i'm taking it one day at a time, with a growing confidence that I may just be able to make it to the finish line successfully for the first time.

Date:   10/7/2006 7:43:26 PM ( 18 y ago)

“The most successful men in the end are those whose success is the result of steady accretion. It is the man who carefully advances step by step, with his mind becoming wider and wider - and progressively better able to grasp any theme or situation -”

Alexander Graham Bell quotes (Scottish born American Inventor and Educator, best known for the invention of the telephone in 1876. 1847-1922)

Sleep: 5 hrs
BM:none, but colon may contain detox waste
urine: sweet, ketolysis occurring (postivie indication of fuel shift)
breathing: unblocked,pass out some mucus, poor olfactory ability
tongue: thin white film 90%, salty viscous saliva
pulse: strong
skin: extensive dryness, outer dead epithelium trying to peel(indication that consumption of EPO may be beneficial), bruises mostly healed, mild itch localized at elbow and knee joints
abdominal: stomach shrinking constantly, explains the rectal and oral passing of an acidic gas(my guess of this phenomenon)
exercise: depends on the haze
sunbathe:depends on the haze

overall feeling: worsening blackouts during standing after sitting, discomfort during stomach shrinkage, played the piano for 3 hrs(crazy crazy crazy)-->termendously exhausted and weak, esp coupled with lack of sleep--> hunger pangs begging me to replenish energy with food (so that is what the ache in my tummy is all about), physically extremely weak, energetic in other aspects, studied 3 hrs

Incident: completed entire study on breast cancer, may want to read deeper later. General Cancer will be covered within the next few days. I have to try my best to grasp the concepts of the ECG--it is a headache! Meanwhile, I shall do what I will not normally have done in my past: mini-celebrate the completion of a case study analysis, good job gal. It was easier than I thought it would be--I think I finally understand the idea of pacing. By pacing, I mean just make each day about no more than 2 main activies. ie. "Breast cancer [study] day"

PBL UNIT 2

HIstory of the presenting complaint

Madam Koh a 48 yr old Chinese lady was referred to a surgeon for a left breast lump of 3 months' duration. She had been quite well till threee months earlier when she noticed a lump in her left breast while bathing. She did not inittially worry as she had not felt any pain. However she noticed that over time the mass did not subside and a close friend of hers advised her to seek medical attention.

Mdmd Koh had gotten married in her early thirties and had two children. She did not breast feed the children and had not taken any contraceptives.

There is no family history of breast cancer, but her younger sister is worried that she might be prone to the same condition.



Clinical findings

The patient appeared generally well, was not obese, anaemic or jaundiced. Blood pressure was 115/65 mmHg and pulse rate was 78 per min.

The main findings were confined to the left breast which appeared of average size with normal looking nipple. There was a 2.5cm lump close to the nipple in the upper outer quadrant of the breast. It was hard and irregular but showed no signs of fixity to the overlying skin or underlying chest wall. No enlarged nodes could be felt int he right axilla.

Abdominal examination revealed no abnormalities such as enlarged liver. The chest was clear, with normal breath sounds.

Investigations

Chest X ray: Normal

Ultrasound and mammorgram: confirmed a mass with malignant features with no evidence of multicentric disease.

Biopsy report

Histological examination showed ductal carcinoma infiltrating into the surrounding stroma. There was significant fibrous reaction around the tumour area. Lymph nodes examined showed no evidence of cancerous involvement.

Management and follow up

The patient underwent total mastectomy and axillary clearance, with post operative chemotherapy and hormonal therapy. Her sister was counselled for her concern regarding her own risk of developing breast cancer.

MY ANALYSIS
Diagnosis: IDC(Invasive Ductal Carcinoma), 80% all breast cancer cases, Stage II with large extent of *invasion of cancer cells to surrounding tisues

T=2.5cm N=0 M=0

T= tumour size
N= nodes inffected by cancer cells
M=distant metastases

Tumour description:

Left breast
2.5cm
close to nipple, UQ of breast
hard and irregular—eliminate fibrocytic condition of breast
no fixation to overlying skin/underlying chest wall—eliminate skin cancer and sarcoma (malignant tumour CT, muscle)

Metastasis

Regional=0
No enlarged nodes could be felt, not always accurate
Biopsy confirms not infected by cancerous cells

Systemic=0

2 pathways:
1. lymphatic-borne spread—eliminated in Regional M=0
2. blood-borne spread—Distant M=0

Cancer cells adhere to BM by receptors
During metastasisextrude proteolytic enzymesdigest BMcancer cells escape BMsurrounfing capillariessystemic metastasis
Common sites of systemic metasized cancer cells:
1. liver—not enlarged
2. bone—Xray normal
3. lungs—breathing normal
4. brain

*Invasion

Large extent
Require total/simple mastectomy
< modified radical mastectomy may be more accurate as lumph nodes are removed>

Treatment
Modified radical mastectomy
Axillary clearance (preventive measure of possible widespread metastasis when signs of lymph node infection is not present as metastasis may currently be microscopic)

??was radiation supplemented after surgery

post operative treatments:
chemotherapy: kill malignant metastazing cells, preventive measure, standaed for Stage II
hormonal therapy:
 tamoxifen??—no results of postive/negative estrogen/progesterone receptors on cancer cells
 herceptin??—no results of positive/negative HER-2 (Human Epidermal Growth Factor)
 others??

Cause:

Idiopathic, may involve complex interplay of factors
Risk factors:
Genetics: eliminated as no family history
Pregnancy: early 30s—increase likelihood for breast cancer
Breast feeding: absent—increase likelihood for breast cancer
contraceptives(esp birth control pills): absent—lower likelihood of breast cancer
age: 48yrs old—1/93 chance of contracting breast cancer
race: chinese, asian—lower risk
abnormal timing of menarche and menopause??
DES(diethylstilbestrol)??
diet??
Drugs??
Alcohol??
HRT??
Exercise??

Overall condition

Healthy
pulse: a little high—overworked heart? Weak heart?
BP:115/65mmHg—normal, no high/low blood pressure
Anemia, jaundice—absent: optimum oxygenation of tissues
Not obese (does not eliminate possible causes in diet or drugs as she may have a high metabolism)

Incident: As the evening wore on, my weakness forced me to collapse in bed. I prayed for strength. Something happened though I have yet an explanation for. During my weakest moments, my mind was beseiged by haphazard rapid thoughts--thoughts of yet-to-complete work,unsatisfactory performance for my work, things I want to do but have no time for, anxiety about my illness, pangs, tension in my back-- which made me very irritable and dazed. What does this mean?



 

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