Fibroadenoma seen in Right Breast

Hello Dr.

1. ID: Kashmira,
2. Age: 24 years,
3. Sex: FeMale,
4. Single/Married: Married having 3 years old Baby(Stop Breast Feeding).
5. Weight: 60 Kgs
6. Height: 5ft 3 inches (157cm)
7. Country: Ranchi, Jharkhand India.
8. climate: Summer, Rainy, Winter

9. List of your complaints:
Ans:

(a)Right Breast shows a solid encapsulated mass present.

(b) Bilateral Polycystic Ovaries in abdomen.

SONOMAMMOGRAPHY done on 06/06/2013 for complaint (a).

Report:
Right breast shows a solid encapsulated mass of size 15X12X8mm at 10o'clock position; adjacent to nipple(about 8mm from int.os). This mass lesion is well defined and of uniformly hypoechoic echopattern with no ovious vascularity. No calcification present.

Both breast otherwise shows normal soft tissue echopattern.
No micro or macro calcification seen.
No duct dilatation present.
No skin oedema, thickning or puckering present.
Normal nipple. Subareolar region is normal.
Axilla are clear, no lymphadenopathy seen.

IMPRESSION- Right breast mass lesion resembling - Fibroadenoma seen.

end of report a.

ULTRASOUND of WHOLE ABDOMEN done on 14/03/2013 for complaint (b).

Report:
Ovaries - Enlarged with multiple tiny follicles arranged around the central stroma. Feature suggests it to be polycystic

ovaries.
R.O.-37X30X23mm of volume 14cc.
L.O.-40X27X20mm of volume 12cc.

and Liver, G.B., C.B.D., PANCREAS, SPLEEN, VESSELS, KIDNEYS, URETERS, UB, UTERUS, FREE FLUID, L.NODE, INTESTINE are Normal

IMPRESSION - Bilateral Polycystic Ovaries.
Other scan organs are normal.


10. Since how long are you suffering from each complaint?
: 1 Months for complaint (a)
and
: 3 Months for complaint (b)

11. Diabetic or non-Diabetic : Non-Diabetic, Fasting-83 mg/dl

11a. Thyroid functioning complications: Thyroid hYPO.

31/01/2013
T3-48 ng/dl (Normal)
T4-150 nIU/ml (Exceed)

04/02/2013
T3-63.96 ng/dl (Normal)
T4-1.50 nIU/ml (Exceed)
TSH- >150 nIU/ml (Exceed)

18/03/2013
TSH-3.70 nIU/ml (Normal while taking medicine)

12. Desire sweets/sour/salt : Sour and salt.

13. Thirst: I don't feel thirsty. Drink almost 1 to 1.5 Lts water every day.

14. Tongue and Taste
: Toung Clear, Taste is Good

15. Current BP (without medicine and with medicine) :120/80 Normal

16. What exactly is happening?
: My sometimes Right Breast pain in upper side. felling a mass object in under nipple for complaint (a).
: Sometimes pain start on Right to left or whole stomach for complaint (b).

17. How do you feel?
: uncomfortable and Tiredness for complaint (a).
: Sometimes Pain in whole stomach for complaint (b).

18. How does this affect you?
: Mentally disturb and Tiredness.

19. How does it feel like?
: it feel a small solid mass and sometime pain around this.
: Sometime pain in Right side of stomach for complaint (b).

20. What comes to your mind? : When pain starts i get irritability and anger also.

21. One situation that had a big effect on you?
: in my mental.

23. What sensation do you experience in that situation?
:Not applicable in for complaint (a).
:felling pain in Right side of stomach for complaint (b).

24. What are you showing by that gesture of your hand (Habits or Actions)?
: Looking Stressed.

25. Current and previous remedies/medicines you are taking or took in the past?
: Allopathic Medicne
(a) Thyrox 100mg. Once Tab Empty Stomach Daily for Thyriod.
(b) No any other medicine taken earlier or before having for complaint (a) and (b).

26. Family Background?
:Mother (50 Years) Having Polycyst in abdoman.
:Father (60 Years) Having Sugar and Thyroid.

27. Educational Qualifications of the patient?
: B.A.

28. Nature of work, what do you do for living?
: I am Housewife doing all the work in my house. my husband earn money.

29. Desires, likes and dislikes for food?
: I like bitter and spicy vegetable. Though I do not like sweets, I like them a lot.
i like fried foods, spicy, oily foods.
Dislike: Sweets.

30. Name of foods which increase your problem: Spicy food increase my stomach problem.

31. Mind-behavior, anger, irritability, hurry, impatient…and so on.. How are you different from other persons, public speaking or not , you can describe all of the details about your behavior, love and affections?
: irritability, I am doing all work for every family member so they satisfied me and i am very happy. but when i am ill i thought all the people asked me and give relaxastion if they donot then i agner with all.

32. Aggravation (increases-time, season,)& Amelioration (Decreases)?
: if some heart me then i clam down in one day. decrease very high when some one talk wrong about me.

33. Attached here your photographs of the affected area. (if required/optional)?
: Not Applicable

34. Location of the disease?
: Right breast mass lesion resembling - Fibroadenoma Seen for complaint (a).
: Bilateral Polycystic Ovaries for complaint (b).

35. Side of the problem (Right or Left), (Upper or Lower part of body).
: Only Right Breast for complaint (a).
: Pain Right side appendix area for complaint (b)

36. Color of the secretions/discharges e.g urine, stool, sputum, Saliva etc.
: Urine : culture is normal tasted one month before.
Stool : Normal
sputum, Saliva: Not Applicable.

For Females Only
37. When is the period during the month approx date? Any monthly cycle issues? Regular, early, late, before problems, after problems, pain, any other discharges?
: My Period is always late 5-8 days, 15th of month and end of 20th of month, right time having 5 days, during that time i feel discomfort and get irritated sometimes. Flow is Normal, colour is Red or Mairun, sometimes small clots. sometime normal pain in my lower abdomen.

38. Are you pregnant? If yes, please give pregnancy start date? Any current issues?
: No

Additional Information:

39. Do you have digestion problem? Explain in details.
Ans : Yes, I have Sometimes digestion problem when taking Antibiotic Allopathic medicine. mostly Gastric Problem in evening.

40. Do you feel good in warm or cold or humid climate? Which climate aggravates your problem?
Ans : I generally feel good humid or Rainy Session.

41. Do you have any stress? Explain in details.
Ans: not right now.

42. Do you get normal sound sleep?
Ans: I take about 7-8 hours of sleep everyday normal.

43. Do you exercise daily? Or any other physical activity.
Ans: I don't do exercise.

44. How is your hunger: Less, Normal or Excessive?
Ans: Normal. At times, I feel hungry more then normal.

45. Is your sweat normal or less or more? Where does it sweat more: Head, Trunk or Limbs?
Ans: I sweat a lot in exposure to heat or while work in summer sesion. Usually I sweat normal.

46. Please give details about your food intake (breakfast-lunch-dinner)?
Ans:
Breakfast (9 am): Chapati with tea or milk or vegitable.
Lunch (1 pm): Rice, Vegetables Dals don't like very much.
Evening tea (4 pm): tea and 4-5 Biscuits or some snakes.
Dinner (8-30 pm): 4 Rotis, vegetables or Rice.

Thanks

Reply ASAP
[message edited by Kashmira on Fri, 07 Jun 2013 08:46:14 BST]