I did my family medicine rotation at SSS Family Medicine with Dr. Streete-Smalls. Dr. Streete-Smalls is an amazing doctor and she is very willing to teach. At the beginning of my rotation, Dr. Streete-Smalls and I would see patients together. She showed me how to do physical exams, and how to use the iClinic EMR system. After I got more comfortable with the EMR system, I started to obtain patient history and perform physical exams on my own, document my findings, and present patients to her. During the last 2 weeks of my rotation, Dr. Streete-Smalls emphasized more on formulating differential diagnoses and assessments and plans. By the end of this rotation, I became very comfortable with taking patient history and performing physical exams; I’m very familiar with health screening guidelines and recommendations. I also got to practice procedures including venipuncture, vaccine administration, and pap smear.

The clinical experience really helps solidify the knowledge I learned during the didactic year. I became more familiar with the common medications such as antihypertensives and diabetes medications. Dr. Streete-Smalls taught me how she would manage patients with hypertension and diabetes and explained why she chooses certain drugs over others. Obesity is another prevalent condition among the patients coming through this office. I learned a lot about the weight-loss medication, Wegovy, and was amazed by how effective it is at helping people lose weight.

In the office, I saw a wide range of medical conditions and patients of all ages. One time, an elderly patient came in complaining of asymptomatic high blood pressure. She stated that she checked her BP at home 3 times that day, each reading was higher than the previous one. She became very anxious and came in to see the doctor. Given that the patient was asymptomatic, and she was compliant with all her medications, Dr. Streete-Smalls reassured the patient that the high BP readings were associated with anxiety. The patient felt much more relieved after hearing that. A lot of times, reassurance from a trusted provider is all the patient needs. Though out this rotation, I gained a better understanding of how to provide comprehensive care to patients in a primary care setting and learned being patient and compassionate is as important as treating the medication conditions.

My site evaluator was PA Fahim Sadat. During my site evaluations, I presented two of the three comprehensive history and physicals and a journal article. During our second in-person meeting, PA Sadat also quizzed us on the drug cards. There were 4 students for each site evaluation. After each patient presentation, we would start a discussion on the case as a group. For each case, we discussed new differential diagnoses, diagnostic tests, and next step management. PA Sadat would also share what his approach would be if he was the one managing the patient, which I thought was very beneficial. After my presentation, PA Sadat asked me to explain why I included certain differential diagnoses and expanded on my plan for the patient. From his feedback, I learned that I need to add more details to my assessment and plan. It should indicate what test was done to rule in/out each differential diagnosis. I also learned a lot by listening to my classmate’s presentations.

FM-Typhon case log

The title of the article is Efficacy and Safety of Bempedoic Acid in Patients With Hypercholesterolemia and Statin Intolerance. The article was published in the Journal of the American Heart Association in March 2019. The first author is Ulrich Laufs. The objective of the study is to evaluate the efficacy, safety, and tolerability of bempedoic acid 180mg daily in patients who can’t tolerate statin therapy for primary or secondary prevention of cardiovascular events. 

Bempedoic acid is a prodrug that’s activated by liver enzymes not present in skeletal muscle. Once activated, it inhibits an enzyme, ATP-citrate lyase, in the cholesterol synthesis pathway. Statin also targets this enzyme. Therefore, it helps reduce LDL-C while preventing the muscular adverse effects associated with statins because the activating enzyme is not found in skeletal muscle.

In this phase 3 clinical trial, 345 patients with high cholesterol and a history of intolerance to at least 2 statins were randomly assigned in 2:1 ration, to take bempedoic acid 180mg or placebo. The primary outcome of the study was the mean percent change of LDL-C in 12 weeks.

The study found that bempedoic acid reduced LDL-C significantly more than placebo at week 12. They notice the reduction in week 4, and it’s maintained throughout the study. There is an average of 21.4% reduction in LDL-C. The reduction in non-HDL-C is 21.1% and in total cholesterol is 14.8%. The improvement was maintained at week 24. Changes in triglyceride and HDL-C were minimal.

Adverse events occurred n 64% of patients taking bempedoic acid and 56.85 of patients taking placebo. The majority of the adverse events in both groups were mild or moderate intensity. The most common adverse events were musculoskeletal and connective tissue disorder (22.2% bemedoic acid, 25.2% placebo), infections, and infestations (17.5% bempedoic acid, 22.5% placebo), and GI disorders (10.7% bempedoic acid, 11.7% placebo). No serious muscle-related adverse events occurred during the study. The most common event was myalgia, experienced by 4.7% in bempedoic acid patients and 7.2% in placebo patients.  

Muscle-related symptoms were not increased relative to placebo, which confirms the expectation that bempedoic acid does not induce muscle-related side effects. Patients in bempedoci acid treatment group did experience a small elevation in mean uric acid levels, but the rate of gout was low (1.7%).

The limitation of the study is that it only followed patients for 24 weeks. The clinical bottom line is that bempedoci acid is effective in reducing LDL-C and has a more favorable side-effect profile. It can be used as an alternative or adjunct therapy for patients who can’t tolerate statins.

Rotation # and Type	Week #	PICO/Mini-CAT	Question
RT 1 – LTC	3	PICO	In patients with stage 4 pressure ulcers, does at-home negative pressure wound therapy provide better wound healing compared to negative pressure wound therapy administered in a skilled nursing facility?
RT 1 – LTC	4	PICO	Is exercise therapy more effective at relieving symptoms of lumbar spinal stenosis compared to laminectomy in elderly patients?
RT2- Family Medicine	1	PICO	Is lifestyle modification alone effective at managing symptoms of polycystic ovarian syndrome in obese women?
RT2- Family Medicine	2	PICO	Does vitamin D improve knee osteoarthritis
RT2- Family Medicine	4	PICO	Should annual MRI screening be recommended to asymptomatic patients with a family history of pancreatic cancer?

Identifying Data:

Full Name: RJ

Address: St. Alban, NY

Date of Birth: xx/xx/1990

Date & Time: 2/10/2022

Source of Information: Self

Reliability: Reliable

Chief Complaint: “I’m always thirsty.” x 3 months.

History of Present Illness:

31 y/o male with no previous medical history presents for annual physical exam, c/o increased thirst and urination for 3 months. He reports drinking 2 liters of water daily and still feels thirsty. Patient has been taking Metamucil for the past 2 months to help alleviate symptoms. Patient states he was trying to lose weight by eating healthier. Patient reports 47 lb weight loss over the past 2 months (240lb – 193lb). Denies dysuria, hematuria, abdominal pain, decreased appetite, weakness, fatigue, dizziness, palpitation, and chest pain.

Past Medical History:

None

Past Surgical History:

Denies past surgical history

Medication:

Metamucil: 1 scoop in 8oz of water, once daily

Allergies:

NKDA

Family History:

Mother: alive, diabetes mellitus, hypertension, anemia

Father: alive, hypertension

Brother: alive, ADHD

Denied family history of substance abuse

Social History:

Habits: Denies tobacco and illicit drug use. Drinks 2 bottles of beer per week.

Travel: No recent travel

Marital History: Single

Sexual History: Sexually active with girlfriend. Denies history of STD

Occupation: Works at post office

Home: Living with girlfriend

Diet: Reports that he consumes a balanced diet, has been eating more lean meat and vegetables, and less carb in the past 2 months

Exercise: Reports that he doesn’t exercise regularly

Review of System:

General – Admitted to recent weight loss. Denied decreased appetite, fatigue, fever, and night sweats

Skin – Admitted to dryness of skin. Denied moles, change of skin texture, sweating, itchiness.

Head – Denied headache, light-headedness, recent head trauma.

Eyes –Denied visual changes.

Ears – Denied tinnitus, deafness, pain, discharge, or use of hearing aids.

Nose – Denied discharge, obstruction, epistaxis, loss of smell, itchiness.

Mouth/throat – Denied sore throat, bleeding gum, mouth ulcers, voice change.

Pulmonary system –Denied SOB, sputum, orthopnea, wheezing, hemoptysis, and cyanosis.

Cardiovascular system – Denied chest pain, palpitations, syncope or known heart murmur.

Gastrointestinal system – Denied dysphagia, abdominal pain, constipation, diarrhea, and hemorrhoids.

Genitourinary system – Admitted to urinary frequency. Denied urinary urgency, oliguria and incontinence.

Nervous system – Denied seizure, weakness, sensory disturbances, and memory change.

Musculoskeletal system – Denied joint pain, back pain and muscle pain.

Endocrine system – Admitted to polydipsia. Denied polyphagia, heat intolerance, goiter, or excessive sweating.

Psychiatric –Denied history of depression, anxiety, suicidal thoughts, hallucination, and obsessive/compulsive disorder.

Physical Examination:

Vitals:

Temp: 98.1 F, oral

BP: 129/93, sitting

Pulse: 96, regular

RR: 16/min, unlabored

O2 saturation: 98% room air

Ht: 69 in

Wt: 193 lb

BMI: 28.5

On general inspection, patient is not in acute distress, appears his stated age, well developed and well groomed. AAO x 3. Lungs clear to auscultation bilaterally, heart has regular rate and rhythm. Overall no abdominal findings on his physical exam.

Finger stick was done, and showed glucose of 473.

General – AAO X3. Not in acute distress. Appears his stated age. Well developed and well groomed.

Skin –Warm and dry, good turgor. No lesions, no rashes, no jaundice.

Hair – Average quantity and distribution

Nails – No clubbing, capillary refill <2 seconds on fingers and toes.

Head – Normocephalic, atraumatic, non-tender to palpation throughout

Ears – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex.

Eyes – Symmetrical OU. EOMs intact with no nystagmus. No conjunctival injection, pallor, or scleral icterus.

Oropharynx – Moist, no erythema, no exudates, no masses/lesions. Uvula midline and rises symmetrically with phonation.

Neck – Trachea midline. No palpable masses, no thyromegaly. No cervical adenopathy noted.

Chest – Symmetrical, no deformities. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout

Lungs– Clear to auscultation bilaterally, no wheezes/rhonchi/rales.

Heart – Regular rate and rhythm. S1 and S2 are distinct with no murmurs. No splitting of S2 or friction rubs appreciated.

Abdomen –Non-distended. Bowel sounds normoactive in all four quadrants. Non-tender to palpation throughout, no guarding or rebound noted. No CVA tenderness.

Musculoskeletal – Full passive and active range of motion in shoulders, elbows, wrist, hips, knees, and ankles. No soft tissue swelling, erythema, deformities in bilateral upper and lower extremities. Non-tender to palpation. No crepitus noted throughout.

Neurologic – Sensation intact to touch in bilateral upper and lower extremities. Strength 5/5 in bilateral upper/lower extremities.

Peripheral Vascular – Extremities are symmetric in color, size, and temperature. Pulses are 2+ bilaterally in upper and lower extremities.

Labs:

Finger stick blood glucose: 473 mg/dl

DDx:

• Type I Diabetes
• Type II Diabetes

Assessment:

31 y/o male with no past medical history here for annual physical, c/o increased thirst and urination for 3 months, and 47 lb weight loss over the past 2 months. Finger stick showed blood glucose of 473mg/dl. Patient’s symptoms and finger stick result consistent with diabetes.

Problem list:

1. Newly diagnosed diabetes
2. Encounter for annual physical

Plan:

Newly diagnosed diabetes

• Labs: CMP, Hbg A1C, C-peptide
• Patient is asymptomatic, give 10 units of regular insulin in office
• Repeat finger stick in 45 mins, discharge home if remains asymptomatic
• Start insulin glargine, 20 units, SC, daily at bedtime until next follow up
• Start insulin glulisine, 5 units, SC, twice a day with meal until next follow up
• Educate patient on insulin administration and glucometer use and documentation
• Educate patient on s/s of hypoglycemia and action to eat candy or sweet drink immediately
• Referral to Endocrinologist for evaluation of newly diagnosed diabetes
• Referral to nutritionist for evaluation and education on proper nutrition
• Follow up in 2 weeks for lab report

Encounter for annual physical

• Labs: CBC w/diff, lipid profile, TSH/FT4 reflex, urinalysis, Hep C ab, HIV Ag/Ab screen by CMIA, syphilis