| Name Of the Patient : |
Smt. Mandakini V. SarDeshpande |
| Age: |
70 Years Female |
| Date: |
21-10-1999 |
| Address : |
558 Shaniwar Peth, Pune 30, Maharashtra India. |
| Diagnosis : |
Ca breast |
| Biopsy Report :(11/10/1999) |
Clinical : Lump in Lt.
breast.
Specimen : Smears of exam.
Microscopic : Smears are cellular & show small or large clusters
or isolated large round to oval cells. Cells show anisonucleosis
& variation in size and show hyperchromatic nuclei with
eosinophilic cytoplasm. Smears are positive for malignant cells.
IMPRESSION :
Present cytology is positive for malignant cells. Infiltrating
duct carcinoma-
Grade II
|
|
|
| Status of the Patient : |
A. No Operation
B. No chemotherapy.
C. No Radiation |
| Treatment Given : |
Only on our Homeopathic medicine
after detection. |
|
Follow Up Investigation : |
HRCT of Lungs(21-10-1999)
HRCT of lungs has been done by taking 2 mm thin axial sections at 10
mm interval. Post contrast images were obtained on mediastinal
windows.
Previous FNAC reports reveal(lump in left breast)- infiltrating duct
carcinoma.
Study reveals focal soft tissue density nodular pleural based
opacities in right upper lobe posterior segment, and focal patchy sub
segment opacification noted in left lingular lobe-? Metastatic ( In view
of clinical details)
Evidence of soft tissue density nodular component measuring 15 x 8 mm
noted in left breast( Medial Compartment).
Mediastinal vascular structures show normal anatomical disposition.
The trachea is central, both the main bronchi are well seen appear
normal.
The pre and para tracheal spaces and subcarinal spaces are well seen
and appear normal.
There is no evidence of lymphnode enlargement.
The cardiac size and configuration is within the normal limits.
IMPRESSION:
1. Study reveals focal soft tissue density nodular pleural based
opacities in right upper lobe posterior segment and focal patchy sub
segmental opacification noted in left lingular lobe - ?
Metastatic ( In view of clinical details).
2. Evidence of soft tissue density nodular component measuring 15 x 8 mm
noted in left breast.(Medial Compartment).
CT Scan of abdomen ( 2-8-2000)
CT scan of abdomen has been done with and without intravenous
contrast. Bowel loops were opacified with dilute gastro graffin.
Liver is normal in size and shows homogenous parenchymal density. No
focal hepatic lesion or mass is noted. No subphrenic pathology is
noted.
Gall bladder is well distended with smooth outline. There is no
evidence of any radio opaque calculi. no intra luminal mass is seen.
Pancreas is seen in its entire length and is normal in size and
configuration. No focal lesion, mass or pancreatitis is noted.
The spleen is normal size shows homogenous parenchyma.
Both the kidneys are normal in size, shape, location and show equal
and prompt excreation of contrast medium. The pelvi-calyceal system
and ureters are normal. No hydronephrosis or perinephric pathology is
noted. No renal or supra renal mass is noted. The peri and para renal
fat spaces are well maintained.
The aorta and the venacava appear normal. No evidence of pre and para
- aortic lymphadenpathy is noted.
Opacified bowel loops appear normal.
No evidence of ascites is noted.
IMPRESSION:
Study is within normal limits.
No evidence of hepatic /ascites / lymphadenopathy.
CT SCAN OF THORAX(2-8-2000)
Known case of Ca left breast.
CT scan of thorax has been done. Multiple section at 10 mm interval
have been taken before and after injection of intravenous contrast.
Small well defined soft tissue density nodule measuring 2.2 x 1.5 cms
in the infero medial portion of left breast. This shows mild contrast
enhancement. No necrotic foci are noted.
Mediastinal vascular structures show normal anatomical disposition.
The trachea is central. Both the main bronchi are well seen and appear
normal.
There is no evidence of lymphnode enlargement.
Both the main pulmonary arteries are well seen and pre vascular spaces
appear normal.
There is no evidence of hilar or para hilar lymphnode enlargement is
noted.
The mediastinal fat planes are well maintained and appear normal.
The cardiac size and configuration is within normal limits.
Both the lung fields appear normal. There is no evidence of any
parenchymal lesion.
The bones and soft tissues are normal.
IMPRESSION :
Study reveals small well defined soft tissue density nodule
measuring 2.2 x 1.5 cms in the infero medial portion of left breast.
No lung metastasis/ lymphadenopathy / pleural effusion.
CT SCAN OF ABDOMEN AND PELVIS(4-1-2002)
Case of Ca left breast.
Previous scan report dated 2-8-2000 has been reviewed.
Plain and contrast CT scan of abdomen and pelvis has been done. Bowel
loops were opacified with oral gastrograffin.
Liver is normal in size and shows homogenous parenchyma density. No
focal hepatic lesion or mass is noted. No subphrenic pathology is
noted.
Gall bladder is well distended with smooth outlines.There is no evidence
of any radioopaque calculi. No intraluminal mass is seen.
Pancreas is seen in its entire length and normal and configuration. No
focal lesion. Mass or pancreatitis is noted.
The spleen is normal in size and shows homogenous parenchyma.
Both the kidneys are normal in size, shape, location and show equal
prompt excretion of conrtast medium. The pelvicalyceal system and
ureters are normal. No hydronephrosis or perinephric pathology is
noted. The peri and the pararenal fat spaces are well maintained.
The aorta and the vencava and pelvis structures appear normal. No pre
/ para aortic lymphadenopathy noted.
Urinary bladder appears well distended with smooth outlines.
Pelvic structures appear normal.
The pelvic musculature and the bony pelvic walls appear normal.
Pelvic fat planes are well maintained.
No abdominal / pelvic lymphadenopathy noted.
Opacified bowel loops appear normal.
No evidence of ascites.
IMPRESSION:
Study is within normal limits.
No liver metastasis / lymphadenopathy / ascites.
HRCT OF THORAX(4-1-2002)
Case of Ca left breast.
Previous scan report dated 2-8-2001 has been reviewed.
HRCT of lungs has been done by talking 2 mm thin axial sections at 10
mm intervals. Post contrast sections have also been obtained. on
mediastinal windows.
Present study reveals a lobulated soft tissue density lesion measuring
2.7 * 2.1 cms in the left anterior chest wall adherent to the
pectoralis muscles. This lesion shows a mild inhomogenous enhancement
pattern.
No clacification.
No underlying bone destruction.
Mediastinal vascular structures appear normal.
Mediastinal fat planes are well maintained and appear normal.
No pleural effusion.
Fibrotic scarring in both lung apices.
No lung metastasis.
Bones appear normal.
IMPRESSION:
Insignificant interval change in the size/ appearance / extent of
the left anterior chest wall lesion as compared to scan sated
2-8-2001.
No lung metastasis / lymphadenpathy / pleural effusion.
HAEMATOLOGY REPORT :
| Parameter |
(22/02/2000) |
(02/01/2002) |
| Haemoglobin |
12.20 gm/dl |
12.20 gm/ dl |
| R.B.C. Count |
4.00
mill/cu mm |
4.10
mill/cu mm |
| W.B.C. Count |
10600 / cu mm |
8400 / cu mm |
|
|
|
Differential Count |
| Neutrophils |
36 % |
51 % |
| Lymphosites |
63 % |
42 % |
| Eosinophils |
0 % |
6% |
| Monocytes |
1 % |
1 % |
| Basophils |
0 % |
0 % |
|
|
|
| Peripheral Smear Examination |
Normocytic & Normochromic Platelets
are adequate |
Normocytic & Normochromic Platelets
are adequate |
| ESR |
17 mm after 1 Hr. |
10 mm after 1 Hr
|
|
Blood Examination Reports(2/1/2002)
Test : Serum Estradiol (E2)
Method : C.L.I.A.
Results : <20.00 Pg/ml
Interpretation :
Normal Range :
Ovulatory Cycles :
Folicular Phase : ND- 160
Filicular Phase(Days 2 to 3) : ND -84
Periovulatory (+/- 3 days) : 34-400
Luteal Phase : 27 - 246 |
ADULTS :
Males : ND-56
Females :
Untreated Postmenopausal ND-30
Treated Postmenopausal ND-93
Oral Contraceptives : ND 102 |
Blood Examination Reports(2/1/2002)
Test : Serum Progrsteron
Results : 0.32 ng/ml
Normal Range :
Ovulatory Cycles :
Folicular Phase : ND- 1.13
MidFilicular (Days 5 to 11) : ND - 0.98
Midcycle : 0.48 - 1.72
Luteal Phase : 0.95 - 21
Midluteal ( 7-8 of LP) : 6.0 -24 |
ADULTS :
Males : 0.27 - 0.90
Females :
Postmenopausal : ND - 1.0
1st Trimester : 9.3 - 33.2
2nd Trimester : 29.5 - 50.0
3rd Trimester : 83.1 - 160 |
Blood Examination : (02/01/2002)
Test Name : Carcino Embryonic Antigen -CEA.
Method : C.L.I.A.
Values : 13.80 ng/ml.
Interpretation :
Normal Range : Non Smokers : 0 - 3.4
Smokers : 0 - 6.2
Blood Examination Report : (02/01/2002)
Test Name : Ca 15.3
Method : C.L.I.A.
Values : 21.60
Units : U/ml
Interpretation :
Normal Range :Less than 53
(Fully Automated Chemiluminescence System) |
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|
|
| Comment : |
As per as the CT scan , blood reports and
clinically too, till today patient is completely under control(10/04/2003). |
