Monthly Archives: September 2011

Pharmaceutical care rotation: Week 2

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I should have shared my objectives before this rotation commenced. Lesson learnt for future. My Objectives for this rotation:

1. Do at least 4 discharge counsels
2. Understand the concepts of fluid/electrolyte imbalance and employ the knowledge in the care of at least one patient
3. Apply the concepts of clinical pharmacokinetics in care of at least 3 patients

The second week was intense and packed with tonnes new knowledge. We discussed my mid-point evaluation yesterday. I do have to say this has been the worst mid-point evaluation so far but I now I am aware of what I need to work on and how to make the best use of these two weeks. Dr. Dillon has been asking me to do things for the past two weeks but it took me a while to get a hang of things and I have finally started feeling more comfortable with the process. There are a lot of areas I need to work on for the next two weeks: 1. Be more prepared with discussions 2. Be more articulate about my recommendations 3. See more patients 4. Write chart appropriate notes 5. Practice reading ekgs 6. Prioritize DRPs. The main thing I need to work on is being more efficient. No doubt I have been working hard for the past two weeks but I need to move to the next level of working smart. This can be only accomplished by doing tasks and not fearing failure. If I do it wrong the first time, the next time would get better.

Conditions I have come across:
Alcohol withdrawal
Wernike-Korsakoff’s syndrome: alcohol misuse can lead to thiamine deficiency which may lead to Wernike-Korsakoff syndrome. Wernicke’s disease is an illness of acute onset characterized by a trial of symptoms that include global confusion, ataxia, and paralysis of eye movements (diploplia, strabismus and nystagmus) It is a neurological emergency that must be treated with parenteral thiamine administration. Delay in treatment increases the risk of permanent defect in retentive memory and learning known as Korsakoff psychosis.

Withdrawal seizures: Chronic alcohol use suppresses a # of neurotransmitters particularly GABA (responsible for sedation, muscle relaxation and raising seizure threshold). Alcohol reduction–GABA deficiency–anxiety, increased psychomotor activity–predisposition to seizures.
repeated withdrawals–risk of seizures increases-phenomenon known as “kindling”. If there is documented history of alcohol withdrawal seizures, give prophylactic dose of diazepam 20 mg PO x 3 doses

The CIWA-AR tool measures 10 symptoms of alcohol withdrawal with a range of scores:
N/V (0-7)
Tremors (0-7)
Paroxysmal sweats (0-7)
Anxiety (0-7)
Agitation (0-7)
Tactile disturbance (0-7)
Auditory disturbance (0-7)
Visual disturbance (0-7)
Headache/fullness (0-7)
Orientation (0-4)

CAGE Questionnaire
1. Have you ever felt the need to CUT DOWN on drinking?
2. Have you ever felt annoyed by criticism of your drinking?
3. Have you ever felt guilty about your drinking?
4. Have you ever had a drink (or drug) first thing in the morning to steady your nerves or get rid of a hangover (EYE-OPENER)?
5. When did you have your last drink?

Evidence Based Medicine

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Activities performed: Critical appraisal of PLATO Trial

Created a draft on the discrepancies between 2010 and 2011 Trials investigating the link between use of ARBs Cancer.

This rotation helped me reinforce the concept learnt during the second week of didactic and employ the skills learnt to critical appraise trials.

Pharmaceutical Care Rotation: Week 1

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This is my first clinical rotation. It is taking a while to get adjusted to the change and get in the mode of asking questions, getting patient’s history and making recommendations. My other rotations were not as intense as this one and it is definitely meeting my expectations in terms of work load. There are readings and homework to do every night. I enjoy it when I am busy and running around doing things, so I am going to embrace the next few weeks and as Dr. Dillon uses the NIKE phrase, “Just Do It!”. We learnt how to take vital signs. I had a hard time with monitoring the blood pressure manually and finding the pulse initially but as I do it more, it would get better. So far, I have completed two case presentations. I didn’t think it would be that hard to present a case to my preceptor, but I have to keep in mind to follow the format and not to ramble! I did feel frustrated after the first presentation, but I should remember. “It doesn’t matter how one starts, it matters how I finish.” It is a new experience and I will get better every week. My goal is to work-up 2 patients per day next week and do one clinical pharmacy note every day. My goal for tomorrow is to revise everything I have learnt so far this week and practice the skills I have learnt. Otherwise, if I don’t use it, I will lose it!

Lessons learnt:
Stick to the format of presentation and clinical pharmacy note
Read up the night before about the disease condition to be presented next morning
Do as much as you can! The more I do, the better I get
Think through before making any recommendations. Chances of success are lower if I do not research well and make a fool of myself in front of other health professionals (hope it doesn’t happen!)

Looking forward to next week!