General English medical recordsaCASE Medical Number JX0049856 General information NameWang Runzhen Age Forty seven Sex Female RaceHan Occupation Teacher NationalityChina Marital status Married Address

s. She doesn't smoke or drink alcohol. She has a healthy lifestyle and exercises regularly. Family history Her father died of lung cancer at the age of 65. Her mother died of stroke at the age of 70. Her elder brother has hypertension and her younger sister has no major health problems. Social history She is a teacher and has been working for more than 20 years. She has a good relationship with her colleagues and students. She is married and has a son who is studying in college. She has a good relationship with her husband and family. She has no history of drug abuse or alcoholism. She has a healthy social life and enjoys spending time with her family and friends. Physical examination Vital signs: Blood pressure: 130/80 mmHg, Heart rate: 78 beats/min, Respiratory rate: 18 breaths/min, Temperature: 36.8℃. General appearance: The patient is conscious and alert, with normal posture and gait. Skin: No abnormality found. Head: No abnormality found. Neck: No enlarged lymph nodes palpated. Breast: A mass of about 3cm in diameter was found in the upper outer quadrant of the right breast. It was hard and irregular in shape, and the skin above it was slightly dimpled. The left breast was normal. Chest: No abnormality found. Heart: Regular rhythm, with no murmurs or gallops heard. Lungs: Clear breath sounds heard bilaterally. Abdomen: Soft and non-tender, with no palpable masses or organomegaly. Genitourinary system: Normal external genitalia, with no abnormal discharge or lesions. Rectal examination: Not performed. Extremities: No edema or deformity found. Neurological examination: No abnormality found. Laboratory data Blood tests: Hemoglobin: 11.5 g/dL, White blood cell count: 7.8×10^9/L, Platelet count: 234×10^9/L, Blood glucose: 5.8 mmol/L, Blood urea nitrogen: 4.8 mmol/L, Creatinine: 72 μmol/L, Total protein: 70 g/L, Albumin: 40 g/L, Total bilirubin: 10 μmol/L, Alanine aminotransferase: 25 U/L, Aspartate aminotransferase: 29 U/L, Alkaline phosphatase: 79 U/L. Imaging studies: Mammography and ultrasound showed a mass in the right breast, which was highly suggestive of malignancy. CT scan of the chest, abdomen, and pelvis showed no evidence of metastasis. Pathology report: Pathology centesis of the breast mass confirmed the diagnosis of invasive ductal carcinoma. Impression: The patient has a 3cm mass in the upper outer quadrant of the right breast, which is highly suggestive of malignancy. Pathology confirmed the diagnosis of invasive ductal carcinoma. No evidence of metastasis was found on imaging studies. Plan: The patient will undergo surgical resection of the right breast mass and axillary lymph node dissection. Further treatment, including chemotherapy and radiation therapy, will be determined based on the final pathology report. The patient will be closely monitored for any signs of recurrence or metastasis