C. Dif GaLoRe!

I finally have a routine when I get to the hospital every morning, and I love it. I'll admit it took me a good 4 weeks to get the hang of how things work and what the heck I'm supposed to be doing, so I'm happy I'll be here for another 6 weeks. On that note, I can't believe the first rotation is over tomorrow. If they all go this fast, graduation will be here before I know it!
My Routine
I'm not sure if all hospitals will have the same computer system/records available to pharmacists as the VA. So, the following may only be useful to people who will be doing their rotation at a VA in the future:

• Print inpatient medications and patient's lab values for past three days. 
• Write patient's significant PMH on back of labs sheet. 
• For atrial fibrillation, calculate CHADS score.
• For CHF, find out most recent ejection fraction and BNP (brain natriuretic peptide). 
• For DM, find last A1C recorded.
• On inpatient medication page, circle any of patient's outpatient medications (and write in any dose differences).
• Write in other outpatient meds not continued as inpatient.
• Check abnormal lab values and attribute each one to something.
• Check microbiology results as well, and make sure antibiotics are covering the bugs (if applicable)
• If there a significant drop in H/H, look to see if there's an increase in BUN (possibly upper GI bleed) or increase in SCr (less epo production by kidneys).
• Write down current vital signs.
• Inpatient medications (keep in mind the emergency department administration of drugs sometimes doesn't show up in the inpatient list available to the medicine teams).
• Look up which day of treatment the patients are on for their antibiotics (if applicable). 
• If on IV antibiotics and likely to get discharged, look up oral equivalents. 
• Check to see if ACEI, vancomycin, aminoglycosides are ordered in patients with increasing SCr (suggest dose changes or discontinuation as necessary).
• Check last dose of furosemide if admitted for CHF.
• If patient has high pain level, check last administration of pain drugs. 
• Read the notes to get an overall picture of the patient's situation. 
• Ask yourself what you may be asked as the pharmacist on the rounding team, and be ready with answers (still working on this one!). 

I'm sure this general procedure will change for me in the future, but this is what I'm working with as of now!

Infectious
Ever heard of vancomycin tapering? I hadn't until this week...apparently it's for patients with a second relapse of C. dif within one year. We had a vanco taper that we counseled on, and the ID department recommended the following: 125mg vancomycin QID for 3 weeks, then BID for 1 week, then Qday for 1 week, then QOD for 4 weeks. I really hope this regimen works for this patient. Treating C. dif is tricky, especially if the patient has comorbidities that require antibiotics. If it's a patient's first C. dif infection, then 20-25% of people usually respond to just discontinuing the offending agent. Patients should also avoid PPIs, since the acid is protecting the stomach from the infection. Keep in mind that hand sanitizers don't kill the C. dif spores, and that handwashing with soap is necessary. Once treatment is started, symptoms should get better in 4-6 days, and should resolve in about 2 weeks. Herpes zoster was also relevant to one of our patients this week. The treatments for this include: acyclovir 800mg 5x/day for 7-10 days, valacyclovir 1g TID for 7 days, or famciclovir 500mg or 750mg TID for 7-10 days. Of these three agents, valacyclovir is preferred, but if cost is an issue, then acyclovir is definitely cheaper. Postherpetic neuralgia is also a problem with herpes zoster. In fact, one of the goals of treatment for herpes zoster is to decrease postherpetic pain. Drugs for this include amitriptyline or nortriptyline 25mg x 90 days. Or gabapentin up to 1800mg/day x 90 days. 

TPN (total parenteral nutrition)
20% of lipids for TPN is equivalent to 2kcal/ml. You would think that 10% lipids would equal 1kcal/ml, but it's actually 1.1kcal/ml...weird. 20% dextrose is 3.4kcal/gram, 5% amino acids is 4kcal/gram. 

Heart
CHF doses of beta blockers are as follows: metoprolol 50-100mg BID, bisoprolol 5-10mg once daily, carvedilol 25mg BID (50mg BID in obese patients is what I saw in practice). These three are the beta blockers that were used in the study to see the use of beta blockers in CHF. If someone comes in with chest pain and are diagnosed with unstable angina or NSTEMI, the TIMI risk score is something clinicians might use to predict a patient's risk of death or ischemic events - stands for Thrombolysis in Myocardial Infarction.


 More again tomorrow, and then 1 rotation down, 5 more to go!