This is my final post regarding my first two rotations (both at the same place). I learned so much these last three months, and cannot thank my preceptors enough! I had a wonderful, challenging experience, and have high standards going into my next rotations. Speaking of my next rotation, I begin #4 (I did an early one last summer), tomorrow in a family clinic in Raleigh, North Carolina. As I've mentioned before, this clinic does not have a pharmacist working there, and I will be their first "taste" of how useful a pharmacist can be, so the pressure is ON! I'm not yet sure what I'll be doing there, but I hope to incorporate myself well into their system by next week. I road tripped from Arizona to North Carolina for this rotation, and will have pictures of the road trip on a subsequent post (I know, not quite pharmacy-related, but the road trip took me to my next rotation site, so it's still fairly relevant) ;)!
Renal
So there’s a saying at the hospital when talking about removing a patient’s catheter. You can either fill and pull, or pull and pray. If you pull the catheter without doing anything, then you’ll end up praying that the patient is able to urinate completely on his own. However, if you fill the bladder (leaving some air on top) prior to pulling the catheter, then you’ll know if the patient empties his entire bladder, since he/she will feel the air bubble come out while urinating. I thought this was interesting, so I thought I’d share! Also, if a patient is losing potassium due to any reason, for example, diuretics, then replenish with 10mEq KCl per 0.1 drop from 4.0 in potassium. The dose for acetylcysteine in contrast-induced nephropathy is 600-1200mg BID for 2 days prior to contrast use.
Infectious
For disseminated cocci, ketoconazole is the only one with FDA approval. Itraconazole and fluconazole have been shown to be effective in prospective trials. They seem to have the same efficacy, except itraconazole 200mg/day is better than fluconazole 400mg/day for skeletal lesions. Fluconazole can increase QT interval, while itraconazole does not. Both, however, are hepatotoxic. The treatment for diverticulitis (e.coli and b. fragilis) is either Unasyn 3g q6h, zosyn 3.375mg q6h, or metronidazole 500mg q8-12h + ceftriaxone 1-2g q24h. We also discussed vancomycin nomograms a few times, and I finally found a nomogram that I liked. There are so many out there, and even the experts don’t seem to agree sometimes. So, it’s just a matter of which one works best for your practice. Here’s the link to the one I found: http://www.venturafamilymed.org/Documents/Vancomycin%20Dosing.pdf.
Heart
We reviewed AV blocks one afternoon…
- First degree AV block: prolonged PR interval of greater than 0.20 seconds.
- Second degree AV block
- Type 1 (Mobitz 1 or Wenckebach): PR interval gets longer and longer, and then a beat is dropped.
- Type 2 (Mobitz 2 or Hay): PR interval stays the same and then suddenly drops.
- Third degree AV block: the atria and ventricles are both functioning, but they’re not communicating with each other. This is also a complete block.
P waves are in relation to the atria, and the QRS complexes are in relation to the ventricles. Switching gears…if a patient has severe CHF or has proteinuria, the ARB + ACEI combination could be considered.
Labs
Parathyroid hormone (PTH) goals depend on renal function…
CKD Stages IV and V: 150-300
CKD Stage III: 35-70
Much of the final days of this rotation was repetition of what I had seen in prior weeks - which was great, because I feel like it's been engrained into my head. I cannot say it enough - I had a wonderful experience here.
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