Rotation Reflection

This rotation was great exposure to the world of surgery, perioperative care, and surgical subspecialties. This was a very hands-on rotation, which I enjoyed and I found myself enjoying the wound care aspect the most. It was interesting to see the patients come back each week and get better and attain a higher level of normalcy. This rotation will help me in future rotations by helping me understand when to call a surgical consult, what kind of cases are surgical, and recognizing surgical emergencies. Furthermore, understanding different types of surgeries as well as their indications will be helpful in interpreting my patients’ past medical history and risk factors regardless of what specialty I work in. 

Regarding what I learned about myself, I found that I do not enjoy the OR, however I do enjoy the perioperative care aspect of surgery, as well as seeing surgical-level presentations. Post-operative patients often require a higher level of care as well as a bit of investigation into the cause of any complications that may arise, and I found myself enjoying that challenge. 

I also enjoyed the diversity of specialties within this rotation, as I did one week of urology and one week of orthopedic surgery, followed by one week of clinic for the specialties of wound care, plastic surgery, bariatric surgery, general surgery, and ENT. I felt that being exposed to these different subspecialties when I am practicing general medicine, whether it be internal medicine or emergency medicine. Furthermore, it was interesting to see how each specialty operates and what things were most important to focus on depending on the service. 

I feel that my last rotation in internal medicine helped me learn to write a good SOAP note and this rotation helped solidify that skill, as well as teach me what to focus on in terms of postoperative patients. 

 

Site Evaluation Summary

For my first evaluation, I presented 4 focused H&Ps and one journal article. For my second evaluation, I presented another 4 focused H&Ps. My journal article was about breast cancer in men, since one of my patients had a hard breast mass for one year and we completed a core biopsy  in office which was positive for mucinous carcinoma. It was stressed to me that when evaluating patients for post-operative problems that it is essential to know their hospital course and surgeries in-depth to be able to come up with appropriate diagnoses. These H&PS helped me learn how to evaluate a patient efficiently while still including the important background information of the patient. 

 

Journal Article

https://www.sciencedirect.com/science/article/pii/S0923753419373065#bb0995

This article is a systematic review evaluating the risk factors, diagnosis, treatment, pathology, and sequelae of male breast cancer. Men make a small portion of overall breast cancer patients at 0.5-1%, equating to about 2000 men per year. Risk factors include BRCA2 mutations, radiation, and any factors that may influence the estrogen/ androgen ratio. Of the population of men with BRCA2 mutations, only 5-10% ever develop breast cancer. Furthemore, BRCA2 mutations are only found in 4-14% of men with breast cancer. The most common breast cancer is men and women is invasive ductal carcinoma. Being that breast cancer is primarily a disease among women, men with breast cancer tend to have more advanced tumors and poorer prognosis at presentation due to low suspicion and absence of screening amongst men. Black men not living in cities tend to have the worst prognosis. Breast cancer in men most commonly presents as a painless subareolar mass and are more likely to have nipple and lymph node invasion. As for treatment, most men will opt for modified radical mastectomy as most are not concerned with losing their breasts, however some men will choose lumpectomy instead because it is a less intense surgery. In terms of endocrine therapy, about 25% of men will not comply because of hot flashes and sexual dysfunction. Recurrence for men with breast cancer is low at only 5%, however some men may opt for a yearly mammogram. BRCA testing may be performed to screen for the mutation in order to see if family members are at increased risk of breast cancer.

1-s2.0-S0923753419373065-main

 

H&P

10/22/20

63 y.o. male s/p inguinal hernia repair presents for left breast mass x 1 year.  Pt reports he first noticed the mass in August 2019 and reports it has been growing since.  Pt reports some mild pain when something brushes up against the mass but denies pain otherwise. Pt reports the mass feels “hard like a rock.” Pt reports he was following up for his hernia repair one year ago (10/23/19) when he mentioned the mass to his surgeon, Dr. Darsen, who sent him for ultrasound, which the patient never completed. Pt denies any family history of cancer, nipple discharge or scaling, lymphadenopathy, weight loss, f/n/v/d, chest pain, abdominal pain, or back pain.

 

PMH: inguinal hernia, eczema

PSH: inguinal hernia repair 2019

Allergies: NKDA

Medications: None

 

Colonoscopy hx: never

Social History: Pt reports he drinks 3-4 beers every other day. Denies tobacco or drug use.

Family History: Mother- unspecified dementia, Father- unspecified seizures. Denies history of cancer or heart disease.

 

ROS:

General: Denies fever, chills, fatigue, recent weight loss

Respiratory: Denies dyspnea, wheezing, cough, sputum, hemoptysis.

Cardiovascular: Denies chest pain, palpitations, syncope, dyspnea on exertion, known murmur/ arrhythmia.

Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, hematochezia, change in bowel movements.

Genitourinary: Denies polyuria, dysuria, hematuria.

Musculoskeletal: Denies pain or swelling of joints.

Skin: Reports left breast mass x 1 year. Pt also complaining of bilateral thickened skin and leg edema. 

Neuro: Denies paresthesia, headaches, confusion, loss of memory, weakness, dizziness.

 

Physical Exam:

There were no vitals filed for this visit.

Physical Exam

Skin: Pt has left breast mass. Venous changes stasis bilaterally.

Head/Face: NCAT

Lymph: No lymphadenopathy throughout.

Heart: Heart sounds are normal.  Regular rate and rhythm without murmur, gallop or rub.

Lungs: Normal expansion.  Clear to auscultation.  No rales, rhonchi, or wheezing.

Breast: 3 cm hard, non-tender mobile mass located under and extending laterally from the nipple at the 3 o’clock position. No nipple discharge, erythema, nipple inversion/ scaling or edema noted.

Abdomen: Soft, non-tender, normal bowel sounds; no bruits, organomegaly or masses.

Extremities: Venous stasis changes and significant edema noted bilaterally.

 

Assessment and Plan:

63 yo male with no PMH presenting for left breast mass. Mass highly suspicious for breast malignancy. Core needle biopsy of left breast mass performed today.

Bilateral diagnostic mammogram

Left breast ultrasound

Return to clinic next Thursday 10/29 to follow-up biopsy results.

Pt has upcoming vascular appointment for venous stasis.

Advise pt to cut down on drinking.

 

Results of imaging after clinic visit:

Left Breast Ultrasound: There is a 2.2 x 2.0 x 1.6 cm hypoechoic irregular angulated mass present in the left breast at the 3 o’clock position at the retro areolar region.   On color flow doppler, there is adjacent vascularity. All four quadrants of the left breast and left axilla performed. There is a 1.9 x 0.5 x 0.8 cm axillary lymph node.

The mass in the left breast at the 3 o’clock position at the retro areolar region is highly suspicious of malignancy. BI-RADS 5- Highly Suggestive of Malignancy

Core needle biopsy results: INVASIVE MUCINOUS CARCINOMA, GRADE 2.

 

Typhon: tally (5)