Friday, July 16, 2010
Do your whole interview, not part of it.
23 y/o active duty E-5 fell and broke her wrist in Afghanistan while on a convoy. Went to see the Dr and was medevac'd out of theater to Norfolk to have pins placed. She seen a FNP on a routine visit while recovering and a family history was done. Mother had died of breast cancer at 29 y/o and grandmother at 32 y/o. Testing was done and she was positive for BRCA 1. So she was sent to Bethesda to be seen at the breast care clinic. While there they determined she needed a pap smear. Pap was done and they found an adnexal mass. Turned out to be cysts on both ovaries and they were scheduling a hysterectomy on a 23 y/o with no kids. She had her exam prior to deployment and was told to get her pap when they got back as they didn't have the time since she was on a short notice deployment. Moral of the story is do a full exam and take the time to take care of our patients as earlier intervention might have had a different outcome.
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James,
ReplyDeleteSuch a sad case. A provider doing their job by obtaining a complete history and doing a PAP when it was supposed to be done may have changed the outcome for this young woman.
This case reminds me of a patient I cared for when I worked in the nursing home. She was a 19 years old girl from Puerto Rico. She had 4 children, having had her first child when she was 14. She was in the nursing home for end-of-life care secondary to cervical cancer and metastasis. She had never seen a doctor (her husband didn't think she needed one) until visiting relatives in the U.S. a couple weeks prior to her admission to the nursing home. We got her pain under control and then she decided to go home to Puerto Rico to spend her last days with her children. We heard that she died about one week later.
Early intervention and proper medical care, including a PAP, would have changed the lives of both these young women.
While I was stationed in LA I was a liaison for a 20y/o patient who came in for bleeding during intercourse and it turned out to be an aggressive rare vaginal cancer. She discussed preservation of her ovaries or eggs with multiple "expert" providers at UCLA and Cedars Sinai but they felt delaying radiation/surgery or chemotherapy would adversely affect her chances of living one year past diagnosis. I PCSd to USUHS one year later--she had undergone a complete hysterectomy, radiation and chemotherapy treatments and had been declared "clear" right before I left. The odds were against her but she was a survivor. Her next battle was a med board and unfortunately I do not know what the final outcome was but she fervently wanted to serve her country and not be discharged. There are some "miracle" cases out there but unfortunately she would not be able to have any biological children.
ReplyDeleteAll 3 of these cases really bring home the point about taking a GOOD personaly & family history. You never know what might be lurking around the corner until you ASK. Great case & commets. Thanks
ReplyDeleteI saw a patient yesterday in the breast care clinic that this discussion reminds me of. She was a 42 y/o Asian female who came in to get a prophylactic left mastectomy. She had been diagnosed with DCIS in her right breast at the age of 27 and subsequently had a right mastectomy with axillary lymph nodes removed. She had been considering reconstructive surgery for many years and finally decided to get it done. She wanted her left breast removed 1) because of risk of cancer and 2)to obtain symmetry with reconstruction. Interestingly, she had no family history of any type of cancer. She had genetic testing 2 years ago and she didn't have any of the major markers, only variations. However, this lady has 4 daughters. (Amazingly, she had delivered only a year after her mastectomy, much to her doctor's dismay, I am sure.) At any rate, this family now has to worry about passing whatever mutation the mom may have onto their daughters. My preceptor recommended that the couple do more genetic testing, since new markers are being discovered every day. I thought this was a great plan, and I will definitely carry this point with me throughout my clinic time. In the meantime, my preceptor would be coordinating with the plastic surgeon to get her surgery scheduled.
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