History and Physical

Journal Article Summary

Article: Risk factors for statin-associated rhabdomyolysis

Journal of International Society for Pharmacoepidemiology, 2007

Authors: Schech et al.

• The article focused on finding risk factors such as age, gender, comorbidities, concurrent medication use, dosage, and duration of statin that could lead to statin induced rhabdomyolysis.
• This was a case control study conducted with a cohort of 252, 460 who just started taking statins. A retrospective cohort study was used to identify cases with rhabdomyolysis. 21 cases with rhabdomyolysis induced from statin therapy alone or statin therapy with a fibrate were compared to 200 controls without rhabdomyolysis. All cases were exposed to Atorvastatin, Cerivastatin, or Simvastatin.
• Although the evidence was not as strong, there was also a relationship of developing rhabdomyolysis amongst patients with high statin dosage (especially with Cerivastatin), patients with renal disease, and female patients.
• Overall, the study found patients 65 and older have a 4x risk of developing rhabdomyolysis and needing hospitalization compared to those under the age of 65.
• Some limitations of this article, includes being published in 2007. Since then, Cerivastatin has been discontinued and instead Rosuvastatin became available in 2010. It would be great if this study was redone with the current statins on the market.
• Another limitation is the small number of cases from statin induced rhabdomyolysis, which was 21. Since this is a small sample, it’s hard to confirm a clear association between the risk factors and statin induced rhabdomyolysis. A larger sample would give a clearer answer if there’s increased risk for female patients developing statin induced rhabdomyolysis.
• This article mainly focused on identifying risk factors of developing statin induced rhabdomyolysis, however, it still doesn’t address the other adverse events that occur with statins such as DM, Hepatoxicity, or Myopathy. Further research should focus on recommending statin dosage for patients 65 and older, along with the risk vs. benefit for continued statin treatment in patients 65 and older who develop adverse events.

Citation:

Schech, S., Graham, D., Staffa, J., Andrade, S. E., La Grenade, L., Burgess, M., Blough, D., Stergachis, A., Chan, K. A., Platt, R., & Shatin, D. (2007). Risk factors for statin-associated rhabdomyolysis. Pharmacoepidemiology and drug safety, 16(3), 352–358. https://doi.org/10.1002/pds.1287

Site Evaluation Presentation Summary

My site evaluator for my third rotation was Dr. Davidson. During my site evaluation, I presented 3 monthly evaluation H&Ps from my time in LTC at St. Albans VA. The 1st H&P was a complicated case of a 79-year-old who was admitted to LTC for assistance with ADLs, after being discharged from Mount Sinai where he was admitted for AKI on CKD 2/2 Rhabdomylosis, Uremic Encephalopathy, and Urosepsis. His hospital course was complicated by E. Coli bacteremia. Initially, when I first presented the case, it was hard to follow along chronologically since the patient had various procedures and events that occurred during his course at Mount Sinai. I was given good and clear feedback on how to re-arrange by first starting his HPI with how his status was in the community normally, then talking about the new event/date, then discussing his ED admission and what was found/diagnosed there/his hospital course with any treatments/developments and then discussing his transfer to the VA and his course since that moment. For my second site visit, I presented a case of monthly progress note on a patient who was admitted to St. Albans for short-stay rehab. I also gave prevention on Anemia of Chronic Disease/Inflammation and how anyone who has a chronic illness with microcytic/normocytic anemia should be considered and worked up. In addition, I presented a journal article on the RF for developing Rhabdomyolysis from Statins. 

Typhon Posting

Rotation Self Reflection

1. What was a memorable patient or experience that I’ll carry with me?

My time at LTC helped me recognize how vital the patient-provider relationship is in improving the patient’s health. It helped me reevaluate my own encounters with patients. A lot of the residents at LTC do not have social support, instead, it’s the nurses and other healthcare providers that act like their relatives. I saw how a simple handshake and greeting from Dr. Newland, can light up a smile on an 80-year-old wheelchair user. 

2. Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them.

It was difficult for me to perform full complete physical exams on a lot of the patients since most were wheelchair-bound, agitated, or A&Ox1. I found it helpful to introduce myself to the charge nurse of that floor, and then informing them I would like to do a physical exam on Mr. X. The charge nurse would then tell me about the resident’s baseline, if they were known to hit staff unprovoked, or if they were currently out. Sometimes the charge nurse would help me distract the patient so I could do a physical exam, which I appreciated. 

3. Types of patients you found challenging in this rotation and what you learned about dealing with them.

The hardest patients I had to deal with, were the ones that were known to become physically and verbally assaultive with staff. After talking to Dr. Newland, I learned that some of these patients resort to that because they felt provoked, and sometimes patients can do it unprovoked. For instance, there was a resident who had multiple code 2000s called, where they were physically/verbally agitated and were unresponsive to nurse and provider redirection. However, he later mentioned he was like this because he hated being on a 1:1 observation. Once Dr. Newland switched him from 1:1 to close observation, the resident did not act up again. 

4. What do you want to improve on for the following rotations? What is your action plan to accomplish that?

For my following rotations, I want to get better at procedures. I had some experience with replacing foley catheters at LTC, however, I want to try using a straight catheter, putting in IVs, and suturing. I also gained a lot of experience with blood draws during this rotation. I understand that each rotation focuses on specific procedures, and I plan on perfecting those procedures at those sites. My next site is Psych and it’s mainly performing a mental status exam along with depression screening.