Site Evaluator: Michael Rachwalski, PA-C

For my first site visit, I decided to submit 4 SOAP notes on cases involving appendicitis, acute vaginal candidiasis, wound check, and suspected pneumonia. Professor Rachwalski went through each case with me where we discussed differential diagnoses and he gave me some constructive criticism on how to better format my physical exam. He also advised me to avoid the use of the word “lesion” as it is vague and doesn’t convey much information. The one case that prompted a little more discussion was the 56 year old female who presented with gradual worsening abdominal pain that has lasted for a day. The patient’s presentation and physical exam were a classic presentation of appendicitis with a sharp pain first starting in her hypogastric region and then migrating to her right lower quadrant, nausea present with no vomiting, positive Mcburney’s point, positive obturator sign, and positive rovsing sign. An ambulance was called immediately for the patient to be taken to the ER for a more comprehensive appendicitis work up. Professor Rachwalski agreed with the majority of my physical exam, assessment, and treatment, only mentioning that I had failed to mention a positive or negative rebound tenderness finding. Additionally, we discussed what “gaurding” means and contrary to my understanding of it meaning the patient contracts away from you due to pain, it is the contraction of the muscles due to pain.

For my final site visit, I presented a full H&P on a 37 year old patient who came into the clinic with a erythematous annular plaque with an outer ring on his right upper thigh accompanied with a mild headache that started 2 days ago following a possible tick bite, while he was in upstate New York. Besides for the skin finding, the rest of his physical exam was unremarkable, including his neurological exam. His vitals were stable and he was not exhibiting any signs of meningitis, facial paralysis, encephalitis, radiculopathy, or arthritis. The patient’s diagnosis was most likely a tick-borne illness, specifically early localized stage (Stage 1) Lyme Disease. He was treated with 10 days of Doxycycline Monohydrate 100mg tablets BID for the Lyme Disease and told to continue Tylenol for the headache. Education on methods to avoid tick bites along with immediate action to decrease risk of Lyme disease was given. The patient was not recommended for diagnostic lab work at this time. Professor Rachwalski complimented me on my physical exam and plan, specifically the education given to the patient. His main criticism of my chart was needing to be more concise with the information in the HPI and assessment. 

In the journal article I presented, researchers sought out to determine if Azithromycin cream had a similar if not more protective effect than Doxycycline cream in an individual with a tick bite.s 

My surgery rotation has been my toughest rotation thus far, with it being emotionally, mentally, and physically exhausting; however, it has been one of the most learned environments I’ve been in with great teachers and exposure to a multitude of areas (ex. wound care, bariatrics, vascular, GI, ENT, plastics, breast-related conditions etc). I was on the OR floor for the first 3 weeks where I had some clinic work in the afternoon and then I was moved to work in the clinic full time for my last two weeks. The most exciting part for me was being able to scrub into cases, have a place at the table, and assist in suturing up the patient. 

Three areas that I felt weak in at the beginning of the rotation and had strengthened by the end was my anatomy knowledge, reading diagnostic imaging, and interpreting lab values. Surgery is very meticulous and knowing everything about the area one is cutting into is a must. For the surgeries I was assigned to scrub into, I would watch videos on the procedures and learn the anatomy in that area the night before because I sometimes found it difficult to determine what structures we were looking at during the actual surgery. One of the first surgeries I scrubbed into was a inguinal hernia repair and the incision site the surgeon made was small making it a bit harder for me to see what was being done, but I remember standing there thinking how are they going to find the spermatic cord structures when everything looks the same. Preparation is key. Another skill that I worked on that will be particularly helpful in the future is reading CT and MRI scans. Throughout didactic year it was difficult for me to determine if something was abnormal; I would identify parts of the scan that looked suspicious to me but turned out to be just the bodies normal asymmetry. The surgical residents were very helpful in walking me through the scans and pointing out landmarks to pay attention to. The last skill I wanted to mention was improving my ability to interrupt lab values and how those lab values changed the treatment management. During my time on the in-patient floor, the students were expected to assign themselves at least one patient that we rounded on in the morning to check up on and follow their labs and tests that were ordered for that day. It gave a real sense of what it’s like to have your own patients and continuity of care.  I was able to get familiar with correcting electrolyte imbalances, what were the next steps if the WBC increased over x fold amount overnight,  different causes behind a patient being in metabolic acidosis etc. 

WIth this rotation, I had the opportunity to practice writing more SOAP notes, which I actually found to be a bit challenging in terms of the amount of information to include. I am so used to writing H&P and following OLDCARTs for the HPI, I was almost shocked by what was not included and what the resident or PA ultimately took out after editing my note. It was great practice for documenting in the future in a timely manner and to be able to really cut down the information to only include the pertinent information. Being “responsible” for physically writing the note also helped with my own learning of what the important questions were to ask, what I should check in the physical exam, what imaging or labs are needed, and finally what the plan will be. The repetitiveness helped cement the information for me. 

The clinic that I particularly enjoyed being in was the plastics/breast clinic. A memorable patient for me was on one of my last days and it highlighted our unforgiving health care system on mental illness. A young slender man came in with significant gynecomastia that has been gradually getting larger for the past couple of years. He was undergoing a workup with an endocrinologist, but was interested in surgical intervention as it has gotten to the point where he was so embarrassed to even go outside. He said that mentally it has been very difficult for him and feels very uncomfortable with his body as the breasts make him feel like a woman. His only symptom was how it has affected him mentally and when we looked up the criteria for coverage under his insurance, psychological/social issues were explicitly stated as not a qualification. Additionally, there were only clear guidelines that addressed a female not a male making it harder to determine the likelihood of him getting the surgery covered. It felt like a helpless situation as the patient was able to pay out of pocket for the surgery; I had asked the PA that I was with what would happen next and he replied with a shrug of the shoulder with the same look as how I felt. He recounted a similar situation with a 14 year old male who was getting bullied at school and his insurance wouldn’t cover the surgery. Though patients may not have a physical symptom, psychological effects can be debilitating and insurance companies need to reevaluate their standards of what is considered medically necessary. 

Site evaluator: Amil Alie

For my first visit, I presented an H&P on a  53 year old male presenting in the clinic for evaluation for possible right thumb amputation and sentinel lymph node biopsy after being diagnosed with sublingual melanoma of his right thumb. The patient states that he had noticed a single linear dark brown patch of the nail about 3 years ago that has since grown to extend over the nail fold. The first biopsy results showed junctional melanocytic proliferation in the nail matrix. A complete nail avulsion with nail matrix biopsy was scheduled two weeks later to rule out malignancy. Results confirmed acral lentiginous melanoma stage pT3a (2.3mm Breslow thickness with perineurial invasion). The physical exam showed a 1 cm x 1 cm brown/blackish lesion on the dorsal aspect of the right thumb tip and a scattered hyper pigmented lesion with undefined borders near the nail matrix. Range of motion was intact. Non-tender to palpation of the MCP, PIP, and DIP joint. The patient was neurovascularly intact; capillary refill less than 2 seconds in the upper extremities. No palpable lymph nodes. The plan for the patient was to get a chest, abdomen, and pelvis CT to rule out metastatic disease prior to scheduling surgery. I chose this case due to the rarity of the condition, with it occurring in only about 0.7-3.5% of all melanoma cases, and because it was the first OR case that I saw an amputation. Professor Alie agreed with my assessment and complimented me on my H&P and choice of case. 

For my final site visit, I had completed 6 SOAP notes. The one that I had presented was a 55 year old female with a PMHx of of invasive ductal carcinoma of the right breast clinical stage IIIA (T3, N1, M0 grade 3, ER/PR+ HER2+) who had presented in the clinic status post right total mastectomy with sentinel node biopsy and left prophylactic total mastectomy with plastic surgery reconstruction (500 ml expander bilateral) on 1/24/2023. She reported pain in the lateral aspect of her right breast and was requesting another infusion of a tissue expander, as it had relieved some of the pain in the past. She recently just completed her 5-week course of external beam radiation therapy on 05/02/2023, with moderate dermal burns on her right neck and right lateral chest. She saw a dermatologist a week ago, who prescribed her Lindex ointment and Mupirocin ointment to put on the affected areas. Physical exam showed moist desquamation on the left neck and axillae with areas of dry desquamation. Hyperpigmentation and erythema over the radiation treated area of the breast, with tenderness to touch. Radiation dermatitis stage II. No signs of cellulitis or purulent discharge. Due to the grade II radiation skin changes on her right neck region and breast, injecting tissue expanders at this time was strongly advised against due to risk of infection. Patient was started on Augmentin and scheduled to follow up back in clinic a week later. I chose this case because I had never seen radiation burns post-treatment before and didn’t know it could be of that severity. I also chose this case for a more personal reason being the mother of one of my close friends was diagnosed was breast cancer grade 2b a year ago, had gone through chemotherapy and mastectomy, and was just about to start radiation therapy. Dr. Alie complimented me on my SOAP note and said it tied nicely with the journal article that I chose. He gave me some constructive criticism on the amount of information included in the SOAP note and said there was some information that didn’t need to be included.  

“Bacterial Decolonization for Prevention of Radiation Dermatitis: A Randomized Clinical Trial.”

Published in JAMA Oncology, Published online May 4, 2023 by Kost, Yana et al.

According to the American Cancer Society, 50% or more cancer patients receive radiation therapy as part of their treatment course; about 4 million cancer patients in the US receive radiation therapy. Unfortunately, a common side effect of such a therapy is radiation dermatitis or burn, ranging in severity from mild to severe. Most are mild, but if severe, can significantly affect one’s quality of life and decision to continue therapy. 

Previous studies have found an association between level of staphylococcus aureus colonization and burn severity. In this 2022 randomized control study, researchers sought out to determine if prophylactic bacterial decolonization can help decrease the burn severity, with a primary outcome of a radiation dermatitis of grade 2-MD or higher. Grade 2-MD dermatitis was defined as “patchy moist desquamation mostly confined to skin folds and creases”, while grade 2 was defined as “moderate to brisk erythema”.   Participants were taken from an urban academic cancer center, where 80 patients (average age 59-60 years old) met the inclusion criteria (18+ years old, diagnosis of breast or head/neck cancer, and whom radiation therapy was included in the treatment plan.) 

Subjects were randomly assigned to either the control group (standard of treatment) or treatment group (bacterial decolonization). The intervention of the treatment group consisted of 5 days every two weeks of intranasal mupirocin 2% ointment twice a day and chlorhexidine gluconate 4% body cleanser once a day through the course of therapy. Standard treatment consisted of regular cleansers. The Common Terminology Criteria for Adverse Events was used to grade the severity of the radiation burns, the SKindex-16 instrument was used to assess for quality-of-life. Bacterial cultures were performed at baseline, at the midpoint, and on the last day of therapy.     

The results confirmed the benefits of prophylaxis bacterial decolonization in reducing the severity of radiation therapy dermatitis. Radiation dermatitis was significantly lower in patients treated with bacterial decolonization compared to patients treated with standard care. None of the patients in the treatment group developed a grade 2-MD dermatitis or higher, whereas 23.7% in the control group did. Only 35.9% of patients treated with bacterial decolonization developed grade 2 dermatitis compared to 52.6% of patients in the control group. Even after adjusting the results for risk factors such as high BMI and radiation dosage, bacterial decolonization was still associated with lower radiation dermatitis grade. Interestingly, S. aureus colonization increased from baseline to after treatment in the control group, while the opposite occurred in the treatment group (5.4% in treatment group, 24.3% in control group).  

This study found that bacterial decolonization is a easy, safe, and low cost prophylactic method in decreasing radiation dermatitis severity, especially among patients with breast cancer. 

Sources: 

• Kost, Yana et al. “Bacterial Decolonization for Prevention of Radiation Dermatitis: A Randomized Clinical Trial.” JAMA oncology, e230444. 4 May. 2023, doi:10.1001/jamaoncol.2023.0444
• https://my.clevelandclinic.org/health/diseases/21995-radiation-burns#:~:text=Radiation%20burn%20or%20radiation%20dermatitis,peel%2C%20itch%20or%20turn%20red.
• https://pubmed.ncbi.nlm.nih.gov/37140904/