1st (non-orange) Vaccination!

I read up on collaborative practice agreements this week, and was inspired by one article in particular: http://www.ncpharmacists.org/displaycommon.cfm?an=13. I'm still on the fence about what kind of residency I want to do - acute care or ambulatory. It's weird because I was so set on acute care before rotations started. I enjoyed it and all, but I'm just not so sure anymore. I know a lot of residencies include both over the year, but it would be nice to be able to focus on just one. We'll see! Anyway, on to my week...

Day XIII.

• Older female patient on Nexium for over 2 years.
• Recs: Change medication to an H2-blocker if possible. If not possible, then patient should be taking some calcium and vitamin D supplements, and getting her magnesium level checked.
• Female with vaginal candidiasis – fluconazole best option, but currently trying to get pregnant.
• Recs: Fluconazole category C or D depending on dose and duration. If it’s a one-time 150mg dose, then category C, but still not good enough. Wait til next month to get pregnant!

Day XIV.

• Upper respiratory infection in a pregnant woman.
• Usually no treatment needed, but there are options to control symptoms for pregnant women. APAP (category B) for aches, diphenhydramine (category B) or chlorpheniramine (category B) if antihistamines are needed.
• Acute sinusitis – usual culprits are H. influenza, M. catarrhalis, and S. pneumo. Safe in pregnancy are: amoxicillin, augmentin, cefpodoxime, cefuroxime, cefdinir. AVOID: quinolones, tetracyclines, clarithromycin. If the patient has a penicillin allergy, then bactrim can be used in the 2^nd trimester or azithromycin can be used anytime during pregnancy.
• H1N1 flu – oseltamivir is safe.
• Community-acquired PNA – azithromycin + ceftriaxone (the latter if severe enough)
• Drug-drug interaction between ciprofloxacin and calcium carbonate
• Recs: Can take both, but space it out. Take cipro 2 hours before and 4 hours after the calcium carbonate.

Day XV.

• Patient came in with CC: “Side effects of medications.” And, of course I wanted to see her. She was taking Rocephin, doxycycline, and metronidazole for PID. I looked up some of the major ADRs before seeing her. Rocephin – anaphylaxis, anemia (if she was feeling tired all the time), C. dif (if she was having major diarrhea), pancreatitis (if she said she was having abdominal pain), increased liver enzymes. Doxycycline – photosensitivity, C. dif, URI symptoms, discoloration of skin, dysmenorrhea, vaginal candidiasis. Metronidazole – encephalopathy, meningitis (if she complained of neck pain), metallic taste, rash, furry tongue. When I went in, her major complaint was itchiness around the vaginal area. Maybe some candidiasis? From the doxycycline? Possibly! Anyway, she was given fluconazole 150mg once for that.

Day XVI.  I wasn’t feeling too hot today, so looked into details for ASHP midyear. The Best Western is 1.2 miles from the convention center, and 0.8 miles from Bourbon street! It’s also fairly priced – about $140 a night including taxes and fees. Plane tickets are still expensive, but I’m hoping they’ll go down soon.

Day XVII.- Vaccine day!!

• Patient came in for “med check.” She’s on Klonopin prn, vitamin D 50,000 U weekly, synthroid 50mcg qday, and levocetirizine prn. Thyroid level was fine. If it was low – would’ve asked about when she is taking it during the day. If it’s not the first thing in the morning, then I’d recommend her trying that before increasing the dose.
• Another patient, he’s actually a physician, is on 5 medications for his blood pressure, diabetes (on metformin), and CrCl of 41ml/min. He should know better!!
• Recs: D/C metformin…got asked about glyburide, but contraindicated with CrCl <50ml/min. Januvia 50mg/day is a possibility, decrease to 25mg/day if CrCl < 30ml/min. 
• When I was getting my evaluation from my preceptor, my boyfriend texted me wanting to know if the clinic had Tdap vaccines. I asked my preceptor and she said, "Of course! Tell him to come on in. Do you want to give it to him?" My first response was no (yes, I'm trained, and we had to practice with saline solutions on our classmates/oranges, but I was still nervous). Then I thought about it for a couple seconds, and figured my first real one might as well be for someone I know. I wanted the nurse to be in there with me though. So, I got a quick run-down of what I'm supposed to do and say to the patient. It's an IM injection, so in at 180 degrees. I put my gloves on, swabbed the area (upper arm), prepared the injection, pinched the skin, and went right in like a dart! Then, to make sure I didn't get an artery, I pulled out some fluid to see if there was blood in it. There wasn't, so I went ahead and injected the vaccine. The feedback I got was that it didn't hurt at all! 

Time for the 3-day weekend.
(or continue it)     :)