Monthly Archives: April 2012

Parkinson’s Disease Clinic and Week 2

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Spending a day with neurologists examining Parkinson’s patients at UBC clinic was an interesting day. Learning about the disease sitting in a class vs. actually seeing the patients in person and listening to their stories is a totally different experience as it allows you to apply the theoretical knowledge gained in class. The two neurologists I followed were super helpful! I was curious about different neurology examinations and ways to adjust medications. They helped me answer questions and put things into perspective.
I learnt about different uses of Botox (a purified neurotoxin complex protein produced from the bacterium Clostridium botulinum). For example I did not know that it is used for dystonia. Patients get a repeat dose every 3-4 months. It takes 48 hrs for onset and reaches peak in about 2 weeks.
One of the patients received it for central dystonia and the other one got it for Meige’s syndrome.
The time spent at the clinic reinforced the fact that the timing of medication is extremely important in Parkinson’s disease patients. Therefore, when they are admitted to the hospital, the pharmacist should learn the dose times and make sure the patient gets it at the same time in hospital as well.

Other tid-bits:
Domperidone is used for both nausea and orthostatic hypotension (usually given half an hour before the levodopa dose)
Dopamine antagonists
– Inhibit the vasodilating and natriuretic effect of dopamine and increase noradrenaline release by blocking receptors for dopamine which exhibits inhibitory control of noradrenaline.
– EPS and tardive dyskinesia limits their long-term use.
Some patients experience Sinemet addiction wanting more even when not required??
Donepezil can worsen confusion in some cases ( very rare)

Some research to do:
Mirtazapine’s use for tremor??
Rasagiline has been shown to have neuroprotective effect??
Donepezil for orthostatic hypotension??

Topics discussed:
Parkinson’s Disease and Multiple Sclerosis
Attended Neuro Grand Rounds

Neurology Week 3

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Case Presentation Neurology
Friday: Warfarin and Dabigatran teaching
Goals for last week:
See more patients: Work up at least 2 new patients every day
Choose patients with other neurologic conditions besides Stroke/TIA
Speak slowly and louder with patients (esp. elderly)

Tuesday: Multiple Sclerosis Clinic at Burnaby Hospital
Thursday: Case Presentation
Topics Covered:
Neuropathic Pain

Stroke Clinic

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Attended Stroke Clinic on Thursday at ARRH with Dr.Constantino at Abottsford Hospital.

It was a great experience as I saw the neurologist conduct different examinations to find neurologic deficits in terms of sensory and motor symptoms.
One of the patients had been on combination of ASA + clopidogrel for few months after a stroke even though evidence shows that there is no evidence of using the combination therapy beyond a month (FASTER trial). Therefore, clopidogrel was discontinued.

I also realized that non-drug measures play a huge role in preventing stroke especially smoking cessation and diet.

The visit to the clinic provided me with an insight of what happens after stroke patients leave hospital and how they are managed as out-patients.

Neurology Week 1

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My learning objectives:

1. Interpret pharmacokinetics of phenytoin in at least 2 patients and document it in the chart
2. Understand the pathophysiology, incidence, treatment options and pharmacology of drugs used in parkinson’s disease. Work up at least 1 patient with Parkinson’s disease
3. Discuss the pathophysiology, incidence, treatment options and pharmacology of drugs used in multiple-sclerosis with preceptor and opportunity comes work up a patient with the disease condition.

Tasks performed so far:
1. Worked up 3 patients with TIA, 1 patient with Pseudo-seizures
2. Assessed phenytoin levels of 2 patients
3. Presented journal club on: Alteplase vs. Tenecteplase in acute ischemic stroke
JC Neurology

4. Topics discussed: Stroke and secondary prevention of stroke (Incidence, pathophysiology, treatment options, evidence behind different treatment options)
5. Attended journal club presented by fellow resident Anita Rasoda and SPEP student
6. Attended Symposium on Stroke oragnized by Fraser Health on April 14/2012

Interventions made:
Medication reconciliation: discontinued two anti-depressants patient was not taking but was started on at the hospital, facilitated initiation of patient’s own medication
Initiated DVT Prophylaxis in a patient with subdural hemorrhage

A nurse asked me a question and I ended up reading a consult which led me to look up some terms e.g.
Levophed: I didn’t know this is the brand name for norephinephrine
Pentaspan: Penta-starch. It is a plasma volume expander like albumin, dextran, hetastarch and tetrastarch used as adjunctive treatment in the management of shock.
Acute tubular necrosis (ATN) follows a well-defined 3-part sequence of initiation, maintenance, and recovery. The tubule cell damage and cell death that characterize acute tubular necrosis usually result from an acute ischemic or toxic event.

Academic Half Day on Endocarditis: This academic half day was very informative and applicable to our practice.
The residents did a great job of going over different treatment options in different scenarios.

Emergency

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What this rotation helped me achieve?

I have become more familiar with medications used in the emergency setting, become better at writing more succinct notes, analyzing pharmacokinetics of medications (digoxin, phenytoin, vancomycin etc.)
I have developed more faith in the contributions made by pharmacists. I have come to realize that pharmacists have the ability to prevent a lot of medication errors be it by medication reconciliation, finding drug related problems, educating a doctor or nurse about a new medication and it’s adverse effects or finding the drug cause of a medical problem.

Some other new concepts I learnt:
Subdural hematoma: collection of blood on the surface of the brain. This is a serious condition since the increase in intracranial pressure can cause damage to brain tissue and loss of brain function.

Bethanechol: Treatment of acute postoperative and postpartum nonobstructive (functional) urinary retention; treatment of neurogenic atony of the urinary bladder with retention

Emergency

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Presentation on CIWA Protocol:
CIWA

Diagnostic Tests Used:
CT Scan
MRI: A noninvasive technique for visualizing many different body tissues. Unlike x-rays, MRI does not use any radiation. Instead, it uses radio waves, a large magnet, and a computer to create images.As with a CT scan, which does use x-rays, each MRI picture shows a different “slice,” or cross-section, of the area being viewed. An MRI of the brain can identify tumors and areas of brain damage caused by a stroke or another neurological condition.

Echocardiogram: Ultrasound of the heart to examine heart valves, how forcefully heart pumps blood, determine the size of heart, and assess how well it is functioning. It can spot areas of the heart wall that have been injured by a previous heart attack or some other cause.
TTE: Transthoracic echocardiography is the primary noninvasive imaging modality for quantitative and qualitative evaluation of cardiac anatomy and function. The test is useful for assessing the size of the heart chambers and walls, heart muscle function, heart valve function, blood clots or masses in the heart, fluid around the heart, presence of holes or defects between the heart chambers, and abnormalities of blood flow within the heart.

TEE: A type of echo test in which the ultrasound transducer, positioned on an endoscope, is guided down the patient’s throat into the esophagus. The TEE test provides a close look at the heart’s valves and chambers, without interference from the ribs or lungs. TEE is often used when the results from standard echo tests are not sufficient, or when doctor wants a closer look at the heart. TEE may be combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart’s valves.

Doppler ultra-sound: A noninvasive test that can be used to measure your blood flow and blood pressure by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells.
ECG
Chest X-Ray

Topics discussed:

Clindamycin use in cellulitis, necrotizing fascitis: appears to have an anti-toxin effect against toxin elaborating strains of streptococci and staphylococci.
Clinicians should consider the possibility of laboratory error, sampling error or blood-sample hemolysis before initiating therapy, especially when patient is asymptomatic and electrolytes were previously normal with little or no change in therapies or clinical condition.
Major organ involved in electrolyte and fluid hemostasis: kidney
Recommended to use adjusted body weight in obese adult patients
AdjBW(men) = ([wt in kg – IBW in kg] x 0.3) + IBW)
AdjBW(women) = ([wt in kg – IBW in kg] x 0.25) + IBW)

Serum osmolality: (2 x serum sodium conc. in meq/L) + (serum urea conc. in mg/dL/2.8) + (serum glucose conc. in mg/dL/18)

Hyponatremia: Symptoms: headache, lethargy, disorientation, restlessness, nausea, vomiting, muscle cramps or weakness, depressed reflexes, seizures, coma, death, altered mental status, seizures. Identify and correct reversible cause of hyponatremia e.g. excessive i.v. administration of hypotonic fluids, such as 5% dextrose injection.

Hypertonic normal saline is a dangerous medication as incorrect rate and volume can lead to permanent neurologic complications, including central pontine myelinolysis which manifests as a gradual onset of neurologic alterations occurring within 1-6 days of rapid correction. Findings may include pseudobulbar palsy, quadriparesis, seizures, and movement disorders. [Source: Treatment of electrolyte disorders in adult patients in the intensive care unit Am J Health-Syst Pharm Vol 62, 2005]. My preceptor shared some real stories and went over the calculations with me on how to find out if the order is safe or not. The maximum recommended increase in serum sodium concentration is 8-12 meq/L per 24 hours with complete correction over 48-96 hours. Serum sodium levels should be monitored frequently (e.g. q 2-4 hrs) until the patient is asymptomatic, then q 4-8 hrs until the serum sodium is WNL.

Amount of Na in 1 L of 3% NaCl = 512 meq, 1 L of 0.9% NaCl = 154 meq/L

Hypokalemia
Types of potassium salts used in hypokalemia

Hyperkalemia

Signs/Symptoms/Questions I would ask/laboratory investigations/treatment procedure
Acetaminophen Toxicity, Salicylate Toxicity, Ethylene glycol Toxicity
Know what dose is lethal, how would you treat it, timeline (e.g. when was the drug ingested) is very important in determining how to treat

Indications for use of IVC filter: http://emedicine.medscape.com/article/419796-overview#showall

ACLS
Treatable causes
5Hs: Hypothermia, hypoglycemia, acidosis, hypo or hyperkalemia, hypovolemia
5Ts: Cardiac tamponade, toxins, tension pneumothorax, thrombosis coronary, thrombosis pulmonary
Algorithms

Clinical Interventions:
Dose adjustment according to renal function of piperacillin/tazobactam
Vancomycin/Phenytoin/Digoxin pharmacokinetics
Angioedema
CIWA Protocol: suggested to discontinue
Warfarin dosing
Discontinuation of linezolid (not required as no evidence of endocarditis)
Streamlining of antibiotics
Assistance with adherence (called patient’s pharmacy to inform about patient’s decision to get her medications blister-packed)
Called Pharmanet to request special authority
Educated patient on how to use MDIs
Medication Reconciliation
Improvement in Triaging: More efficient with time
DRPs