Archive for the ‘Clinical Interventions’ Category
Nephrology rotation…wrap up
Posted on: April 3, 2010
The last two weeks of my renal rotation were busy. I got to meet most of the nephrologists and participated in rounds with a couple of them. Some of the patient work ups presented to be a challenge as many patients have no idea what they are taking or live in a care home so it was a matter of tracking down their MARs.
One thing I liked about the rotation was I able to easily follow up on interventions I made because patients returned to the renal unit three times a week. For example, I suggested stopping a PPI in a patient who really had no indication for the drug and I was able to follow up, in person, to see if the patient started having any issues with GERD or dyspepsia the next week.
One of my goals for the rotation was to learn about calcium and phosphate metabolism in renal patients and how to manage patients with pharmacotherapy. Most of the patients had some issues with their phosphate and PTH so I had a lot of practice in terms recommending changes to vitamin D analogues and phosphate binders. Of course by now, I’ve become pretty comfortable with anemia management so I recommended a lot of loading doses for IV iron!
I’ve attached copies my journal club and case presentation handouts below:
Journal club handout: JChandoutrenal
Case presentation handout: renalpresentationhandouts
Internal Medicine – Final Week
Posted on: October 16, 2009
On Wednesday, I faciliated a journal club on an article which compared varenicline to transdermal NRT for smoking cessation. We had VGH teleconference but we were having technical difficulties and unfortuantely the JC did not flow quite as well as I would have liked. They were having trouble hearing our discussion so we ended up repeating comments multiple times. Here is a copy of my handout: JChandout.
An interesting patient I had this week was a 69 year old patient admitted with acute HF exacerbation. He also had atrial fibrillation and is on warfarin for stroke prophylaxis. His INR was 5 on admission (but was not bleeding) and is also taking clopidogrel due to a history of TIAs. The senior resident wanted to continue dalteparin 5000 units daily for VTE prophylaxis. But I was concerned with an increased bleeding risk and the patient was technically already protected from VTE due to his “supra-therapeutic INR”. After a long discussion, the resident reluctantly agreed to stop the dalteparin. I have had doctors refuse to take my recommendations in the past but I was genuinely concerned that the patient would have a severe bleed if we did not intervene.
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.
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