General Surgery Rotation

• The most commonly seen adenopathy in breast disease is axillary adenopathy (85%).
• Other adenopathies seen are internal mammary, parasternal, and supraclavicular.

Fibroadenoma: Solid, mobile, well-circumscribed round breast mass. Most common breast tumor in women < 30 years.

Fibrocystic breast disease: common benign breast condition consisting of fibrous and cystic changes in breast. Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous (“nodular”) fullness.

• Aspirated cysts - usually straw-colored or green fluid

Risk factors (increased exposure to estrogen): NAACP

• Nulliparity
• Age at menarche (<13 yrs)
• Age at menopause (>55 yrs)
• Breast cancer (self, family)
• Pregnancy of 1st child >30yrs

USPSTF guidelines for breast cancer screening:

• Baseline mammogram every 2 years from age 50-74
• Every 2 years beginning at age 40 if increased risk factors – 10 years prior to the age the 1st-degree relative was diagnosed. 
• Clinical breast exam: every 3 years in women aged 20-39 years, then annually after age 40
• Breast self-exam – monthly beginning at age 20 – immediately after menstruation on days 5-7 of the menstrual cycle

The most common type is infiltrating Intraductal Carcinoma

• Infiltrating ductal carcinoma (~75%)
• Medullary carcinoma (~15%)
• Infiltrating lobular carcinoma (~5%)
• Tubular carcinoma (~2%)
• Mucinous colloid carcinoma (~1%)
• Inflammatory breast cancer (~1%)

Sites of metastases: 

• Lymph nodes (most common)
• Lung/Pleura
• Liver
• Bones
• Brain

1. Duct ectasia
2. Intraductal papilloma
3. Carcinoma

In premenopausal women, spontaneous multiple duct discharge, unilateral or bilateral, most noticeable just before menstruation, is often due to fibrocystic condition (FCC). Discharge may be green or brownish.

• A milky discharge from multiple ducts in the nonlactating breast may occur from hyperprolactinemia

• Pain in General Surgery:
  • Postoperative Pain: Common after surgical procedures, varying in intensity based on the type of surgery.
  • Chronic Pain: Can result from conditions like hernias or gallbladder disease.
• Pain in Obstetrics:
  • Labor Pain: Intense pain during childbirth, requiring effective pain management strategies.
  • Postpartum Pain: Including pain from cesarean sections or perineal tears.
  • Breast Pain:
    • Mastitis: superficial infection of the breast - usually occurs during breastfeeding.
    • Breast abscess: often a progression of mastitis
    • Nursing: Staphylococcus aureus
    • Nonlactating: mixed infection
• Pain in Gynecology:
  • Menstrual Pain: Dysmenorrhea, a common issue causing significant discomfort.
  • Pelvic Pain: Associated with conditions like endometriosis, ovarian cysts, or pelvic inflammatory disease.

Skin changes during pregnancy

Melasma (ie, chloasma or mask of pregnancy) is the most cosmetically disturbing pigmentary change and occurs in up to 75 percent of pregnant women

• The characteristic hyperpigmentation of the face may also occur in nonpregnant women and women taking oral contraceptive pills

Vascular changes — Estrogen and other factors cause vascular distention and instability and proliferation of blood vessels during pregnancy

• Spider angiomas - They appear in the second to fifth month of pregnancy as red lesions with branches extending out from a central puncta
• Varicosities — Saphenous, vulvar, and hemorrhoidal varicosities all occur at an increased rate during pregnancy and cannot be prevented

Striae gravidarum — Connective tissue changes, such as stretch marks (ie, striae distensae, striae gravidarum), are a common source of cosmetic concerns among pregnant women

Pruritus in pregnant women may be physiologic, related to a flare of disorder present prior to conception, or related to pregnancy-specific dermatoses

• Chlorpheniramine has been recommended as the first-generation antihistamine of choice for use during pregnancy

Hirsutism is noted most frequently on the face, but may also be seen on the arms, legs, back, and suprapubic region

Nails grow faster during gestation. Changes that may occur include development of transverse grooves, subungual keratosis, and distal onycholysis, and melanonychia

Androgenic alopecia — Rarely, late in pregnancy, hair in the frontoparietal area recedes in a mild form of androgenic alopecia

Vaginal – Bluish/purplish coloration of the vagina (Chadwick sign) and cervix (Goodell sign) are early anatomic changes historically important in the diagnosis of pregnancy

• The blue appearance is related to increased blood flow