Name of Patient: Gene Malabanan Hospital: DLS-UMC

Informant: Patient Department: Surgery

Reliability: Good Preceptor: Dr. Lampa
Historian: Salvatore Juliano M. Elardo Date Taken: July 30, 2018
Group No.: 18B Date Submitted: August 1, 2018

GENERAL DATA

GM, female, 49-years-old, Filipino, married, Roman Catholic, was born on September 19,
1969 in Agusan Del Norte, Mindanao and is currently residing in Sampaloc, Cavite consulted at
the OPD for the first time last July 30, 2018 in DLSUMC at 2:30 PM.

CHIEF COMPLAINT: “Masakit na bukol sa kanan na dede”

HISTORY OF PRESENT ILLNESS

The patient was apparently well until 1 week prior to consultation when she felt a stabbing pain
that was localized on her upper right breast which she had rated an 8/10 on the pain scale. The
pain was described as intermittent, only appearing and becoming aggravated when the patient
was doing chores that would strain her right arm. Patient took 500 mg amoxicillin, which was not
prescribed by anyone, to relieve her symptoms. Symptoms were also relieved with rest.
4 days prior to consultation the patient noted a small mass with a soft consistency on the
painful area that had become violaceous and became bigger every which prompted her to seek
consult. The mass was painful upon palpation and was approximately the size of a coin the day
of consult.

PAST MEDICAL HISTORY

Patient had only one hospitalization when she had undergone ligation 12 years prior to
consult in the month of July. Patient has no known allergies, no history of any accidents, surgeries,
or medications, and could not recall her immunizations. She is not diagnosed with diabetes, PTB,
pulmonary, hematologic, gastrointestinal, and neurologic diseases.

FAMILY HISTORY

The patient has no known type of disease on either side of her family.

OB-GYNE HISTORY

The patient is a G6P6 6006. Patient’s last LNMP was 1 month prior to consult. She had
an irregular cycle and usually had a 3 day duration of menses. Patient does not use contraception
and has not used in the last 6 months prior to consult.

PERSONAL AND SOCIAL HISTORY

 Patient finished high school and is currently a house wife. Her husband is the breadwinner
of the house and is a tricycle driver. They live with their six children. Patient’s daily routine consists
of doing household chores and taking care of the children. Patient’s daily diet consists of fish,
rice, and vegetables. Patient likes sweets and is not fond of drinking water. They’re trash is
segregated and is picked up every week. They use a gas stove in the home and obtain their water
from the water district. Drinking water is mineral water. Patient does not drink alcohol nor does
drugs.

REVIEW OF SYSTEMS

General: (+) weakness, (-) low grade fever, (-) weight loss, (+) easy fatigability, (-) loss of
appetite

Integument: (-) pallor, (-) hyperpigmentation, (-) wound, (-) rashes, (-) clubbing of nails

Head & Neck: (+) Headache, (-) stiffness, (-) neck vein distention, (-) mass, (-) dizziness, (-)
swelling

Eyes: (+) corrective lens, (-) pain, (-) loss of left visual field (-) redness, (-) discharge, (-) icteric
sclera

Ears: (-) difficulty of hearing, (-) otalgia, (-) vertigo, (-) tinnitus
Nose and Sinuses: (+) discharge, (-) epistaxis, (-) obstruction

Mouth and Sinuses: (-) toothache, (-) hoarseness, (-) dysphagia, (-) ulcers, (-) tongue fasciculation

Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis, (-) tachypnea, (-) dyspnea

Cardiovascular: (-) palpitations, (-) orthopnea, (-) angina, (-) paroxysmal nocturnal dyspnea

GIT: (-) nausea, (-) vomiting, (-) anorexia, (-) diarrhea, (-) abdominal distention, (-) abdominal
pain, (-) constipation

GUT: (-) oliguria, (-) nocturia, (-) flank pains, (-) dysuria, (-) palpable mass

Vascular: (-) claudication, (-) ulcers

Hematologic: (-) pallor, (-) easy bruising, (-) easy bleeding

Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) diaphoresis, (-) heat/cold intolerance
MSS/ Extremities: (-) joint pains, (+) edema, (-) fracture, (-) back pain

CNS: (-) seizures, (-) syncope, (-) tremors, (-) slurring of speech, (+) nervousness
 PHYSICAL EXAMINATION

GENERAL SURVEY

The patient is well nourished, fairly developed, conscious, coherent, oriented to time,
place, and person, has high blood pressure due to anxiety of consult, and appears to be her stated
chronological age of 55.

VITAL SIGNS
BP: 160/100 mmHg, sitting, right arm
PR: 93 beats/min
RR: 18 cycles/min
T: 36.2 C, axillary
O2 Sat.: 99

BREAST EXAMINATION

Patient has a 3 x 2.5 cm soft, palpable mass superior to the right areola which is violaceus in
color. No palpable lymph nodes on the right axillary area. Tenderness is also present on the area
superior to the left areola but no mass. No palpable lymph nodes on the left axillary area as well.
The left nipple is inverted and no nipple discharge in both nipples.

Salient features:
 49-years-old, female
 Irregular menstruation
 Palpable mass and tenderness on the right breast
 Tenderness on left breast
 Relatively quick growth of mass
 Weakness/easy fatigability

PRIMARY IMPRESSION: BREAST ABSCESS SECONDARY TO NON LACTATIONAL

MASTITIS

CASE DISCUSSION

This is a case of GM, a 49-years-old female who was admitted in our institution due to a
painful breast mass on the right breast associated with weakness and easy fatigability. Patient
developed breast mass 7 days prior to admission and complained of intermittent, stabbing pain.
Patient self-medicates with amoxicillin to relieve pain.
A breast abscess is a localized collection of inflammatory exudate in the breast tissue.
Commonly, breast abscesses develop from mastitis or cellulitis not responding to antibiotics.
However, Breast abscess can also appear as the first presentation of a breast infection, it can
develop de novo or occur as a complication of another disease such as periductal mastitis or skin
infection over the breast. Primary breast abscess usually develop as a consequence of lactational
mastitis, however, since it has been 12 years since the patient had undergone ligation and since
the patient no longer breast feeds, it is more likely that the patient has breast abscess secondary
to non lactational mastitis. Patients with breast abscess present with localized, painful
inflammation of the breast which can be associated with malaise along with a fluctuant, tender,
palpable mass. It can have a variable course of time where the abscess and mastitis develops in
5 to 28 days. Additionally, a primary breast abscess may develop when mastitis does not respond
to antibiotic treatment. Since the patient had taken self-prescribed antibiotics, primary breast
abscess may have developed due to the poor response from the drug. Finally, most cases of
primary breast abscess are caused by Staphylococcus aureus. Furthermore, methicilln-resistant
S. aureus infections are becoming increasingly common with patients having an increased
incidence of mixed flora and anaerobic infection in recurrent breast abscess.

Differential Diagnosis

Diseases Rule in Rule out

Mammary Duct Ectasia (+) Breast Mass, (+) Acute (-) Nipple discharge, (-) Fever,
local breast pain, (+) (-)
Inflammation (+)
Discoloration, (+) Tenderness
Inflammatory Breast Cancer (+) Breast Mass, (+) Breast (-) Weight loss, (-) Edema, (-)
pain, (+) Irregular Axillary lymphadenopathy
menstruation
Periareolar Mastitis (+) breast pain (+) breast (-) smoking (-) age, usually
mass on areolar area occurs in young patients

Systemic Lupus Chronic kidney insufficiency, (-) joint pain, (-) malar/discoid
erythematosus (+) hematoma, (+) edema of rash, (-) chest pain, (-) fever,
extremities (-) neurologic disorders

Plan of Management:

Diagnostics:
 Further Physical Examination
 Ultrasound – to evaluate presence of fluid collection in the mass
 Ultrasound guided aspiration and biopsy
 Blood culture – necessary to check for infection

Therapeutics:
 Empiric Antibiotic therapy – to prevent recurrence of infection

Non-pharmacologic:
 Advise patient to not self-prescribe and only take antibiotics upon professional prescription
 Have an annual breast examination.
  Exploration of social support

Surgery:
 Needle Aspiration – initial approach for abscess drainage; ultrasound guidance can
increase probability of complete drainage; needle aspiration must be repeated every 2 or
3 days until no collection remains
 Surgical drainage – warranted if the overlying skin becomes necrotic or ischemic and in
cases where abscess is not responsive to needle aspiration and antibiotics

References:
 Dixon, J.M. (2018). Primary Breast Abscess. In J. A. Melin (Ed.),
UpToDate. Retrieved July 31, 2018, from
https://www.uptodate.com/contents/primary-breast-
abscess?search=breast%20abcess&source=search_result&selectedTitle
=1~31&usage_type=default&display_rank=1