Adam Fights Elephants This SATurday

(5/24 stuff)

I'm rounding with a new team this week and it's been fun! Just as a side note, when I say team, I mean the medicine team that discusses each patient assigned to them every morning before going and seeing each one individually. There's the Attending, Resident, 2 Interns (all doctors), Pharmacist, Nurse, sometimes social worker, and then some students. As always, I've learned a lot this week.

Diuretics
Adam Fights Elephants This SATurday. Acetazolamide works on the proximal tubule, Furosemide and Ethacrynic acid work on the loop of Henle, Thiazides work on the distal tubule, and Spironolactone, Amiloride, and Triamterene work on the collecting duct. Often times, if a patient isn't getting rid of all the fluid they need to on just Lasix, metolazone (thiazide-like) will be adding to his/her regimen (metolazone 30 minutes before Lasix). It makes sense if you think about it. The Lasix is working on the loop of Henle, but when the fluid gets to the distal tubule, some of it is reabsorbed back into the body. With metolazone, this is prevented. To get an idea of how much more fluid a patient can get rid of...it could be 500ml with just Lasix, and 1500 with both. Spironolactone can be used if the SCr <2.5, and the K <5.5.

Infectious
PO antibiotics for bacteremia is crappy, BUT the exceptions are: quinolones and linezolid (the latter for Gram (+) only), because the blood concentration when given PO is good. When thinking about ID, think about where you want the antibiotic to concentrate...is it the blood, the urine? Cipro definitely concentrates in the urine, and is about 70% bioavailable in the blood. In general, ampicillin PO can be used when necessary, but the dose is 500mg BID whereas the IV dose is 2g TID. If someone has bacteremia, would you use the IV or PO dose (if the drug adequately covers the bugs)? Probably IV. The attending in our team asked a question that no one in the room knew the answer to...he wanted to know which bug is covered by Augmentin but NOT Zosyn (pip/tazo). The answer is Stenotrophomonas. Maybe it won't be useful in clinical practice, but now you know for trivia! The following drugs are used for treating MRSA PO: Clindamycin, Bactrim, doxycycline. Bacterial meningitis...what are two tests you could do to test for severe neck stiffness? Brudzinski's and Kernig's. The following link shows a positive Brudzinski's sign: http://www.youtube.com/watch?v=jO9PAPi-yus, and the first suggested link shows a positive Kernig's sign. I realize a pharmacist won't be doing these tests, but it may be mentioned in rounds, so it's good to know.

Heart
Tuesday was a big Congestive Heart Failure (CHF) day. A few of our patients had CHF, so our preceptor gave a really good talk about it. Labs: look at ejection fraction (normal is 60-70%), brain natriuretic peptide (BNP...>500 is bad, and a patient this week had around 10K). The classification for the severity of CHF is by the New York Heart Association (NYHA Classification). Class I is no limitations during normal activity. Class II is mild symptoms on exertion/during normal activity. Class III is pretty bad symptoms on exertion, or during less than normal activity. Class IV is symptoms at rest. Treatment: Loop diuretics will relieve symptoms but doesn't prolong life. Spironolactone, ACEI/ARBs, BB, and Hydralazine/ISDN all improve survival. The only BBs that have actually been studied are: carvedilol, metoprolol XL, and bisoprolol. Digoxin has no affect on mortality. If a patient comes in with CHF exacerbation, look to see if he/she is taking DM meds like the glitazones, pain meds like NSAIDS, and dihydropyridines (d/t dilation).

Miscellaneous
If phosphate is elevated above 5, don't use vitamin D because vitamin D will increase phosphate.

Interesting incident...a nurse found a joint filled with "goodies" under one of the patient's pillows! But of course he found it on the floor in the hospital, and was going to turn it in. Riiight ;)