---

Patient Details

• Name: Amadapuram Manisha
• Age: 26
• Gender: Female
• Address: Shamshabad
• Telephone: 7842812414
• Father's/Husband's Name: A. Ramesh
• IP No.: 20260326206
• OP No.: R-260326249

---

Reason for Admission (Complaints)

1. Lump in the left breast — since 6 months
2. Easy fatigability — since 1 year

---

History of Present Illness (H/C Present Illness)

• Patient was apparently asymptomatic 6 months back
• She then noticed a lump in the left breast, which has been gradually increasing in size
• No associated pain or redness
• No easy fatigability (noted as a separate complaint lasting 1 year)

---

History of Previous Illness (H/C Previous Illness)

• Not mentioned / Not available in the visible portion of the document
• The section appears to be blank on the form

---

Medications

• Not documented in the visible section of the case sheet
• No current medications listed

---

Additional Findings Noted

• No pain, no redness
• No easy fatigability at this point (al- easy fatigability pencil note)

• Menarche: 15 years
• Cycle: 3/28 days — Regular
• No clots
• Not associated with painful periods

---

Note: The sections for History of Previous Illness and Medications appear to be blank or not filled in on this form. You may need to check subsequent pages of the case file for that information.

"c/o – Easy fatigability :: 1 year" "al – Eating slate pencils"

---

Revised / Updated History

Complaint Added:

• Eating slate pencils (Pica behavior) — this is a significant clinical finding

---

Clinical Significance of Eating Slate Pencils (Pica)

Most Common Cause in a Young Female:

---

Putting It All Together — Clinical Picture:

---

Likely Working Diagnoses:

1. Left breast lump — ? Fibroadenoma / ? Malignancy (needs investigation)
2. Iron Deficiency Anemia — supported by Pica (slate pencil eating) + easy fatigability

---

Updated Patient Summary

---

How Age Changes the Clinical Picture

Breast Lump in a 20-Year-Old Female:

A gradually increasing, non-tender, non-red lump in a 20-year-old is classic for Fibroadenoma.

---

Anemia Picture Remains the Same:

---

Final Working Diagnoses:

1. Left breast Fibroadenoma (most likely given age + presentation)
2. Iron Deficiency Anemia (Pica + fatigue)

Recommended Investigations:

• USG Breast (first-line imaging in women under 30)
• FNAC of breast lump
• CBC, Peripheral smear, Serum Ferritin, Iron studies

Provisional Diagnosis for Manisha, 20F

---

1. 🔵 Left Breast Fibroadenoma

• Lump in left breast × 6 months
• Gradually increasing in size
• No pain, no redness — classic benign feature
• Age 20 — fibroadenoma is the single most common breast lump in women under 25
• Lump is likely well-defined, mobile, rubbery ("breast mouse")

---

2. 🔴 Iron Deficiency Anemia (IDA)

---

Provisional Diagnosis (to write in the case sheet):

1. Left breast lump — ? Fibroadenoma 2. Iron Deficiency Anemia

---

Why Not Malignancy?

However, all breast lumps must be investigated regardless of age — USG breast + FNAC will confirm the diagnosis.

---

How a Patient with Fibroadenoma Presents

Typical Patient Profile

• Young woman in her 20s–30s (most common in reproductive years)
• Often notices the lump accidentally while bathing or dressing
• May have multiple lumps, sometimes in both breasts

---

What Complaints the Patient Gives

Manisha's case fits perfectly — lump in left breast × 6 months, gradually increasing, no pain, no redness.

---

History Taking for Fibroadenoma — Step by Step

1. Chief Complaint

• "Where is the lump?" — which breast, which quadrant
• "Since when?" — duration
• "How did you notice it?" — accidentally or pain-driven

2. History of Present Illness (HPI)

3. Menstrual History (Very Important)

• Age of menarche
• Cycle regularity
• Does the lump swell or become tender before periods? (cyclical mastalgia)
• Fibroadenomas are hormonally responsive — may grow during pregnancy

4. Obstetric History

• Has the patient been pregnant? Fibroadenomas can grow rapidly during pregnancy
• Is she breastfeeding?

5. Family History

• Any breast cancer in mother, sister, aunt?
• This helps assess malignancy risk

6. Drug History

• Any oral contraceptive pills (OCP)? Hormonal drugs?
• Cyclosporin A (after kidney transplant) — known to cause multiple bilateral fibroadenomas

---

Classic Examination Findings to Expect

---

Key Differentiating Questions from Malignancy

---

Summary: Questions You Must Ask in This Case

1. When did you first notice the lump?
2. Is it painful?
3. Has it grown since you noticed it?
4. Does it move when you press it?
5. Any changes in the skin over it?
6. Any discharge from the nipple?
7. Any lump in the armpit?
8. Does it change with your periods?
9. Any family history of breast cancer?
10. Are you on any hormonal medications?

---

Physical Examination (Continued) — Manisha, 20F

---

Past History

• No k/c/o (known case of): HTN / DM / Thyroid disorders
• Family History: Not significant
• Surgical History: Not significant

---

Drug Allergy ⚠️

Iron injection — patient complains of reactions after injection

---

Personal History

Vegetarian diet further supports Iron Deficiency Anemia — vegetarian sources of iron have lower bioavailability than non-vegetarian sources.

---

Physical Examination

• Conscious / oriented — well oriented

---

PICKLE Examination

Pallor is PRESENT — this directly confirms anemia, consistent with Iron Deficiency Anemia from Pica (slate pencil eating) + vegetarian diet.

---

Vital Signs

Low-normal BP can be seen in chronic anemia as the body compensates.

---

Top Note on the Page

• HBsAg: +ve (Hepatitis B Surface Antigen — POSITIVE)

This is a significant incidental finding — the patient is Hepatitis B positive. This must be noted for:

• Infection control precautions during any surgical procedure
• Pre-op workup if excision of breast lump is planned
• Liver function tests needed

---

Complete Clinical Picture — Updated Summary

"Iron injection — complaints of reactions after injection"

---

Pruritis (Itching) After IV Iron — Is It Common?

Known Reactions to IV Iron Injections:

---

Why Does IV Iron Cause Pruritis?

• IV iron causes histamine release → leads to itching, flushing
• The iron complex itself can trigger mast cell degranulation
• Iron dextran is the most notorious for allergic reactions
• Newer preparations (ferric carboxymaltose, iron sucrose) have fewer reactions but can still cause pruritis

---

Clinical Significance for This Patient

---

What to Write in Case Sheet:

Drug Allergy: Iron injection — pruritis/allergic reaction post injection Plan: Oral iron preferred. IV iron only with premedication and monitoring.

Medications Given After Admission — Manisha, 20F

Diagnosis confirmed:

• Iron Deficiency Anemia
• Fibroadenoma of Left Breast

---

📋 Inpatient Medications Table

Note: Tab. Autrin (Iron + Folic acid) was written but marked HOLD — due to patient's known iron injection reaction history and likely GI intolerance being assessed first.

---

🏠 Recommended Discharge Medications Table

---

🔬 Lab Reports Summary (from reports shown)

CBC — Confirmed Severe Iron Deficiency Anemia

Red Cell Morphology (ticked):

• ✅ Hypochromic — pale RBCs, less Hb
• ✅ Microcytosis — small RBCs
• ✅ Anisocytosis — variable RBC sizes

Classic picture of Iron Deficiency Anemia — Hypochromic Microcytic Anemia confirmed on peripheral smear.

Biochemistry — All Within Normal Limits

Liver and kidney function are normal — safe to prescribe oral iron and antibiotics at standard doses.

---

Looking at the Prescription — What's Missing?

There is NO specific medical treatment written for Fibroadenoma.

---

Why? — Because Fibroadenoma Has No Medical Drug Treatment

Fibroadenoma is Managed Surgically or by Observation:

No Drug Cures Fibroadenoma

• There is no tablet or injection that dissolves or treats fibroadenoma
• Hormonal manipulation has been tried but is not standard practice
• The antibiotics (Monocef + Amikacin) given are likely pre-operative prophylaxis — suggesting the team is planning surgical excision

---

What Likely Happened in This Case

Step 1 → Correct the anemia first (Hb was only 6.4 g% — too low for surgery) Step 2 → Once Hb improves to safe surgical levels (>10 g%), plan lumpectomy / excision of fibroadenoma Step 3 → The antibiotics are being given in preparation for that surgery

---

Summary

The IDA is being treated medically. The fibroadenoma will be treated surgically — but surgery is being deferred until anemia is corrected. This is why there is no drug for fibroadenoma in the prescription — it is intentional and correct.