HISTORY

IDENTIFICATION DATA
Name: Aziah bt Nordin
I/C no: 520220-08-6256
R/N: 479266
Age: 55 years old
Gender: Female
Ethnicity: Malay
Religion: Islam
Address: Tok Sira, Telok Cempedak
Occupation: Not worked
Marital status: Single
Date of admission: 1 January 2007
Date of clerking: 5 January 2007

CHIEF COMPLAINT
Right breast lesion for more than 2 month

HISTORY OF PRESENTING ILLNESS

She was presented with right breast lesion for more than 2 month. It was near the nipple at the
outer part. Initially, the lesion was only in small size like mosquito bite, red in colour, no pus or
discharge, no fluid and not itchy or pain. She noticed the lesion during dressing her cloth. She
just ignored about the lesion as it did not affect her life such as not cause discomfort. About one
month later, the size of the lesion increase to about 50cent coin and become ulcerated and had
pus discharge. However, there was no blood or nipple discharge seen. There was also skin
changes noted which the skin become dark in colour. She also can feel a lump at the site of lesion
which about 20 cent coin size. She describes it as hard and not mobile. However, there was no
pain or tenderness and she did not realized any increased in the size of the lump. There was also
no pain associated with menses and the lump does not vary in size with the menstrual cycle.
There was no history of trauma to the breast. She did not notice any other lump elsewhere. She
claimed that there was no abnormality in her left breast. There is no history of bachache,
palpitation, difficulty in breathing, pleuritic chest pain, headache or jaundice. Since then, she
seeks traditional medicine and the discharge dried. She never told the family members about the
problem and did not seek medical attention.

She also noticed of right upper limb swelling since she realized the breast lump. It occurred after
she ate prawn. The swelling was progressively increased. It was not red, no pain, tender or
itchiness, no numbness and not affect her movement or sensation. She claimed to be able to do
house chores such as wash cloth and dishes. She never seeks treatment for the swelling.

On further questioning, she claimed that she had on and off low grade fever for more than 6
month ago. It was sudden in onset with no specific pattern or spiking in nature. The fever
resolved after she took anti-pyretic. It was not associated with chills, rigor, night sweating, cough,
runny nose, vomiting, diarrhea, abdominal pain, increase in urinary frequency, pain during
micturation, headache or alteration in behaviour. She also had no easily bruising, gum or teeth
bleeding, joint pain, muscle pain or easily lethargy. She had no contact with Tuberculosis patient.
She also had loss of appetite since the recurrent fever but did not notice any loss of weight.

Two days prior to admission, she had moderate to high grade fever which associated with chills
and rigor. The fever was sudden in onset and was constant. The fever was not spiking and not
associated with night sweat. The fever was not relief by anti-pyretic. She also experienced about
5 times vomiting since the fever. The vomiting occurred after meals and contains food particles
and fluid. The vomiting was non-projectile and had no blood, bile or fecal odour. The amount of
each vomiting is about 1 tea cup. Besides, a day before admission, she also had 2 episodes of
diarrhea which she passed out loose stool. There was no bleed or mucous noted. However, there
were no changes in odour, colour or amount of the stool. There was no complained of abdominal
pain. There was no history of eating outside or change in dietary habit. She also complained of
mild giddiness since the onset of diarrhea. However, there was no fainting attack.

The family members then brought her to Hospital Tengku Ampuan Afzan as they just also knew
about the breast lesion.

REVIEW OF SYSTEMS
Gastrointestinal system: there is no history of abdominal pain, dysphagia, regurgitation, rectal
bleeding, heartburn, flatulence, abdominal distention, incontinence, vomiting of blood, tenesmus,
constipation.
Cardiovascular system: there is no history of retrosternal pain, orthopnea, ankle oedema,
paroxysmal nocturnal dyspnoea, cyanosis or claudication.
Respiratory system: no history of chest pain, cough, haemoptysis, wheezing or stridor.
Central nervous system: no history of head injury, syncope, loss of consciousness, dizziness,
muscle weakness, fit or blurring of vision.
Genitourinary system: no history of dysuria, nocturia, haematuria, frequency, urgency,
hesitancy, urinary incontinence, vaginal or urethral discharge.
Musculoskeletal system: no history of joint or back pain, joint swelling, stiffness or deformity,
muscle pain or locking of joints.
Dermatological system: no history of rashes, pruritus.
Haematological system: no history of pallor.

PAST MEDICAL HISTORY

There was no significant past medical history. She had no history of asthma, heart disease,
Diabetes Mellitus or Hypertension before. She had never been hospitalized before.
She has allergy to seafood except fish, which she will sometimes developed mild itchiness at the
arm.
She had no known drug allergy and not takes any supplement, oral contraceptive pill or hormone
replacement therapy.

PAST SURGICAL HISTORY

She had never undergone any surgical procedure

PAST MENSTRUAL HISTORY

She attained menarche at the age of 12 years old with regular cycle and normal volume. There is
no history of menorrhagia or dysmenorrhea. She had menopause at the age of 52 years old.
FAMILY HISTORY
She is the fourth out of 9 siblings. Her mother and father had passed away. Her father had
Diabetes Mellitus. Her mother had Diabetes Mellitus, Hypertension and history of unilateral
mastectomy however she didn’t know the cause of the mastectomy. She also did not know the
cause of her mother’s death. One of her sister also had Diabetes Mellitus and had amputated her
leg. Otherwise there is no history of other malignancy in other members of the family.

SOCIAL HISTORY
She is a single and nulliparous lady. She didn’t work and lives with her sister. She is
taking care of her sister’s children. She is a non-smoker, never consume alcohol, and not drug
abuser or sexual promiscuity. She had normal adult diet. She denied any exposure to radiation.

PHYSICAL EXAMINATION

GENERAL INSPECTION
On inspection, she was lying supine comfortably, alert, concious and cooperative. She was not in
pain and not dyspnoeic or tachypnoeic. She looked pink and no signs of cyanosis. Her nutritional
status and hydrational status were fair without any evidence of coated tongue. There was gross
oedema at the right upper arm. There was branula attach to the dorsum of left hand.

GENERAL EXAMINATION
Vital Signs:
Blood pressure: 109/63 mmHg
Pulse rate: 88 beat per min
Respiratory rate: 18 breath per min
Body temperature: 37.5 °C

Head : tongue was not coated and not dry, no central cyanosis
oral hygiene was fair
pharynx and tonsil were not inflammed
no discharge from ears
no lymphadenopathy

Eyes : the palpebral conjunctiva was not pale

the sclera not jaundiced

Hand : pitting oedema at the right hand

warm and moist palm
no pallor on the palmar surface
no clubbing, leukonychia, koilonychia
no palmar erythema of the palm

Skin : the skin was not pale and not dry

no rash, no signs of skin infections

Lower limbs : no ankle edema

 no joint swelling
SYSTEMIC EXAMINATION

Breast Examination:
Inspection -in semi recumbent (450) position:
• Arms by the sides: Normal size, well developed, symmetry, and normal contour, no overlying
skin changes (no puckering, oedema, nodularity, discoloration or ulceration) on the left
breast. The right breast looked dark, ulcerating, oedematous, satellite nodule and the lesion
was ill-defined measured around 10 x 8 cm, at the lower outer and lower inner quadrant.
There was no blood. There was also pus discharge at the lesion, some necrotic changes and
granulation tissues. The floor consists of solid yellowish-brown or grey dead tissue. There
was nipple retraction on the right breast. There was also foul in smelling. The nipple at the
left breast was normal. There was no visible enlargement of the axillary or supraclavicular
lymph node or distended veins.
• When the patient raised her arms above her head: there was no changes in the appearance of
the breast. Lower surfaces of the breasts were normal. No visible axillary swelling,
discoloration, puckering or ulceration.
• Hands pressed against her hips: No visible lump or skin changes were seen.
• Patient bend forward: both breasts fall freely off the chest wall.

Palpation of the breast:

• In semi-recumbent position with the arms on her sides: The left breast was normal; soft and
smooth. No lump was palpable. However, there was a lump in the upper-outer quadrant of the
right breast. It was non-tender, normal temperature, 5x3 cm size, regular surface, well-defined
margin, hard, immobile, fixed to the skin and there was lesion at the surrounding area.
However the right breast was movable vertically and horizontally.
• Both hands on her hip with the arm relaxed: the lump is fixed.
• Hands pressed against her hips: the lump is fixed.

Palpation of the nipple:

• No discharge was present after pressing on each segment of the breast.

Palpation of the axilla and supraclavicular fossa:

• No lymph node palpable in supraclavicular fossa and left axilla.

• There were three palpable lymph nodes in the right axilla. They were in the central, medial
and lateral aspect, non-tender, normal temperature, 1x1 cm in size, hard and fixed.

Palpation of the arms:

• There was pitting oedema on the right arm, erythematous, not warm, the capillary refill time
is less than 2 second and the pulse was good.
• No venous, artery or neurological abnormalities.
Cardiovascular system:
On inspection, the chest was normal without any deformity. The pulse was normal in rate
(88/min), volume, and rhythm and bilaterally equal in the radial, carotid and femoral arteries. The
artery was normal in character – there was no thickening or hardening.
There was no visible Jugular Venous Pressure.
The apex beat is ffelt in the 5th intercostal space, medial to the mid-clavicular line, on the right
side.
On auscultation, the first and second hearts sounds were audible i.e. dual rhythm was normal.
There were no murmurs, no thrills.

Respiratory system:

On inspection, there was no chest deformity, the anteroposterior diameter was not increased, no
barrel chest. The respiratory rate was 18/min, she was not tachypnoeic and there was no
wheezing. There was no flaring of alae nasai. There was no usage of accessory muscles, no
subcostal, intercostal or suprasternal recession.
On palpation, there was no tracheal deviation, the chest expansion was symmetrical, and the
vocal fremitus was equal on both sides.
On percussion, the chest was normal resonance.
On auscultation, the air entry was equal and bilateral with presence of ronchi. There was no
crepitation. Vocal resonance was normal and equal.

Abdomen Examination:

On inspection, the abdomen was not distended and normal in shape. It moved with respiration.
No evidence of surgical scar, dilated veins or abnormal peristaltic movement. The umbilicus was
inverted and centrally located.
On superficial palpation, the abdomen was soft and no masses detected. There was no guarding
or tenderness. On deep palpation, the liver and spleen are no palpable. The kidneys are not
ballotable. No herniation noted.
On percussion, shifting dullness was negative and no signs of fluid thrill. On auscultation, bowel
sound was present and there was no bruit.
Per rectal examination was not done.

Musculoskeletal System:

The tone, power and reflex were normal. There was no proximal muscle weakness or
hyperreflexia.

Central Nervous System:

Grossly intact.
CASE SUMMARY
Aziah bt. Nordin, a 55 years old, nulliparous, Malay lady from Tok Sira presented to
Hospital Tengku Ampuan Afzan with a right breast lesion for more than 2 month duration prior
to admission. There was pus discharged, ulcer and skin darkening. There was also lump sized of
20 cent present which was hard and immobile. There was also right arm swelling for 1 month.
She also complains of on and off low grade fever for the past 6 month without any symptoms of
upper respiratory tract infection, urinary tract infection, gastrointestinal tract infection or
meningitis. She also experienced loss of appetite.
On physical examination, there was dark, ulcerating, oedematous, satellite nodule and the
lesion was ill-defined measured around 10 x 8 cm, at the lower outer and lower inner quadrant.
There was also pus discharge at the lesion, some necrotic changes and granulation tissues. The
floor consists of solid yellowish-brown or grey dead tissue.There was nipple retraction on the
right breast. There was also foul in smelling. There was a lump in the upper-outer quadrant of the
right breast. It was non-tender, normal temperature, 5x3 cm size, regular surface, well-defined
margin, hard, immobile, fixed to the skin and there was lesion at the surrounding area. There
were three palpable lymph nodes in the right axilla. They were in the central, medial and lateral
aspect, non-tender, normal temperature, 1x1 cm in size, hard and fixed. There was pitting oedema
on the right arm, erythematous, not warm, the capillary refill time is less than 2 second and the
pulse was good.

PROVISIONAL DIAGNOSIS
Advanced Breast Cancer

DIFFERENTIAL DIAGNOSIS
- Breast abscess
- Fibroadenoma
- Phylloides tumor

DISCUSSION ON PROVISIONAL/DIFFERENTIAL DIAGNOSIS

Advanced Breast Cancer

Points for:
- Patient age > 5o years old
- Nulliparous
- Chronic course
- Painless, hard lump
- Recurrent infection – fever for last 6 month
- Loss of appetite
- Swelling of the right limb suggestive of lymphoedema
- Probably positive family history of breast cancer (mother)
- On examination there were three axillary lymph nodes palpable at the right side

Breast abscess
Points for:
- There is pus discharge
- Enlarged axillary lymph nodes

Points against:
- More common in child bearing age
- Grow progressively within one week (acute onset)
- No history of trauma to the nipple
- Non tender

Fibroadenoma
Points for:
- Non tender
- Not noticed any changed in size
- Well defined margin
- Smooth surface

Points against:
- Usually in age <35 years old
- Immobile
- High risk factor for carcinoma
- Loss of appetite
- Palpable axillary lymh node

Phylloides tumor
Points for:
- Normal overlying skin
- Age 50 years old
- Enlarged axillary lymph node due to metastasis.
- Slow growing

Points against:
- No previous excision at the site of lump
- Moderate size lump
- No enlargement of the whole breast

INVESTIGATION

Full Blood Count

Purpose: To look for evidence of anaemia.
To assess the white cell count for any infections
To assess the platlet count

Result:
WBC 12.1 x 103 / µl ↑
RBC 5.01 x 106 / µl
HGB 9.3 g/dl
HCT 29.7%
MCV 59.3 fl ↓
MCH 18.6 pg ↓
MCHC 31.3 g/dl
Plt 190 x 103 / µl
Lymphocyte 12.1 %
1.5 x 103 / µl
RDW-CV 15.7%
PDW 12.1 fl
MPV 80 fl

Comments:
There is hypochromic microcytic anaemia. The white blood cell count is high may be due to
infection. The platlet count is normal.

Random Blood Sugar

Purpose: To detect Diabetes Mellitus

Result:
10.8 mmols/L (N=3.9-6.1)

Comments:
High. The test should be repeated

Renal Profile
Purpose: To know the urea and other electrolyte status and detecting any imbalance

Results:
Urea 4.2 mmol/L
Sodium 141 mmol/L
Potassium 4.1 mmol/L
Chloride 102 mmol/L
Creatinine 69 µmol/L
Uric Acid 244 µmol/L

Comments: Normal

Liver Function Test

Purpose: To look for evidence of metastasis

Results:
Total Bilirubin 15.3 µmol/L
Direct Bilirubin 2.7 µmol/L
Indirect Bilirubin 12.6 µmol/L
Total Protein 63.8 g/L
Albumin 28.7 g/L ↓
Globulin 35.1 g/L ↑
AG Ratio 0.8 ↓
Alkaline Phosphatase 118 U/L ↑
ALT 44 U/L ↑
AST 41 U/L ↑

Comments:
Albumin is reduced, globulin raised and A/G ratio is reduced. This may indicate that most
albumin bound to calcium. The liver enzymes are all increased could be evidence of
metastasized. This should be confirmed by other investigations such as abdominal ultrasound or
CT scan.

Swab Culture and Sensitivity

Purpose: To isolate the organism from the pus discharge for treatment.

Result:
Organism isolated – Proteus Mirabilis

Ampicillin – sensitive
Ampicilin-Sulbactam – sensitive
Cefuroxime – sensitive
Cefoperazone – sensitive
Ceftriaxone – sensitive
Cephalexin – sensitive
Gentamicin – sensitive
Trimethoprim-Sulfamethaxazole – sensitive

Chest X-ray
Purpose: To asses the lung condition or any metastasis

Result:
No nodules noted. Normal lung tissues. Lytic lesion and bubbles appearance at the left clavicle.

Comments:
No lungs metastasize. ? bone metastasize of left clavicle

Coagulation Test
Purpose: To detect hematological disorders or metastasis (assess liver ability to produce factor II,
VII, IX, X)

Result: Not done

Biopsy
Purpose: To do histopathological examination for malignancy

Result: Pending

Serum calcium
Purpose: To assess bone metastasis

Result: Not done

 • Patient was KIV for mammography
• Patient was planned for Abdominal CT scan on 22 January 2007
• Further investigation can be done:
- Ultrasonography – to assess metastasis in other organ

MANAGEMENT AND PROGRESSION IN WARD

Upon admission, she was alert and conscious, had mild fever, giddiness and few episodes
of diarrhea and vomiting. However, she can tolerate orally in minimal amount. IV drip also given
as maintenance. Dressing was done on her. IV Unasyn 1.5 g and IV Maxolon 10g were started
TDS. She was given Paracetamol PRN and Ranitidine 500mg TDS
The next day, due to her lympoedema, she was told to put her right arm in parallel with
waist by supporting with 2 pillows in sitting position. She had no more fever, however her blood
pressure was fluctuating from normal to high. The treatment was continuing.
On the day 3 of admission, hydration and appetite were fair. She was well; no more fever,
vomiting or diarrhea. However, there was still on and off giddiness. She can tolerating orally and
was able to ambulate. Her dressing was clean and done for once in a day.
The next few days, she remains afebrile. She was encouraged to ambulate. T.Daflon 2
tablet BD was prescribed for her. The breast cancer staging was T4b N3 M1.
On the 7th day of admission, she was brought to physiotherapy unit to have physiotherapy
of the upper limb.
The next 2 days, due to her well condition, and she was waiting for Abdominal CT scan
the next 2 weeks, so the doctor discharge her first and to come again for the appointment. She
was been told about the plan of treatment such as chemotherapy after several other investigations
and based on patient condition.

DISCUSSION OF THE DISEASE

ANATOMY

A female breast overlies the 2nd to the 6th ribs. Two-thirds of it rests on pectoralis major,
one-third on the serratus anterior, while its lower medial edge just overlaps the upper part of
rectus sheath.
Breast is made up of 15-20 lobules of glandular tissue embedded in fat. This fats account
for its smooth contour and most of its bulk. These lobules are separated by fibrous septa running
from the subcutaneous tissues to the fascia of the chest wall (the ligament of copper).
Each lobule drains by its lactiferous duct on the nipple, which is surrounded by the
pigmented areola.
Blood supply:
1. lateral thoracic artery ( from axillary artery)
2. perforating branches of internal mammary artery.
3. lateral perforating branches of intercostals arteries.
Lymph drainage:
1. along tributaries of the axillary vessels to axillary lynph node.
 5 group of axillary lymph nodes
• apical
 • anterior
• posterior
• lateral
• central
2. along the tributaries of the internal thoracic vessels.
Rotters node is found between 2 pectoral muscles.
These lymphatic drainage is very important for the spread of growth of breast carcinoma.

PATHOLOGY
The female breast is a specialized gland that develops after puberty. The breast tissue
often responds to menstrual cycle of estrogen and progesterone. Hypertrophy and hyperplasia of
breast during pregnancy is a normal physiology.
Breast cancer is the commonest cause of cancer in developed country; however it is still
not uncommon in developing countries.
The cause of breast cancer is not known, some believe that dietary factors have a role in
its etiology, breast cancer is a predominantly a disease of females, however it can –rarely- still
occur in males where genetic factors play a big role. Early menarche and late menopause increase
risk of developing breast carcinoma. The usage of Oral Contraceptive Pills and Hormone
Replacement Therapy also increases risk. Another risk factor for breast carcinoma is age, as the
risk increases with age reaching the peak between 50-60 years. The Family history in breast
cancer is important as the susceptibility to it is inherited as an autosomal dominant trait, however
this patient possess no family history of the disease. Breast epithelial hyperplasia in the absence
of pregnancy is a risk factor for carcinoma. Factors associated with an increased risk factor
represent key step toward breast neoplasia. Early stage of disordered growth through loss of cell
cycle control can result in benign proliferative changes. BRCA1 & BRCA 2 are the 2 common
gene related in breast carcinoma. (BRCA1 is also associated with ovarian cancer, BRCA2
associated with breast cancer in male). HER2 over expression often leads to higher growth rate,
with more aggressive clinical behavior. Loss of expression of nm23, which encodes for a
nucleoside kinase, has been linked to an increased potential of lymphatic involvement as well as
lower survival rate.
The cancer once it invades the underlying skin or muscle, it will be fixed and difficult to
move. Metastasize occur through blood or lymphatics. When it involves the lymphatics along the
fibrous septa, blockage occurs leading to oedema of overlying skin between the many small pits
which mark the opening of hair follicle and sweat gland. Extensive involvement of the axillary
nodes may cause lymphoedema of the arm or venous thrombosis of superficial vein
(mondors disease). The lymph nodes on the other breast also can be enlarged. On the other hand
if it metastases via blood, then most likely it will spread to bone (giving rise to sciatica like
problem, bowel and urine disturbance), lung, liver and brain. The staging of cancer is done via
Manchester staging or TNM classification.

TNM CLASSIFICATION
T = TUMOR
TX = UNNOWN
TIS = TUMOR IN SITU
T1 = 2cm diameter. No fixation
T2 = 2-5cm diameter with tethering or nipple retraction
T3 = 5-10cm diameter + infiltration, ulceration, peau d’ orange or deep fixation
T4 = any tumor with infiltrating or ulceration wider than its diameter. > 10cm
T4a = Extension to chest wall
T4b = Edema, ulceration of the skin of the breast (including peau d’orange) or satellite skin
nodules confined to the same breast
T4c = Both (T4a and T4b)
T4d = Inflammatory carcinoma

N = NODES
NX = Node not assessable
N0 = no palpable axillary nodes
N1 = mobile palpable nodes
N2 = fixed axillary nodes
N3 = palpable supraclavicular nodes. Oedema of the arms.

M = METASTASES
MX = Metastasis not assessable
M0 = no evidence of distant metastases
M1 = distant metastases.

Stage and prognosis according to TNM classification – UICC (International Union against
Cancer)

UICC Stage TNM Category 5-year suvival

I T1, N0, M0 Early cancer 84%
II T1, N1, M0 Early cancer 71%
T2, N0-1, M0
III Any T, N2-3, M0, T3, Any N, Locally advanced 48%
breast cancer
IV Any T, Any N, M1 Metastatic 18%

Treatment of early disease (Stage I and II)

Aim: to achieve cure, if possible conserve the breast and to achieve loco regional control
- Surgery: foe e.g. wide local incision (lumphectomy), simple mastectomy with axillary
clearance, Patey mastectomy, Quart therapy by Veronasi, Radical Mastectomy
- Postoperative radiotherapy indications: tumor margin is positive, pectoralis major involved,
inner quadrant tumor, high grade tumor, axillary clearance not satisfactory, breast conservative
surgery and tumor size more than 5cm
- Hormonal theray: steroid hormone receptor (estrogen and progestrerone) are assessed. This will
indicate prognosis of breast cancer
- Chemotherapy: indicated in premenopausal women whom axillary lymph node positive
chemotheraphy usually given when the cancer is poorly differentiated.

Treatment in locally advanced breast cancer

- Biopsy done to confirm diagnosis and identification of ® status, neoadjuvant chemotherapy
given to shrink the tumor, surgical resection, radiotherapy at supraclavicular and chest wall area
and additional chemotherapy if required.

Treatment of metastatic disease of breast

- Palliative, chemotherapy followed by excision of fungating mass/mastectomy. Tamoxifen (anti
estrogen) given for 5 years. Chemotherapy can be repeated.
DISCUSSION OF THE CASE

My patient, Aziah Nordin, a 55 years old, nulliparous, Malay lady from Tok Sira
presented to Hospital Tengku Ampuan Afzan with a right breast lesion for more than 2 month
duration prior to admission. The lesion was increase in severity. It was also associated with hard,
immobile and painless lump which is typical characteristic in breast malignancy. She also had
symptoms of loss of appetite and recurrent fever for the last 6 month which may suggestive of
malignancy condition. Besides, she also had lympoedema at the right upper arm which suggestive
of lymphatic obstruction by tumor metastasis.
Initially, she was refused to seek medical treatment as the patient was in denial state. She
did not tell the family and only seek traditional treatment. However because of the worsen
condition such as high grade fever and vomiting, then the family found out that she had breast
lesion.
This patient had several risk factors for developing breast cancer. She is at the age of 55
years old, nulliparous woman and menopause quite late at the age of 52 years old. Hence, she had
prolonged hormonal factor. She also most probably had family history of breast cancer because
her mother had undergone mastectomy.
Upon physical examination, the breast lesion and lump suggestive of breast cancer.
Clinically, the staging was T4b N3 M1. Based on her condition, she is in metastatic category of
prognosis which 5 year chance survival is only 18%.
On investigations, she had hypochromic microcytic anaemia which may due to chronic
disease such as malignancy. Several investigations should be done to determine the definite site
of metastasis and hence treatment should be started once the patient is stable. In ward, she was
treated conservatively to reduce the arm swelling by elevation of the arm parallel to the waist and
went for physiotherapy. She also was encouraged ambulation to prevent thromboplebitis.
Cooperation should be achieved from the family members to make sure she’ll going to the
next appointment hence to proceed for further investigation and management.