CASE PRESENTATIONDr. Vaibhav Wavhal

JRII, Shalya.

Name- Dharmavati Devi Age- 22years Sex- female Address- Baliya, U.P. Occupation- House wife Social status- lower middle class Marital status- married

Chief complaints:- duration

1.Movable lump in both breast 1 year

History of present illness

According to patient, she was asymptomatic before 1 year. Then she gradually developed small movable lump in right breast. After 2 months, she noticed lump in left breast too.

During the course of disease she neither suffered from fever nor had any pain in same region.

She had taken conservative treatment from local doctors, but since no relief she came in BHU for better management.

History of past illness

No h/o DM, TB, HTN,BA

No any H/o drug allergy

No any operative history

Personal history

Family history- no relevant family history Diet- mixed Appetite- good Bowel- 2 times/day, with normal colour &

consistency Micturition- no any complaints Sleep- not altered Addiction- no

Personal history……

Marital history- Married at 20 years of age

Menstrual history- 4-5 days/28-30days Not painful, regular No h/o excessive or decreased menstrual flow Menstruation does not aggrevates pain in breast

lump

Physical examination

GC- Fair Temp- Afebrile P/R- 76/min BP-122/82mm of hg No pallor, icterus, cyanosis, clubbing,

oedema No any palpable lymph nodes

Systemic examination

CNS- NAD CVS-NAD RS-NAD GIT-NAD

Local examination

Inspection- No any scar seen Nipples- not retracted

Palpation- No rise in local temperature No tenderness Lump - 2 in Rt breast- upper outer & upper inner

quadrant Lump- 1 in Lt breast- lower lat. quadrant Consistency- firm

Local examination……

All the lumps globular in shape and size Lump margins- well defined Fluctuation- not present Lump tend to slip while palpating with fingers Lump not fixed to skin & breast tissues

Provisional diagnosis

B/L fibroadenoma

Diffential diagnosis

Mastitis Fibroadenosis Cysto-sarcoma phylloids Duct papilloma CA Breast Galactocele Traumatic fat necrosis

Investigations

All blood investigations- within normal limits

FNAC – s/o Fibroadenoma of breast

management

Surgical procedure performed- Enucleation of Fibroadenoma was done.

Thank you