Author Archive
On Wednesday, we had our session of ARF. We went through a real patient case and discussed how ARF could have been prevented in this patient. A few interesting things I learned were:
– A increase in > 100 micromol/L of SCr is indicative of ARF
– Having “Normal” aminoglycoside (or other nephorotoxic drugs) levels does not necessarily mean ARF will be prevented.
– Rifampin has been known to cause acute interstitial nephritis.
– Hydration is key in ARF, followed by diuretics if fluid overload is occuring. This gets the kidneys per fusing.
– Earthquakes victims who are caught under rumble are at increased risk of hyperkalemia when they are “rescued”. People in Turkey (where earthquakes are common) keep kayxelate in their earthquake disaster kits. (This last point was not part of the case but one of Dan’s random facts at the end of the session).
Five weeks goes by fast! Friday was my last day. I do admit I was getting a bit overwhelmed with the number of patients I had to cover but I made it through. A few things I have taken away from the past five weeks:
1) Developing a relationship with other health care professionals is really important. I had the opportunity to work with one geriatrician who was very appreciative of my suggestions and often came to ask my input. The same relationship is also very important with nurses too. I got to know a few of them and they would often ask me questions about what was on the formulary and this is where my experience in the dispensary came in handy! Nurses are also a great source of information because they interact with the patients so much more than we do and have great insight into things such as pain control, bowels, mood, etc.
2) Learning to juggle your patients. I had up to fourteen patients I think at one point and toward the end I admit that I got a bit overwhelmed as it was my first rotation. I developed a word document to help me keep track of progress and basically updated it with relevant information.
3) Backing up your recommendation is very important. This is something I struggle with when I write my SOAP notes. I know what I’m going to recommend most of the time but giving concrete reasons is something I am having difficultly with for some reason. This is something I really need to work on over the next couple of months.
Lastly, I’ve attached a copy of my slides for my case presentation. Geriatrics case presentation
Geriatrics – week 3 update
Posted on: September 3, 2009
I can’t believe I’m half way done this rotation. It seems like I just started. I have a lot of patients and never thought I would ever be able to keep them straight. But somehow I am keeping them organized! Things I have been doing over the past three weeks:
1) Putting almost every patient on calcium and vitamin D and I’d say half of them I’m recommending a bisphosphonate as well. The risk of falls and fractures is huge on this ward!
2) Learning so much about chronic pain – both MSK and neuropathic. I’ve maxed out most patients with pain on Tylenol 1 g QID for those with MSK pain! Gabapentin seems to be the “go-to” drug for neuropathic pain but I am seeing that even small intial doses can cause dizziness and sedation. We actually had to recommend a starting dose of 50 mg qhs (using liquid ) today because the patient got extremely sedated and dizzy when they started him on 200 mg qhs three days ago.
3) Assessing compliance. This is often overlooked when pharmacists assess compliance and even if it is assessed nothing is done about it at discharge to ensure that they can actually handle their medications at home. Patients also lie a lot more often than you think. I think a lot of times they want to be “good patients” and are actually scared to tell you that they have difficulty managing their medications.
4) Learning about the statin controversy. Most statin trials exclude patients older than 85 so whether the results can be extrapolated to the geriatric population is debatable. Unless a patient has multiple CV risk factors, some doctors are not keen on starting/ keeping them on a statin.
Depression….
Posted on: September 3, 2009
Yesterday, we had our therapeutic session on depression with Dr. Bree Zehm. The session was a nice review and I also learned a few new things.
1) Seroquel XR is indicated as monotherapy for depression.
2) Sertraline has relatively few drug interactions with the exception doses which exceed 150 mg/per day. It exhibits CYP 2D6 inhibition at higher doses.
3)Venlafaxine doses greater than 300 mg per day are more likely to cause an increase in blood pressure.
4) Acutely suicidal/psychotic patients and pregnant patients are people most likely to receive ECT.
I am looking forward to doing my psych rotation in April. Psychiatry is an area I really feel I need more exposure to as I am not usually comfortable making recommendations with psych meds!
Side note: Bree is going to try to arrange for me to watch a patient getting ECT when I am on rotation with her. I am looking forward to that!
We had a therapeutic session on aminoglycosides yesterday. It was primarily focused on empiric dosing and treatment. It was a really good review of AGs. We worked together to develop an algorithm to help us assess orders for AGs. I felt that was a really effective way of having the session and I retained more from it then simply being presented a topic.
The session re-iterated how important it is to monitor for ototoxicity and nephrotoxicity. Serum levels don’t necessarily correlate with toxicity so it’s important to ask the patient daily if they have any new onset of nausea or vomiting, tinnitus, dizziness, hearing loss etc and also monitor SCr/Urea at least twice weekly.
I think one thing I will always try to do as a pharmacist is to get my patient OFF aminoglycosides if there is a safer effective alternative out there.
Journal Club – HORIZON trial
Posted on: August 25, 2009
Today I facilitated my first journal club as a resident! I was a bit nervous because I haven’t done a journal club since 4th year but there was a good turnout. I tried as much as I could not to “lecture” and attempted to ask the group questions and people participated so it was good. I was scared that I would ask questions, no one would answer and I would be the only one talking! Here is a copy of the one page summary I prepared (HORIZON summary).
Geriatrics – 3 days down!
Posted on: August 19, 2009
My first clinical rotation started off with an unexpected twist. The first patient I interviewed spoke very little english and I had to interview her in Cantonese. It was really hard trying to translate medical terms and medications but I think I got a pretty good history considering the circumstances. It was a little un-nerving since I’m still trying to develop my interview technique in english but in the end it worked out! The patient was also very appreciative of the fact that I made the effort to talk to her in her native tongue.
All the staff on 7N are really nice and the doctors are easily accessible so you don’t have to page them or track them down. There are weekly rounds and the atmosphere is extremely “multi-disciplinary”. All the patients I have interviewed so far have been really great and answer most of my questions. I have learned to really tailor the interview to the patient as some have hearing problems, vision problems and/or have cognitive impairment. So far, I have done 4 patient assessments and have 4 more to go. Tomorrow we are getting a new admission so I have to do an initial med rec followed by a more thorough assessment.
7N is a great place to start as a first rotation. Right now the ward isn’t too busy so I can take my time and get my bearings.
Friday, we learned about chronic pain. It was a good extension of our DPC rotation as we were dealt with two patients in the pain clinic. I realized over the past couple of weeks that I had no idea how to assess a patient for pain. Donna developed a good nnemonic ABCD (not E) and F. A-ask, B-behavior, C-characterize pain, D-depression and F-function. I will definitely use this and also the PQRST to help characterize pain. A few things I took away from the session:
1) Although pain scales are helpful, it better measure of pain control is function (ADLs, IADLs, social/recreational activities) because ultimately that is what is important to the patient.
2) Depression and pain often co-exist. It is important to assess for depression when doing a pain assessment.
3) I always forget how to convert doses of opioids off the top of my head. I learned an easy way to remember it:
Codeine 100 mg = Oxycodone 5 mg (to 7.5 mg) = Morphine 10 mg = Hydromorphone 2 mg (parenteral doses are usually half the PO dose and morphine 60-100 mg is roughly equivalent to a 12.5 mcg/hr fentanyl patch)
On Wednesday, I attended a therapeutic session on liver function and drugs. This is an area I have never felt comfortable with, mainly because I have not dealt with patients who have liver disease. The “process” for dosage adjustment is not as clear-cut as with renal impairment. I also find all the different types of liver function tests a bit confusing too. The main points I learned from the session include:
1) There are 3 types of drug-induced liver injury: Hepatocelluar, Cholestatic and Mixed
2)Albumin, pre-albumin and PT are tests of a liver’s synthetic capabilities.
3) Dieting depletes glutathione levels and increases a patient’s potential for acetminophen toxicity.
4) In alcoholics, you often see an AST to ALT ratio of 2 (or more) to 1 with an increase in GGT
Final Week of DPC Rotation
Posted on: August 14, 2009
We had our final week of our DPC rotation. We got to watch a couple of patients interviews and determine their DRPs. Then we wrote SOAP notes and discussed and critqued them as a group. This really helped me determine what I needed to work on when writing chart notes (i.e. giving reasons WHY I’m giving a recommendation or choosing one therapy over another and to be as concise as possible).
We got to interview a patient at EMP who had bipolar disorder with manic symptoms. It was definitely something I have never experienced. The patient was exhibiting classic symptoms of mania, talking extremely fast, very tangental, and was “in your face”. I think my psychiatry rotation in April will be very interesting and I think it will keep a different perspective compared to the types of patients on my other rotations.
On Thursday, I interviewed a patient on 7N by myself and I am happy that she was really nice and easy to talk to. There are a few things I think I will change, especially when I do a review of systems. I am hoping to establish my own “process” when I interview patients over the next couple of months.
Today we ended with a couple of different activities. I did a five minute presentation on my research project to the undergrad pharmacy students. Afterward, I was paired up with a couple of the students and we went over an anemia case. Even though I am doing a residency and often “feel like I don’t know anything”, I realized I did know/learn SOME things. It was different to be the “teacher” in this case. I am looking forward to taking SPEP students when I am actually working as a pharmacist.
The past two weeks have prepped me for Monday. I start my first clinical rotation (geriatrics) on Monday. I am a little nervous but also excited at the same time.
heatherchui
Heather Chui's E- Portfolio 