MINI CAT/ PICO TOPIC TABLE

Rotation	Week	PICO/Mini-CAT	Question
Family Med	Week 3	PICO	Is antibiotic prophylaxis an effective method of preventing recurrent UTIs as opposed to nonantibiotic measures?
Family Med	Week 4	PICO	Is metformin more effective than lifestyle changes in preventing the development of diabetes in prediabetic patients?

Rotation: 1 Family Medicine

Family Medicine HPIs

Journal Summary

Rotation #1: Journal Article Summary
Title: “Memory Loss in Alzheimer’s Disease” by Holgan Jahn, MD

Alzheimer’s is one of the most common causes of dementia and is often on top of a provider’s differential when a patient comes in complaining of memory loss. This article focuses on the relation between memory loss and Alzheimer’s and how this disease affects short term memory, long term memory, and how other outside factors affect the severity of this disease.

Earlier onset of dementia can become evident in patients as early as in their forties; genetics plays a strong role in such cases. However, this is a rare case, occurring in 1% of all patients with AD. More commonly, onset of dementia begins around age 65. According to the article, the most common genetic risk factor for late-onset Alzheimer’s is the apolipoprotein E4 genotype, which increases the risk for AD by 4-10x.

Patients with AD typically have amyloid plaques or neurofibrillary tangles found in their brain autopsies. These lesions first appear in poorly myelinated limbic neurons in areas related to memory and learning such as the hippocampus—thus affecting short-term memory. When assessing patients, the effect of these lesions on the hippocampus directly correlated with performance in memory tasks and a decline of performance in the Boston Naming Test Mini-Mental Status Exam.

Patients with AD may come to the clinician initially complaining of cognitive decline which further develops into cognitive impairment, which progresses to dementia. These deficits in attention and working memory often impair the patient’s ability to plan, problem-solve, and impairs goal-directed behavior.

The impact AD had on memory was tested in a study where patients with subjective memory underwent an episodic memory task where they had to match face to professions (including processes such as encoding, recall, and recognition) as well as a working memory task all while the patient was observed using a functional MRI. The result was that there was a reduction in the right hippocampal activation during episodic recall, further proving the connection between memory loss and the way AD affects the brain.

Moreover, sleep disturbances have also been associated with AD, which also affects a patient’s cognitive state. These sleep disturbances include daytime napping and insomnia, and they affect 25-40% of patients with mild-moderate AD. Sleep changes in patients who are already experiencing mild cognitive impairment, can experience worsened memory deficits due to interference to sleep-dependent memory consolidation.

Using this information, it would be useful as future clinicians to notice these “red flags” that may indicate possible early development of AD in our patients. We can then hope to implement therapeutic interventions which can prolong the cognitive impairment process.

Typhon Summary

Reflection on Rotation

My first rotation was Family Medicine in South Shore Family Medical, located in Far Rockaway. This was an underserved area with a population consisting mostly of Black and Hispanic patients. Most patients were not properly educated on their health status and did not have much of an understanding in regards to the diseases they had. Therefore, a great deal of patient education was required. Some pros about this rotation was that I felt this was a great rotation to start off with. It wasn’t so fast paced that I became overwhelmed, but rather, I felt I had a steady introduction into clinical year. This rotation gave me an opportunity to learn how to speak with and educate patients, listen to their problems, and decipher what issues caused them the most distress and focus the visit on those issues. I was also able to practice skills, such as venipunctures and EKGs, several times throughout the rotation to the point where I feel quite comfortable drawing blood (even on harder sticks). I learned to speak to patients confidently and make them feel taken care of by taking my time with them and addressing all the issues they brought up to me. 

Because it was Family Medicine, I saw a large variety of conditions and disease states, ranging from hypertension and diabetes, to chronic back pain, to BPH and Prostate cancer. This rotation definitely helped me build my differential list, and taught me how to manage, screen, and test for conditions that most patients tend to deal with. 

One thing that I wasn’t used to but had to learn how to do, was to see patients both efficiently and quickly. Shorter patient visits are encouraged by insurance companies and spending 30+ minutes on each patient is often looked down upon. As much as I wanted to be thorough with the patients that I saw, I had to learn to determine what their biggest problem was and focus on that rather than having the patient unveil a plethora of issues that they have been dealing with. Learning to allocate time properly and efficiently while seeing patients is definitely a skill that will serve me well in more fast-paced environments and when working in the field. 

Site Visit Summary

For one of my site visits, one of the patients I presented was a 56 year old woman complaining of dizziness and vomiting for the past day.She reported an episode of vomiting the prior morning. Later that night she experienced dizziness and felt that the room was spinning. The dizziness continued into this morning and has since improved. She denies hearing loss, tinnitus, ear pain, fever, chills, night sweats, or any other complaints. One of the first things that came up in our minds on our differential was vertigo, and it came down to trying to distinguish if the cause could be Meniere’s or BPPV. This was a good review of distinguishing between the two conditions. Meniere’s causes vertigo but it is also associated with tinnitus, hearing loss and ear fullness. The patient had denied these symptoms and so we assessed the patient for BPPV. In order to do this, we conducted a Dix- Hallpike maneuver on the patient, in which we turn the head of the patient by 45 degrees and have them lie down quickly in a trendelenburg position in order to observe for nystagmus. The Dix-Hallpike maneuver came out negative for nystagmus. We deduced that considering that the vertigo was improving, that it may have been secondary to her episode of vomiting and we educated the patient on staying hydrated and to stay rested. In order to treat her symptoms we prescribed Meclizine HCl 25 mg 1 tablet as needed. I felt that this was a great example of how we could utilize fairly simple physical exams to rule in and out our differentials and provide the patient with appropriate treatment.  I also learned when it is necessary to treat the disease or to alleviate symptoms, which is something that is very important to know how to distinguish.