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Next week I will lead the discussion with a patient I worked-up on Friday. Adherence is one of the key points of discussion. My preceptor and I had a discussion about how one can check adherence. This is the list we came up with:
1. Pill count
2. Timing (including interaction with other drugs)
3. Ease of administration, is patient okay with remembering? (Ways they can remember: blister packing, dosettes, timer, team-up with roommate/partner)
4. Have they missed any doses?
5. Missed vs. late doses
6. If applicable are they taking doses with or without food

Drug Interactions: Taking any other drugs?
Experiencing any side effects?
Review the labs
What is the plan for this patient?

Other topics discussed:
Pathophysiology of HIV:
Good source:
When to start therapy?

When should you genotype a patient?
1. Baseline: May be the patient has primary resistance
2. Suspected resistance: virologic failure
Best scenario when patient is on treatment when he/she shows first sign of virologic breakthrough
Routine check for CD4/viral load: every months unless patient is <40 (undetectable), then every 2-3 months

Recommendations for initiating Antiretroviral treatment (ART) in treatment-naive adults with HIV-1 infection:
ART recommended regardless of CD4 count:
Symptomatic HIV disease
Pregnant women
HIV-1 RNA >100 000 copies/mL
Rapid decline in CD4 cell count, >100/uL per year
Active hepatitis B or C virus coinfection
Active or high risk for cardiovascular disease
HIV associated nephropathy
High risk for secondary HIV transmission e.g. serodiscordant couples
New recommendations:
Antiretroviral therapy (ART) is recommended for all HIV-infected individuals. The strength of this recommendation varies on the basis of pretreatment CD4 cell count:
CD4 count 500 cells/mm3 (BIII)

Drugs available through BC Centre for Excellence:



This is the last rotation of my residency! I am glad I am finishing with an elective and that too HIV/AIDS.
My goals for this rotation are:
1. Gain understanding of the pathophysiology of HIV infection and how it progresses to AIDS.
2. Become familiar with the anti-retrovirals currently used
3. Become familiar with drug interactions associated with anti-retrovirals and how to manage them
4. Counsel at least one patient on ARVs.
5. Work-up at least one new patient every day starting week 2
6. Know when to start ARVs and what to start
7. Gain understanding of opportunistic infections and know how to prevent and treat them especially PCP

Neurology Week 1


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.



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



Presentation on CIWA Protocol:

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.
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

Types of potassium salts used in hypokalemia


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:

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

Clinical Interventions:
Dose adjustment according to renal function of piperacillin/tazobactam
Vancomycin/Phenytoin/Digoxin pharmacokinetics
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

Emergency so far…


Gradually, I am learning to be skeptical about everything as the key is to question everything unless you are convinced why something is being done. Physicians are great at diagnosis but it is my role as a pharmacist to make sure everything pertaining to medications is being taken care of. My preceptor has shared many real examples from her practice which have made me realize how important it is to convince myself. For example, if someone has recently been diagnosed with atrial fibrillation and I have been asked to anticoagulate the person, I am not just going to blindly follow that. It is my responsibility to ask is this drug even indicated, is the dose effective and safe. May be the patient has hypethyroidism which can be treated before I think of starting an anti-coagulant.
As a licensed practitioner, I have the right to say no when something doesn’t make sense to me and I feel it is unsafe for the patient. For example, my preceptor shared a case where a patient was put on ASA, plavix, warfarin and heparin all simultaneously in an acute stroke. Even if the physician disagrees with me, I need to voice my opinion and chart my role in the process.

Topics discussed:
Advanced Cardiac Life Support
Phenytoin dosing

Wrote notes in the chart re:
Digoxin, warfarin and phenytoin dosing

Emergency is a busy atmosphere but I find it very rewarding as it provides me to exposure to lots of different disease states. I am being given the opportunity to talk to different physicians and make changes to the orders. This is being very helpful as my communication skills and confidence will only improve with more practice.

Emergency Medicine: Week 1



1. Pharmacokinetic interpretation and documentation of phenytoin levels for at least 1 patient
2. Pharmacokinetic interpretation and documentation of vancomycin and aminoglycosides of at least 2 patients
3. Read and discuss topics with my preceptor on: electrolyte imbalances, seizures, stroke
4. Apply concepts of electrolyte imbalance treatment and work up at least one patient

This week I did not get to spend much time on the ward due to job fair and exam.
Monday: Orientation, Patient Triage introduction, worked up one patient with hypernatremia
Thursday: Worked up one patient, attended a presentation at a local high school by my preceptor exposing high school students to role of a hospital pharmacist as part of the Pharmacist Awareness Week
Topic discussed: Diabetic Ketoacidosis in Adults
Friday: Triage, Followed up one patient from Thursday, worked up a new patient

Concepts/terms I looked up so far:

1. Double disk diffusion test: Performed for the detection of inducible clindamycin resistance. Some isolates of Staphylococcus aureus have in vitro resistance to erythromycin and susceptible to clindamycin.
The disk diffusion (D-test) method can detect S. aureus isolates with inducible macrolide-lincosamide-streptogramin B (iMLSB) resistance.

2. Plt clumps/EDTA:EDTA-induced platelet clumping is possibly the most common cause of pseudothrombocytopenia. EDTA (ethylenediaminetetraacetic acid) is the most commonly used anticoagulant in evacuated tubes. EDTA reduces platelet activation by protecting the platelets during contact with the glass tube that may initiate platelet activation. Activation causes platelets to clump in the presence of calcium and platelets adhere to the glass surface at a rapid rate. Chelation of calcium using EDTA results in decreased platelet adhesion or retention to glass.

3. GJ feeding tube: gastro-jejunal feeding tube.
Medication administration through enteral feeding tubes:

4. IVC filter:

Cannulation is the process whereby a cannula (a small hollow plastic tube) is inserted into and kept inside the vein for a period of time.

5. Evidence behind use of CCBs in heart failure:

6. Troponin I timeline:

7. Uncapping dalteparin: LMWH in Renal impairment and Obesity

8. Prolia (Denosumab): Can cause hypocalcemia (symptoms: Spasms, twitches, or cramps in muscles, numbness or tingling in fingers, toes, or around mouth)

9. ESBL treatment: Carbapenems are the most reliable and most effective. Among the available carbepenems, meropenem is the most active against ESBL-producing organisms in vitro, with MICs generally lower than those of imipenem (0.03-0.12 µg/ml vs 0.06-0.5 µg/ml).

10. Aspiration pneumonia antibiotics (Source: Bugs and Drugs)
Community-acquired or nursing home acquired pathogens: S. pneumoniae, H. influenzae, S. aureus, Enterobacteriaceae (Alcoholism and enteral feeding may be risk factors for colonization with these organisms)
Antibiotics recommended: Cefuroxime IV/PO 2. Gatifloxacin or Levofloxacin or Moxifloxacin for 7-10 days

Community-acquired or nursing home acquired with poor oral hygiene, severe periodontal disease, putrid sputum: S pneumoniae, H. influenzae, S. aureus, Enterobacteriaceae, Oral anaerobes, Streptococcus spp, Eikenella corrodens
Amoxicillin-clavulanate or Cefuroxime IV/PO + Metronidazole Iv/PO
Gatifloxacin or levofloxacin or moxifloxacin + metronidazole IV/PO
Treat for 7-14 days

11. BOOP (Bronchiolitis obliterans with organizing pneumonia): A rare lung condition in which bronchioles and alveoli become inflamed and plugged with connective tissue. The disorder is also known as cryptogenic organizing pneumonia (COP). Associated with other health conditions:
Infections. BOOP sometimes occurs after people have had certain infections, including chlamydia, influenza or malaria. (2) Inflammatory disorders: Risk appears to be heightened for people who have disorders such as lupus, rheumatoid arthritis or scleroderma. (3) Chemotherapy or radiation can put you at risk of developing BOOP. (4) Transplanted tissue. Bone marrow, lung, kidney and stem cell transplants sometimes trigger bronchiolitis obliterans with organizing pneumonia. (5)Drug exposure (include cocaine, gold salts and some antibiotics and anti-seizure medications).

Most people recover after weeks or months of treatment prednison but in some it can progress in spite of treatment. Source: MayoClinic

12. Glicliazide and renal insufficiency: Avoid renal function of 10-50 ml/min and <10 ml/min
Source: Dosing guidelines for Adults:
13. Phenytoin:
Dose related side effects: drowsiness, confusion, nystagmus, ataxia, slurred speech, nausea, unusual behavior, mental changes, coma
Non-dose related side effects: hirsutism, acne, gingival hyperplasia, folate deficiency, osteomalacia, hyper-sensitivity reactions, steven-johnson syndrome