is currently being treated for HER2 (+) breast cancer that was diagnosed in
2022 at age 45. She also had a brother who had leukemia and died when he was 39 years old.
Both her mother and father had hypertension, while her mother also had diabetes. Her father
was also treated for tuberculosis in his 40s. Her paternal aunt has brain cancer, and her
paternal uncle had liver cancer and died in his 50s.

G. Personal and Social History

Patient VB graduated from BS management. She is currently a housewife and lives
together in one house with her husband and 23 year-old son. Her husband is a minister in the
Iglesia ni Cristo church. Their financial situation is sufficient, but the patient mentioned being
interested in applying to become a Social Services patient in St. Lukes just like her sister. Their
living environment is clean with regular trash collection.

​ Her diet is more vegetable-based, but she also eats rice and meat. These meals are
usually home-cooked. Her water intake is less than 8 glasses od water. She jogs for 1.5 hours
per day and does household chores. Her daily routine mainly consists of household work. She
sleeps an average of 6 hours everyday.

​ Patient VB does not drink alcohol, smoke, or do illicit drugs. Her husband has been
informed of her condition and is supportive and encourages her to get a mammogram. Her most
recent travel history was spending the New Years at Zambales.

H. Review of Systems
General No recent weight change, fever, dizziness, chills, difficulty in sleeping

Skin Non-vesicular, flat, erythematous ashes that appears yearly on her

torso (under breast until umbilical line)
Hair loss was noted by the patient
No nail changes

HEENT Patient VB noted her vision blurring when she has read too much, but
no redness, tearing, double vision, or pain experienced
No decrease in hearing, ear pain, ear discharge, ear ringing, ear
bleeding
No nose congestion, anosmia, or pain
No gum bleeding, toothaches, or loss of taste
No throat hoarseness, sore throat, thrush, no dry mouth.
Had an episode of stiff neck once the past 2 weeks, no palpated lumps
on neck

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 Respiratory Experienced back pain aggravated by inspiration after physical
exertion from household chores.
No difficulty of breathing, chest pain, or cough

Cardiovascular No chest pain, palpitations, shortness of breath, edema, easy

fatigability, orthopnea, or syncope

Gastrointestinal No swallowing difficulties, heartburn, epigastric pain, change in diet,

nausea/vomiting, change in bowel habits, diarrhea, constipation

Urinary No dysuria, incontinence, urinary hesitancy, change in urinary stream,

urgency, hematuria, frequency of urination, unusual discharge

Peripheral Vascular No muscle pain, leg cramps, intermittent claudication, prominent

varicose veins, coagulation abnormalities

Muskuloskeletal Had an episode of back pain after household chores

Hematologic No abnormal bleeding or easy bruisability

Endocrine Patient is naturally sweaty. No abnormal changes to heat or cold

Neurologic Noheadaches, syncope, weakness, numbness, tingling sensations

I. Physical Examination
General Survey: Patient was awake, alert, ambulatory, and well-groomed. She showed
no signs of pain or respiratory distress.

Anthropometrics: Height: 159 cm

Weight: 72 kg

BMI: 28.5 kg/m2 (Asian standards: Obesity Class I)

Vital Signs: Blood 130/80 mmHg

Pressure:

Heart Rate: 92 bpm

Temperature: 36.7℃

Respiratory 22 cpm
Rate:

Oxygen 98%
Saturation:

Skin: No abnormal skin textures noted on the limbs, but there were flat,
non-vesicular rashes noted on her anterior torso.

Head, Eyes, Ears, Head: No gross deformities and masses on the head were
Nose, Throat observed.

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(HEENT):

Eyes: No exophthalmos. No swelling eyelids, anisocoria,

strabismus, discharge, pain, or redness. Pupils were
equally round and reactive to light. There was
symmetrical eye movement with uniform accommodation
and convergence.

Ears: No gross deformities and lesions observed. No

discharge, discoloration, or masses on external ears.
Otoscopy and hearing test not performed.

Nose: No gross deformities and lesions observed, midline nose

bridge. No swelling, redness, or discharge of external
nose. Both nares patent. Rhinoscopy not done.

Throat: No sores or masses seen in the oropharyngeal cavity.

Uvula midline with non-inflamed posterior pharyngeal
wall. Tonsils were not enlarged. Pinkish mucosa.

Neck: Clear voice with no hoarseness. No cervical lymphadenopathies

palpated. Trachea is midline. Thyroid not palpable.

Chest and Lungs: No chest deformities seen on inspection. No increased work of breathing
or use of accessory muscles. Schamroth’s window present
Symmetric chest expansion and fremitus
Both lungs are resonant
Vesicular breath sounds with no appreciated wheezing, rales, or rhonchi

Cardiovascular: No pallor or clubbing of fingers

JVP: 1 cm from sternal angle
No thrills, heaves, lifts
Tapping PMI found in the 5th ICS midclavicular line
Distinct, rhythmic heart sounds with no murmurs heard
S1 louder than S2 at apex, S2 louder than S1 at base with physiologic
split

Abdomen: Flat abdomen with CS scar (low vertical cut) noted. Erythematous rashes
present (from inferior border of chest to umbilical line)
Normoactive bowel sounds
Liver edge 2 cm below right costal margin. Tympanic abdomen with
scattered dullness across all quadrants
(-) Murphy’s sign, no guarding, tenderness, masse, or organomegaly

Genitourinary: Pelvic exam not performed.

Peripheral No peripheral cyanosis, pain or numbness on fingers and toes.

Vascular:

Musculoskeletal: Extremities have no edema or limitation of movement. Pulses are strong

and equal on both upper and lower extremities. 5/5 motor strength in all
extremities.

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 Upper Extremities:
●​ Locked joint found in the distal phalangeal joint of the fourth finger
(ring finger) on the right hand.
●​ No scarring, lesions, discoloration
●​ Normal skin turgor
●​ No tenderness, pain, Bouchard nodes, or other deformities noted
on both hands
Lower Extremities:
●​ No tenderness, bogginess, or swelling of the anterior aspect of
the ankle joint on both feet
●​ No lesions found on the plantar surface of both feet
●​ No tenderness or pain in joints and toes

Neurologic: Mental Patient was alert and oriented to person, place, and time.
status: Speech is fluent, coherent, and appropriate

Cranial CN 2 (Optic Nerve): Visual fields are full to confrontation

nerves: CN 3,4,6: Pupils are equal, round, and reactive to light
and accommodation. Extraocular movements are intact
without nystagmus, strabismus, or ptosis
CN 5: Sensation is intact in all three divisions bilaterally.
Jaw strength is normal and symmetrical
CN 7: Facial movements are symmetrical with no
weakness or asymmetry.
CN 11: Shoulder shrug and head turn against resistance
are strong and symmetrical bilaterally
CN 12: The tongue is midline with no atrophy or
fasciculations. Tongue strength and movement are
normal.

Motor: (See MSK PE)

Breast Rashes visible on upper chest

Symmetrical breasts with no d8impling on both breasts. Outward-turned
nipples with brown areolas and no apparent discoloration or swelling.
Mass on left breast is not visible on inspection.
5 cm (widest diameter), irregular, solid, soft to firm, fixed mass at the 2A
position of the left breast. No axillary lymphadenopathies palpated.
No nipple discharge

J. Problem Representation
​ Patient VB is a 49 year old woman who palpated a mass on her left breast 1 year PTC.
An episode of stabbing pain on her left lateral breast is felt around once a week, lasting 3 min in
duration (rated 4/10 in pain) but does not interfere with daily activities. She is a known diabetic
and hypertensive maintained on Metformin (500 mg, 3x/day) and Amlodipine (5 mg, 1x/day) .
She has a history of ovarian cyst removal (left) and recurrence (both ovaries) in 2019 and 2020.
Her doctor gives her regular injections (once every 3 months) of an unrecalled medication to

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stop menstruation and prevent ovarian cyst regrowth. On physical examination, a 5 cm,
irregular-bordered, solid, soft to firm, fixed mass at the 2A position was palpated on the left
breast. No axillary lymphadenopathies palpated. No recent weight changes, change in breast
pain, mass size, or mass tenderness.

K. Differential Diagnoses
DDX 1: Breast Cyst
​ Breast cysts are often solitary masses seen in women aged 35 to 50 years old. They are
derived from the terminal duct lobular unit and can form well-circumscribed circular/ovoid
masses or an ill-defined mass that presents grossly. They are often ballotable on palpation,
smooth, and firm in texture, similar to a water balloon (Laronga & Mooney, 2024). The
development of a cyst is usually not sudden, with a growth period that can reach years. They
can be painless or tender upon palpation or the menstrual cycle of the patient. Simple cysts
belong under the Page nomenclature of nonproliferative disorders of the breast which accounts
for 70% of benign breast conditions and carry no increased risk of breast cancer development
(Brunicardi, et al., 2019). Cysts can be classified as simple, complicated, or complex depending
on the ultrasound results of the cyst’s structure and vascular flow. This classification is also tied
into the Breast Imaging-Reporting and Data System (BI-RADS) final assessment categories that
can guide clinical decisions for biopsy. Simple cysts are BIRADS 2 (benign) and does not
usually warrant tissue sampling, while complex cysts are usually BI-RADS 4 or 5 (suspicious or
highly suggestive of malignancy) and warrants a biopsy. A mammogram is also an imaging tool
that can be used to assess breast cysts, though ultrasound is often enough to diagnose this
condition. Due to the morphologic variability of breast cysts, a thorough physical examination,
medical history, and imaging modality should be done to guide clinical decisions.

DDX 2: Sclerosing Adenosis

​ Sclerosing adenosis is classified under proliferative disorders without atypia, and is
prevalent in women in their childbearing and perimenopausal years. Thus, this is not an acute
condition, but one that develops through the years. This is a benign condition that has no
malignant potential, but it is a mimic for breast cancer due to the distorted breast lobules that
can manifest as multiple microcysts or a gross, ill-defined mass that prompts a patient to consult
a doctor once palpated. Histologically, there are proliferative changes (ductal proliferation) and
involutional changes (stromal fibrosis and epithelial regression). Benign calcifications are also
often associated with this disorder. Aside from its similarity to breast cancer on palpation, this
condition can also mimic breast cancer on mammography and gross pathologic examination
that would likely call for excisional biopsy to be done to differentiate the two conditions. A larger
tissue biopsy is recommended such as vacuum-assisted biopsy or open surgical excision
biopsy is recommended over smaller biopsy samples (e.g. core needle biopsy) as the specimen
showing benign disease may conflict with more malignant-adjacent radiographic findings
(Brunicardi, et al., 2019).

DDX 3: Invasive Breast Carcinoma

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​ Unlike ductal or lobular carcinoma in situ that are localized to their affected duct or
lobules, invasive breast cancer is defined as the malignant proliferation of epithelial cells lining
the ducts or lobules of the breast. Breast cancer is a predominantly sex hormone-dependent
disease that is affected by estradiol and estrone. Risk factors for developing breast cancer
include: early menarche (<12 years), late first full-term pregnancy (>35 years old), and
exogenous hormone therapy. In menopausal women, hormone replacement therapy with
estrogens plus progestins increases the risk of developing breast cancer significantly by
encouraging tissue growth (Loscalzo, et al., 2022). Ductal carcinoma is more common than
lobular carcinoma, and more commonly presents as a discrete mass. Lobular carcinoma
commonly presents as more poorly-delineated masses (Limaiem, et al., 2023). On
histopathology, cords and nests of cells are seen, while lobular carcinoma are characterized by
small cells that infiltrate the mammary stroma and adipose tissue in a single file pattern

Axillary adenopathy and skin findings such as erythema, thickening, or dimpling are
marks of locally advanced disease. Mammographic findings for this condition will indicate a soft
tissue mass and the possibility of microcalcifications. However, similar to the other differentials,
a biopsy would be more specific in determining the type of breast carcinoma involved. On
ultrasonography, suspicious findings that may suggest malignancy include: hypoechogenicity,
internal calcifications, shadowing, a taller-than-wide lesion, and indistinct margins. The BI-RADS
criteria may still be applicable to guide clinical decisions as needed.

L. Lead Diagnosis: Invasive breast carcinoma (Grading to be investigated)

The description of the patient’s mass as irregularly-shaped and fixed makes the
diagnosis of cysts less likely. Although cysts can sometimes present irregularly with less signs of
being fluid-filled, the mass has been present for a year and the patient noted that the texture of
the mass did not change. She also has concerning family history that would warrant a more
cautious diagnosis of a malignancy over a cyst. In the same thread of thought, sclerosing
adenosis is a benign condition that may mimic breast cancer in terms of mass characteristics.
Although fibrocystic changes in the breast such as sclerosing adenosis cannot be ruled out
completely without a better visualization of the mass, her history of ovarian cyst growth and
siblings diagnosed with malignancies increases her risk of malignancy above those of the
general population as will be discussed below.

Patient VB’s mass has suspicious characteristics that would necessitate further
investigation that include: soft to firm texture, ill-defined borders, fixed, and causes occasional
breast pains. Her family history of many of her close relatives being diagnosed with cancer, and
her sister being diagnosed with breast cancer and brother dying of leukemia also point to a
genetic predisposition that may be more vulnerable to the development of malignancies. She
also had a personal history of ovarian cyst growth that can indicate hormonal dysfunction that
was inherent to the patient and can increase her risk of developing breast carcinoma. Although
the medication injected by her doctor (assumed to be GnRH or progestin) can play a protective
role against breast cancer, her hormonal dysfunction may not be totally resolved. GnRH
injections may help reduce estrogen levels, but this is not a long-term therapy modality as there
are also associated risks with its long-term usage. As breast cancer is a predominantly

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hormone-based disease, other factors such as her obesity, hypertension, and diabetes may also
play a role in hormonal imbalance. It is also of note that the patient is an active person, with
daily jogging, household chores, and a predominantly vegetable-based diet. Even with these
healthy habits, she is still categorized as obese, which may also indicate that there are
hormonal imbalances that could be affecting the patient. However, it stands that it is the
patient’s mass characteristics, family history, and personal medical history that ultimately raises
red flags for the patient’s mass as a possible malignancy.

M. Diagnostic Plan
​ Imaging modalities such as ultrasound and mammogram (sonomammogram is done so
the lymphnodes can be ultrasounded to check for lymphadenopathies) are first-line diagnostics
needed to evaluate the patient’s breast mass. The structure, contents, and margins of the mass
can be investigated via these modalities. Once the mass is identified, tissue biopsy and
histopathology can be considered as needed if the patient’s mass is suspicious. Blood tests
including CBC, biochemistry, and metabolic panel can assess if other organs can have
etiologies related to the patient’s mass and will also serve as a method to check for other
metabolic abnormalities that may need to be corrected. Familiarize the BIRADS category

N. Management Script
​ Excisional biopsy is the mainstay treatment for breast masses that are indicated for
removal. If the patient’s mass is confirmed to be carcinoma, chemotherapy or radiation may also
be indicated. Monitoring of her hormones and other comorbidities is also needed to increase the
patient’s capacity to withstand treatment.

O. Prevention and Health Maintenance

​ Maintenance of her diabetic and hypertensive medications is necessary. Although the
patient is relatively active and consuming a healthy diet, more guidance regarding her weight
may be needed to lower her BMI.

References:
Brunicardi F, & Andersen D.K., & Billiar T.R., & Dunn D.L., & Kao L.S., & Hunter J.G., &
Matthews J.B., & Pollock R.E.(Eds.) (2019), Schwartz's Principles of Surgery, 11e.
McGraw-Hill Education.
https://accesssurgery.mhmedical.com/content.aspx?bookid=2576&sectionid=208294867
Laronga, C. & Mooney, B. (2024). Breast cysts: Clinical manifestations, diagnosis, and
management. Uptodate. Retrieved from
https://www.uptodate.com/contents/breast-cysts-clinical-manifestations-diagnosis-and-m
anagement?search=fibroadenoma&topicRef=804&source=see_link#H9
Limaiem F, Khan M, Lotfollahzadeh S. Lobular Breast Carcinoma. (2023). StatPearls Treasure
Island (FL). Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK554578/
Loscalzo J, & Fauci A, & Kasper D, & Hauser S, & Longo D, & Jameson J(Eds.), (2022).
Harrison's Principles of Internal Medicine, 21e. McGraw Hill.

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