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.