Let's bet on it. Price is right rules.

After some time off, my preceptor is back! So, even though I'm at the same place for another 6 weeks, it'll feel like a slightly different rotation, since every preceptor does things a little differently. All the residents are slowly leaving one by one this week though, so that's sad since they were all awesome. Speaking of the residents, the resident that I was following on rounds and I would sometimes place bets on follow up lab values. This time, a patient's INR was 4.2 on warfarin and azithromycin. The medicine team wanted to bring the INR back down, so the warfarin dose was held for the day and azithromycin was discontinued. The bet was on what the INR would be the next day. The guesses were: 3.0, 3.3, 3.5, and 3.6. The result came back today and it was 3.4...almost therapeutic! This transitions well into a topic that has, again, been coming up this week...

Anticoagulation
For lovenox, if a patient is on a prophylactic dose, the regimen is 40mg qday or 30mg q12h (30mg qday with renal dysfunction). However, if the patient is being treated for a DVT or PE, then the dose is 1mg/kg BID. Speaking of PE/DVT, the Well's score for likeliness of PE/DVT being the diagnosis can be calculated. Here's how to do it:

• Suspected DVT: 3 points
• PE diagnosis more likely than alternative diagnoses: 3 points
• Tachycardia: 1.5 points
• Surgery or immobility in previous 4 weeks: 1.5 points
• History of DVT/PE: 1.5 points
• Hemoptysis (coughing up blood): 1.0 point
• Current cancer: 1.0 point

If a patient scores >6, then the likelihood is high. At this point, I would recommend starting a blood thinner and putting in an order for a chest CT as well (just to confirm). If patient scores 2-6, then there's a moderate likelihood of having a PE/DVT, and <2 is a low likelihood. Some things that can cause a PE include hormone replacement therapy, surgery, and being a smoker among others.

CBC
Pancytopenia means that all 3 cell lines are down: the red blood cells, white blood cells, and platelets (this can be caused by chemotherapy). Neutropenia means a low absolute neutrophil count (ANC). A normal ANC level is >1500cells/microliter, and a low ANC is defined as <500cells/microliter. ANC = (%neutrophils + %bands) x WBC. This value becomes important in diagnosing neutropenic fever, which is a medical emergency. The "neutropenia part" is defined above, and the "fever part" is defined as a temperature of 101'F once or a sustained temperature of 100.4'F over an hour. I learned that for neutropenic fever, you would want to cover for pseudomonas. Another tidbit about CBC is that steroids tend to increase WBC. So, if someone on prednisone presents with a high WBC but no signs of infection, he/she probably doesn't need to be unnecessarily started on antibiotics. I hear this all the time at the hospital...treat the patient, not the numbers. Also, packed red blood cells (PRBC)...1 unit has about 200mg of iron. So, if someone is severely anemic and has a low iron saturation (<20%), and he/she is going to be getting PRBC, then there may not be a need to give supplemental iron.

Heart
We had a few patients come in for atrial fibrillation this week, or at least a history of it. Something interesting that came up was the correlation between a-fib and hypothyroidism. In a patient with both these conditions, despite an elevated TSH level (conferring hypothyroidism), this patient's levothyroxine dose was decreased. Switching gears, when you think of someone with hypERthyroidism, what comes to mind? For me, it's increased metabolic activity, increased heart rate, etc. So, the dose of levothyroxine may have been decreased in an attempt to decrease HR (so it wouldn't exacerbate the a-fib).

Infectious
Now Micromedex has this amazing feature where you type in a bug, and the drug of choice and alternatives are given. I think this will be a great learning tool for me this year. I definitely don't want to constantly rely on it though...it should all be in my head. So, we put in a few bugs to see if we already knew the drugs of choice. Community acquired pneumonia: Azithro 500mg IV x 2 days, and then 500mg PO to complete 7-10 days (+) ceftriaxone 1g q24h x how many ever days depending on the severity of the infection. Hospital acquired pneumonia: Vanco 1g q24h x 10-14 days (+) Zosyn 4.5g q6h x 10-14 days. Listeria: ampicillin 2g IV q4-6h. There was a patient who was in for pneumonia this week, and he was having a horrible non-productive cough. Apparently, things like guaifenesin and robitussin have more of a placebo effect than anything. The only drugs that really suppress cough are narcotics. We gave the patient guaifenesin yesterday, and today he stated that his cough is much better :). Last topic...C.dif (again!). There's a way to categorize the severity of C.dif, and relate it to the most appropriate treatment to give to the patient:

• Patient's first experience with C.dif that is mild-moderate: WBC<15000 and no renal dysfunction.
• Treat with PO Flagyl 500mg TID x 10-14days
• Patient's first experience with C. dif that is severe: WBC >15000 and SCr is >1.5x baseline 
• Treat with PO Vanco 135QID x 10-14 days
• Patient's first experience with C dif that is severe and complicated: WBC >15000 and SCr is >1.5x baseline and patient has a megacolon, ileus, or shock. 
• Treat with Flagyl 500mg TID IV and Vanco 500mg QID PO x 10-14 days. Rectal vanco is also an additional option. 
• Patient has recurrent C. dif infections: Vanco taper as mentioned in a previous post.

 Recommendations
I've been noting the recommendations that I've had this week:
Monday: Patient has a saddle embolism (a thrombus that blocks two arterioles, to put it simply), and had an INR of 1.3 on a 5mg dose of warfarin at night. I wanted to increase the dose to 10mg for the night to get the INR up a little faster (goal was 2-3 for her). The dose was changed to 7.5mg and the INR went up to 1.5.

Wednesday (today): Patient came in for a CHF exacerbation. He's on a home dose of Lasix of 80mg in the morning and 40mg in the evening, including a potassium supplement. He had acute kidney injury in the hospital, so the lasix was held; however, the KCl was still kept. The potassium increased from 4.5 to 5.0 (nothing too traumatic, but still trending up). My recommendation was to D/C the KCl unless there were plans to start Lasix again tomorrow.

More again later this week!