Psychiatry Final Week


Tasks performed:
In-service to Psychiatrists, nurses and pharmacists on Memantine + antipsychotics

Memantine Presentation Final

Case presentation: Pisa syndrome

Psych case presentation Final

Counselled two patients on their medications

Clinical Pearls:
Take a lithium level on any patient on Li on admission (2) aim for lower levels in elderly population
Terms I get confused about:
Dystonia: neurological movement disorder in which sustained muscle contractions cause twitching and repetitive movements or abnormal postures. Two forms: acute and delayed

Patient is defined as having metabolic syndrome if the patient has central obesity plus 2 of the following 4 risk factors; elevated triglycerides, reduced HDL, elevated BP, elevated blood glucose

Cardiometabolic monitoring form used by BC Mental Health and Addiction Services monitors for following:
Waist circumference, weight, BMI, blood pressure, fasting blood glucose, Hgb A1c, LDL cholesterol, Total cholesterol, HDL cholesterol, triglycerides, Cholesterol/HDL ratio, ECG abnormalities, QTc

Goals for next rotation:

See more patients: Aim for 1 new patient every day
Follow-up with patients everyday

Psychiatry rotation so far


I am currently placed at Riverview Hospital in Coquitlam which only houses Psychiatry patients. The hospital is closing this year and patients are being moved to other locations e.g. UBC, Burnaby Hospital etc. The atmosphere is that of change and getting ready for a new pharmacy.

The patient population I have encountered and will encounter in the future in this setting, does not have much insight into their illness. This makes it difficult for them to understand why they are on certain medications and if it has been helpful for them. Side effects are a big issue in this population and almost every patient is experiencing some sort of side effects, for example EPS, tardive dyskinesia etc.

Tasks performed so far:

Reviewed tapes on movement assessments
Observed pharmacist perform Abnormal Involuntary Movement Scale (AIMS) assessments on three patients
Interviewed two patients in regards to AIMS assessment, Drug Attitude Inventory (DAI) and UKU Side Effect Rating Scale.
Attended Ward rounds
Attended Patient Safety Meeting
Journal Club Presentation
Answered Drug Information Questions
Drug Information Shellfish Allergy
Lorazepam Drug Information
Topics discussed with preceptors: Antipsychotics, Antidepressants, Mood Stabilizers

My goals for the next two weeks:
To see at least two new patients
Analyze and interpret a clozapine level
Educate at least two patients about their medications

My goals for psychiatry rotation


Psychiatry is one of my elective rotations. I have always been interested in this area and I am glad I got an opportunity to learn about it for four weeks and see real patients vs. just learning about it in class. Below are my objectives for the rotation:

1. Interpret and document clozapine level for at least 1 patient

2. Understand the pharmacokinetics and dosing of Valproic acid and lithium

3. Conduct UKU Side effect rating scale, DAI (Drug Attitude Inventory) and AIMS (Abnormal Involuntary Movement Scale) assessment for at least 3 patients

4. Educate at least two patients about their medications




General Surgery: Last week


Worked up patients on:
Pancreatitis x 2
Small bowel obstruction

Topics discusses:
Vaccines post spleenectomy
Electrolyte replacement

Tuesday: shadowed a wound care nurse and observed colostomy change

Thursday: Case presentation
Case presentation General Surgery

Much improvement from last presentation: better pace, easy to understand, good pauses
Answered questions well
Good format and layout

General Surgery: Week 3


Worked up patients affected by:
Upper GI Bleed
Small bowel obstruction
Post-operative nausea & vomiting

Nursing in service to 3rd year nursing students from Douglas College
Topic: Analgesics for acute pain

Nursing In Service: Pain Medications

Journal Club presentation
Topic: Record 1 Trial

Journal Club RECORD 1 TrialActivities performed:

General principles\ of surgical prophylaxis guidelines:

Complete antibiotic infusion prior to skin incision. Recommendations regarding administration times:
Cefazolin, metronidazole or clindamycin: begin infusion 60 min or less, prior to the initial skin incision
Vancomycin and Ciprofloxacin: 60-120 min prior to skin incision
Oral ciprofloxacin tabs must be administered 2-4 hrs prior to incision
Guidelines recommend that antimicrobials must be discontinued within 24 hrs after the end of surgery

Redosing guideline: repeat antimicrobial dose if procedure is > 4 hrs or if there is rapid blood loss and/or fluid administration that will reduce (or dilute) effective serum antimicrobial conc. during the surgery

1. Speak slower
2. Try to give audience time to register information being presented
3. There were times when I sounded nervous, so I need to improve on that.
How? Practice few times before final presentation.

I have become more familiar with signs/symptoms patients present with in terms of types of intra-abdominal infections. For example right upper quadrant pain for cholecystitis, right lower quadrant pain for appendicitis. We will discuss intra-abdominal infections in more detail this coming week.

Wednesday: Academic Half-Day on Electrolyte Imbalance
Topics discussed: Potassium, magnesium and phosphate imbalances. This is one topic I was not comfortable with in terms of treatment and have always wanted to learn it since we were introduced to it in second year pharmacy. Pharmacists are consulted about dose on a everyday basis. Therefore, it was great that we got to work on cases in groups and apply the knowledge acquired. I need to read it in more detail and practice it few times, until it becomes second nature to me.

General Surgery so far….


Goals for the rotation:

1. Be familiar with peri-operative medication use
2. Become familiar with peri-operative use of anticoagulants
3. Understand the roles of other health care professionals (PT,OT, dietician)
4. Perform pharmacokinetic interpretation of drug levels in the care of at least 3 patients
5. If feasible, become familiar with TPN: calculations, indications and long-term complications

Topics discussed so far:
Peri-operative antibiotic use
Types of anticoagulants and anti-platelet agents
Peri-operative medication use
Digestive System Anatomy
Post-Op Nausea and Vomiting
GI Bleed
Surgical Prophylaxis Guidelines
Small bowel obstruction
Pre-Procedure Crossover Therapy

Attended class delivered by nurse, OT and PT to patients going for knee replacement in 2 weeks

Worked up patients on:

1. Knee replacement
2. Hip replacement
3. Infected knee prosthesis
4. Infected hip prosthesis

General Medicine: Lessons


Lessons learnt:

1. Gather all the pertinent information in order to understand a patient’s condition
2. Understand why certain diagnostic tests were performed and what were the results
3. Develop a relationship with other health professionals. We all work as a team in order to make the patient feel better.
4. Comprehensive Clinical Pharmacy Notes: Make them less wordy, create tables in order to show objective lab values and the trend associated with them
5. Digoxin dosing: Be cautious in elderly patients, better to go low and slow. Use IBW and not total body weight!
6. Keep your work-ups organized. It would be easier for another pharmacist covering for you or in case the patient gets transferred.

Attended a presentation on Delirium.

Delirium is not dementia. It is sudden change in usual behavior with:
Fluctuation: comes and goes in the course of a day
Inattention: easily distracted, difficulty focusing

Almost any medication or medical illness or change in environment can lead to delirium
Some causes: metabolic (hyponatremia, hypoglycemia, hypoxaemia)
Drugs: digoxin, lithium
CNS:opioids, benzodiazepines, anticholinergics, antihistamines, corticosteroids, anticonvulsants, alcohol, antidepressants, caffeine
CVS: clonidine, nifedipine, nitroprusside, beta-blockers, digoxin, antiarrhythmics, nicotine
GI: H2 blockers, metoclopramide
Antimicrobials: acyclovir, amphotericin B, cephalosporins, ciprofloxacin, septra

Antipsychotics: agent of choice. Literature supporting efficacy is limited. No benefit when used for prophylaxis.
Benzodiazepines: masks symptoms of delirium through sedation, does not treat delirium, increases its risk. Benefit is seen with acute agitation.

Haloperidol agent of choice, IV causes less EPS than oral form (pyridium metabolite)
Chlorpromazine: not recommended due to high anticholinergic activity, CSF conc. is 5X more than plasma, main role to control intractable hiccoughs
Methotrimeprazine: potential analgesic effect, causes sedation and lowers BP
Atypicals (olanzapine, risperidone, quetiapine equally effective to haloperidol)

Role of atypicals: used with underlying parkinsons disease, prolonged QT interval, when experiencing EPS

Calculating maintenance dose:
Add up first 24 hour dose requirement
Give 50% of this dose over the next 24 hrs in 4 divided doses e.g. Q6H
Reduce maintenance dose by 25% each day if symptoms remain controlled
Continue prn regimen as needed for breakthrough doses

Causes: Infection: UTI, pneumonia
Structural: Subarachnoid haemorrhage, urinary retention
Environmental: being in hospital or the ED

As health care professionals we can help by treating the cause of delirium: e.g. manage pain, fluids for hydration or review medications,

Pneumonia summary:
signs/symptoms: cough with yellow or green mucus, which may have traces of blood
sharp or stabbing chest pain made worse by deep breathing or coughing
fever with chills
rapid, shallow breathing
SOB. Other symptoms may include: headache, sweating, clammy skin, loss of appetite, feeling of weakness or fatigue, confusion

Hypophosphatemia causes: alcoholism, diarrhea, starvation, Vit D deficiency
Symptoms: bone pain, confusion, muscle weakness

Secondary prevention of stroke:
The GOLD Standard: ASA (ATTC 2009) NNT=125
ASA+ Dipyridamole SR (ESPS-2, ESPRIT) better than ASA, Ticlopidine (TASS)
Similar to ASA = Clopidogrel (CAPRIE), Warfarin (WARSS), Clopidogrel + ASA (MATCH, CHARISMA)
(Source: Loewen P Undergrad Lecture 3rd year Therapeutics)

The serum anion gap = Sum of serum chloride and bicarbonate concentrations subtracted from the serum sodium concentration.
Used in the detection and analysis of acid-base disorders, assessment of quality control in the chemical laboratory, and detection of such disorders as multiple myeloma, bromide intoxication, and lithium intoxication.
The normal value can vary widely, reflecting both differences in the methods that are used to measure its constituents and substantial interindividual variability.
Low values most commonly indicate laboratory error or hypoalbuminemia but can denote the presence of a paraproteinemia or intoxication with lithium, bromide, or iodide.
Elevated values most commonly indicate metabolic acidosis but can reflect laboratory error, metabolic alkalosis, hyperphosphatemia, or paraproteinemia. Metabolic acidosis can be divided into high anion and normal anion gap varieties, which can be present alone or concurrently.

Why is ACEI beneficial in heart failure, left ventricular dysfunction, acute MI, chronic kidney disease?
reduces aldosterone (which also facilitates collagen deposition and fibrosis)
Angiotensin II promotes VSMC (Vascular smooth muscle cell) growth and migration and glomerular hyperfiltration leading to microalbumin angioedema (nose, throat, larynx – airway obstruction may be fatal)
Renin release is increased by decrease in renal arterial pressure, decrease in sodium in the distal tubule.
alpha-1 blocker: vasoconstriction and increase in contractility
Verapamil and diltiazem: have a more cardiac depressant effect (cardiac arrhthmias and bradycardia)

Venous thromboses are mainly composed of RBC
Arterial ones are mainly composed of platelets
Virchow’s triad: Causes — Stasis, vascular injury, hypercoagulopathy

Drug related causes of VTE: Estrogens/progestins: Hormone replacement therapy, oral contraceptive therapy, SERMs (tamoxifen, raloxifen)
Initial treatment of DVT/PE:
IV UH or SC LMWH or SC fondaparinux or SC UH immediately
Give first dose of warfarin on same day
UH/LMWH: minimum 5 days
Continue until INR > or = 2 for at least 48 hours
Baseline INR, then daily or every 2 days until stabilized in therapeutic range
Baseline CBC, then daily or every 2-3 days while on UH/LMWH (bleeding, HIT)
LMWH associated with less HIT and osteoporosis
poor renal function: UH preferred

Fatal PE is the # 1 cause of maternal mortality worldwide in pregnancy. Risk 5X greater during postpartum period than during pregnancy.
UH, LMWH and warfarin are safe choice in a nursing mother

Approaches to angina drug therapy
antianginal: nitrates, b-blockers and CCBs
vascular protection: antiplatelet agents (ASA), ACEI, lipid lowering therapy

Statins: increased clearing of LDL, not much effect on HDL. promotes plaque stability, reduction in inflammation at site
Activity of key enzymes involved in cholesterol synthesis peaks between midnight and 2 am.
Statins decrease risk of major coronary events by 30%
Stroke by 20%
All cause mortality 12-15%

ACS management: Clopidogrel in addition to ASA for 1-12 months post ACS (duration of dual ASA and clopidogrel based on if coronary stents inserted and type of stent).
B-blocker use post-MI decrease morbidity and mortality

General Medicine: Case Presentation



1. Better to use diet for low HDL first vs. suggestion of using niacin

2. Easy to follow presentation, good format

3. Do not read off all the details in the table. It is better to say out only the important and pertinent information and leave the rest for the audience to read later. This way it is easier to keep them engaged.

Case presentation General Medicine

General Medicine: Journal Club Presentation


Journal Club Presentation

Suggestions from my preceptor and other attendees for future:

1. Have a flow chart for audience to make it easier for them to understand the background and methods

Conclusion: There are many limitations with the study as mentioned in the presentation, therefore we need more studies in order to support use of rivaroxaban for treatment of PE and DVT.

Journal Club Presentation