History & Physicals:
Journal Article Summary
Expert groups have advocated for the screening of pancreatic cancer in high-risk individuals, but prior research establishing if there is a beneficial outcome to screening measures had not previously been performed. Therefore, the multicenter Cancer of Pancreas Screening (CAPS) study aimed to establish the benefits of screening in terms of earlier detection, impact on management, and overall survival outcomes. Over 1700 participants were enrolled and of those individuals, 48.5% had a pathogenic variant in a PDAC-susceptibility gene. The screenings resulted in 1/160 individuals being diagnosed with pancreatic cancer. Of those diagnosed, 57.9% still had stage I and only 5.2% were diagnosed with stage IV disease. For perspective, 85.7% of typical diagnose are stage IV. The-fiver year survival rate for screening individuals was 73.3% which is significantly improved compared with standard combined survival rates which is 5-10%. Patients enrolled in the study lived an average of 9.8 years after diagnosis whereas individuals typically only live 24-39 months after initial diagnosis. In conclusion, yearly screenings with MRI for individuals identified as high-risk based on genetic predisposition should be implemented based on the strong evidence presented in this randomized controlled trial.
Site Visit Summary:
For my first site evaluation I presented two cases. The first was a case of a young male with an open wound over his left knee secondary to a motor vehicle accident. I chose this case because it helped me exercise my knowledge of wound care and a trauma workup in an outpatient setting. I enjoyed the writing up the wound care note and carefully thinking over the steps to rule out other injuries and use the physical exam to determine the most likely MSK diagnosis. The second case was a physical exam which I felt was equally as important because although there is no presenting complaint, I must examine the patient thoroughly from head to toe, gather medical history, and determine necessary labs to determine that someone is in a good state of health. Many common diseases such as hypertension, hyperlipidemia, and diabetes mellitus must be considered during the exam, as well as other diagnosis that may present through the patient history or physical exam findings.
During the second site evaluation I presented one case and one journal article. The case was based on a patient presenting for follow up pertaining to injuries sustained from their job eight months prior. I felt this was a good case to present because I am used to seeing patients in acute settings and making initial diagnosis or very recent follow up but in this case, the patient had primarily healed from their injuries and the H&P focused on the discharge of the patient from the practice. Being that CitiMed is not traditional family medicine, patients only continue to see the family medicine providers here if the injury remains. The feedback I received from my site evaluator was that it was a very well written, thorough HPI.
The journal article focused on primary care screenings for individuals at high risk of developing pancreatic cancer. My site evaluator and I discussed the need to better identify who is at high risk but agreed that the findings of the article are significant and suggest a longer five year survival rate and surgical options for those screened versus those not screened.
Typhon Case Logs:
My family medicine rotation was located at CitiMed JFK which specializes in personal injuries. Specialties such as pain management, orthopedics, and physical therapy are all located in the same building which provided me the opportunity to partake in the interprofessional collaboration. Prior to this rotation, an area I felt weak in was orthopedics/musculoskeletal injuries but after completing this rotation I feel much more confident in the diagnosis and management of such.
I was able to newly diagnosis several heart murmurs ranging from mitral valve prolapse to aortic stenosis. I was also able to pick up adventitious lung sounds in multiple patients which in one case was able to identify “walking” pneumonia. The most challenging diagnosis I made was a 29 y/o male with Cushing’s disease. The patient presented for cervical disc herniation secondary to a motor vehicle accident, but I noted multiple physical exam findings leading to a further workup and investigation that later led to a diagnosis. Knowing that this patient came in for a different complaint and I was able to pick up on this diagnosis before his disease progressed was rewarding.
Over the course of the rotation, I noticed growth in my leadership skills. There were several students at the site on their very first rotation, and our preceptors would allow me to present findings I picked up to the other students. I was also able to teach them how to prep and suture an open wound. I was not expecting to get to do as many suturing procedures and wound care as I did in family medicine which excited me being that I am very fond of performing these types of clinical skills. My preceptor subsequently gave me a good presentation on different suturing materials and size along with general principles of wound care management that has helped me better understand choosing which material will work best for the individual patient. The medical assistants were also very knowledgeable and allowed me to perform many EKGs and venipunctures which I had not done for the last two rotations so this was a good skills refresher for me.
One thing I want to continue to work on after this rotation ends is delivering bad news. I did notice marked improvement in my delivery from start to finish of this rotation but I feel this is an aspect of medicine I should always work towards further improving. In the beginning of the rotation I was not used to patients becoming emotional as I read results from their medical records that were not what they were hoping for. In addition to rereading bates “Breaking Bad News”, I also read the publication from the AAFP and would practice my mannerisms, technique for homework over the course of the rotation.
Overall, I very much enjoyed my family medicine rotation at CitiMed. I learned more of my strengths and weaknesses which helped guide me on what skill sets and areas of improvements I should focus on for my upcoming rotation in Urgent Care.