Test Yourself!

The last 2 weeks have been extremely hectic - moving always is. My time at the VA is almost over (only 4 more work days), which also means I'll be leaving Tucson soon. I thought Tucson was the perfect college town to experience the last 5 years in :). Switching gears, just because I haven't updated in a couple of weeks doesn't mean the learning suddenly stopped! I've been taking careful notes qday, which I will summarize over the next few days. Until then, I put together a pre/post self assessment for future rotation students. Personally, I would have liked a stress-free "test" to assess how much knowledge I gained from this rotation. Here it is!

Acute Care

1.     What are the 5 stages of Chronic Kidney Disease?

a.     Stage 1:

b.     Stage 2:

c.      Stage 3:

d.     Stage 4:

e.      Stage 5:

2.     What lab change(s) define acute kidney injury? Circle all that apply.

a.     30% increase in serum creatinine from baseline

b.     50% increase in serum creatinine from baseline

c.      0.5 mg/dl increase in serum creatinine from baseline

d.     0.3 mg/dl increase in serum creatinine from baseline

3.     What does the Blood Urea Nitrogen (BUN): Creatinine ratio tell us regarding kidney dysfunction in AKI (acute kidney injury)?

a.     BUN:Cr > 20:1 –

b.     BUN:Cr >10:1 and <20:1 –

c.      BUN:Cr <10:1 – 

4.     What two classes of drugs most commonly cause prerenal kidney damage?

a.     Steroids and Beta Blockers

b.     ACE inhibitors and Calcium Channel Blockers

c.      ACE inhibitors and NSAIDs

d.     NSAIDs and Steroids

5.     Which drugs can cause pancreatitis? Circle all that apply.

a.     Steroids

b.     Sulfonamides

c.      NSAIDs

d.     Diuretics

e.      Azathioprine

f.       Antipsychotics 

6.     Which penicillins can be used for Staphylococcus infections? Circle all that apply.

a.     Ampicillin

b.     Nafcillin

c.      Oxacillin

d.     Penicillin

e.      Dicloxacillin

7.     What is drug of choice for enterococcus infections?

a.     Cephalosporins

b.     Aminopenicillins

c.      Aminoglycosides

d.     Fluoroquinolones

8.     Which class of antibiotics will NOT cover enterococcus?

a.     Cephalosporins

b.     Aminopenicillins

c.      Aminoglycosides

d.     Fluoroquinolones

9.     Which cephalosporin does not need to be renally adjusted?

a.     Cefuroxime

b.     Ceftazadime

c.      Cephalexin

d.     Ceftriaxone

10.                        When do you measure a trough for vancomycin and what is the therapeutic range for complicated skin infections, bone infections, bacterial meningitis, bacteremia, and hospital-acquired pneumonia?

a.     Before the 3^rd dose, 10-20mg/L

b.     Before the 4^th dose, 15-20mg/L

c.      Before the 3^rd dose, 15-20mg/L

d.     Before the 4^th dose, 10-20mg/L

11.                        Atypical pneumonia organisms include: (circle all that apply).

a.     Kleibsiella

b.     Legionella pneumonia

c.      Mycloplasma pneumonia

d.     Streptococcus pneumonia

e.      Chlamydia 

12.                        Which oral antibiotics can you use for MRSA? Circle all that apply.

a.     Bactrim

b.     Augmentin

c.      Clindamycin

d.     Doxycycline

e.      Ceftobiprole

13.                        Drug of choice for community acquired pneumonia is:

a.     Vancomycin and Zosyn

b.     Azithromycin and Zosyn

c.      Azithromycin and Ceftriaxone

d.     Vancomycin and Ceftriaxone

14.                        Drug of choice for hospital acquired pneumonia is:

a.     Vancomycin and Zosyn

b.     Azithromycin and Zosyn

c.      Azithromycin and Ceftriaxone

d.     Vancomycin and Ceftriaxone

15.                        The CHADS2 score is associated with the risk of stroke in a patient with atrial fibrillation. What does CHADS stand for?

a.     C:

b.     H:

c.      A:

d.     D:

e.      S:

16.                        If a patient presents with chest pain in the emergency department, certain medications are given with the acronym MONA-BS. What does this stand for?

a.     M:

b.     O:

c.      N:

d.     A:

e.      B:

f.       S:

17.                          Which medications have been shown to improve survival in congestive heart failure patients? Circle all that apply.

a.     Furosemide

b.     Beta blockers

c.      Calcium channel blockers

d.     Spironolactone

e.      ACEI/ARBs

f.       Hydralazine/isosorbide dinitrate 

18.                        Shown in literature, which three beta blockers have shown benefit in congestive heart failure?

a.     Metoprolol

b.     Metoprolol XL

c.      Atenolol

d.     Carvedilol

e.      Bisoprolol 

19.                        What is the reversal agent for benzodiazepines

a.     Narcan

b.     Flumazenil

c.      Vitamin K
d.     Tricyclic antidepressants

   
      20.          Match the following situations with the appropriate doses.    

a.     DVT prophylaxis dose of Enoxaparin (2 options):

b.     DVT prophylaxis dose of Enoxaparin renally adjusted:

c.      DVT treatment dose of Enoxaparin (2 options):

d.     DVT treatment dose of Enoxaparin renally adjusted:

Answer Choices: 30mg BID, 30mg Qday, 40mg BID, 40mg Qday, 1.5mg/kg Qday, 1.0mg/kg BID, 1.0mg/kg Qday, 1.5mg/kg BID

21.                       What is the CrCl cutoff for the need to renally adjust enoxaparin?

a.     <40ml/min

b.     <20ml/min

c.      <35ml/min

d.     <30ml/min

22.                        What is the goal INR range for a patient with atrial fibrillation and a CHADS2 score of 4 (who is currently taking warfarin)?

a.     2.5-3.5

b.     3.5-4.5

c.      2.0-3.0

d.     3.0-3.5

23.                        What is the goal INR range for a patient with a mechanical mitral heart valve (who is currently taking warfarin)?

a.     2.5-3.5

b.     3.5-4.5

c.      2.0-3.0

d.     3.0-3.5

24.                        Regarding the causes of metabolic acidosis, what does MUDPILES stand for?

a.     M:

b.     U:

c.      D:

d.     P:

e.      I:

f.       L:

g.     E:

h.     S:

Good luck! 

Pain, the 5th vital sign

There's a new schedule at the hospital as of last Friday, and I'm still trying to figure it out. It used to be a system consisting of 5 different call schedules, and each medicine team would just rotate everyday. So, every 5th day would be postcall, and the team would round at 7am (instead of 9am), and we'd have to be there extremely early to work up our patients. Everyone is still getting used to it. For example, we didn't start rounding today until about 10:15 or so. The good news is that I don't have to be at the hospital at the crack of dawn every 5th day :). Also, the new medical interns started last Friday. It's definitely been crazy at the hospital this week, especially since my med team doesn't have a resident...so we have 2 doctors straight out of med school, and one doctor with 10 months of experience. I've noticed myself catching a few more drug therapy mistakes than usual, but it's all part of the learning process...for them and me :).

Pain
There was a patient yesterday with an intractable migraine. He had a PMH (past medical history) that included vasculitis and peripheral vascular disease, so the med team didn't want to start him on triptans or ergotamines. Anyway, neurology wanted to try an alternative, and decided on valproate acid intravenously. My preceptor hadn't really heard of this being done too often, so I did a drug information on this topic. My conclusion was that as an alternative, valproate acid 300-500mg IV diluted in 50-100ml of normal saline and given over 5-10 minutes is an option for patients with intractable migraines. Also on the topic of pain, my preceptor was called by the attending to recommend an opioid drip for a cancer patient with a 10/10 pain level. The patient was on 100mcg/hr fentanyl patch as well as about 10mg of hydromorphone IV push a day. Our job was to figure out an equivalent dose of hydromorphone drip. We found that about 8-10mg of hydomorphone was roughly 100mcg/hr of fentanyl. Since this was a cancer patient, we decided to use the higher end of the range. So, 10mg + 10mg hydromorphone she was getting over a day = about 20mg of hydromorphone. As a drip, we initiallly recommended diluting 100mg in 100ml normal saline, and giving it at a rate of 1mg/hour, which would be good for 100 hours. BUT, the drug expires in about 48 hours, so we changed it to diluting 50mg in 50ml normal saline and keeping the rate at 1mg/hour...this way the drip will empty in about 48 hours. Awesome. Another things about pain...according to our attending, the ONLY indications for NSAIDs in the hospital are gout and pericarditis! 

Renal
A quick tidbit - if a diabetic patient had to have imaging done with contrast, then his/her metformin would have to be held for 48 hours before restarting it, but glipizide can be started right away. With the contrast, we're already cautious of CIN (contrast-induced nephropathy), and we don't want to make things worse with the metformin. 

Drug Fever
Christie gave us a presentation about “drug fever” today. Basically, if a patient is started on certain drugs and develops a fever during therapy (and the fever goes away when those drugs are d/c’d), then the patient has drug fever. When a patient has a fever from infection, then you’d expect the patient to be tachycardic. With drug fever, the patient really isn’t tachycardic, and actually looks “inappropriately well for their degree of fever.” The most common mechanism of drug fever is hypersensitivity to the drug. Drugs include: allopurinol, antibiotics, carbamazepine, heparin, methotrexate, azathioprine, methyldopa (safe for pregnant women to use for hypertension), phenytoin, procainamide, sulfonamides. Thanks Christie!

Anticoagulation
I’ve finally memorized lovenox dosing and how to differentiate the doses based on what the indication is. For prophylaxis of DVT: 30mg BID or 40mg Qday (for CrCl <30ml/min, 30mg Qday). For treatment of DVT: 1mg/kg BID or 1.5mg/kg Qday (for CrCl <30ml/min, 1mg/kg Qday).

Recommendations
Wednesday (7/6): A patient was on amlodipine, atenolol, and HCTZ/lisinopril combo. His blood pressure was controlled on these medications, and the question was whether his drugs could be cleaned up since his HR was declining. The patient is on a CPAP machine at home, and the intern wasn't aware that it could be ordered in the hospital as well. My recommendation was to order the CPAP machine, and just see how the patient does for a day before messing with his medications (since they were working for him). Also, a patient's potassium was increasing, and I recommended that the lisinopril should be stopped (especially since it was a new medication on this admission).

Thursday (7/6): There were quite a few STEMI patients on our team today, so I was checking to make sure they were on appropriate therapy for that. One patient was on MONAB (but not the S), so I recommended the patient be started on a statin. The patient was on rosuvastatin as an out patient, so rosuvastatin 40mg was started on the patient. 

More to come in a bit!

A bottle of gatorade...

...has 3 mEqs of potassium! We had a patient last week whose hyponatremia (low sodium) was getting worse and worse because he was constantly drinking water or eating ice. He had xerostomia (lack of saliva...dry mouth), which explains his constant fluid intake. Since his hyponatremia was worsening, he was put on fluid restrictions. He wasn't okay with this, so the medicine team let him have gatorade. The next day we checked his electrolytes, and his hyponatremia was improving, but his potassium had increased more than we'd like. We went to his room, and there were about 4-5 empty gatorade bottles laying around the room, which led us to look at the label:

Potassium = 30mg per serving x 4 servings = 120mg.

If 1 mEq = 39mg of potassium, and each bottle has 120mg, then each bottle has about 3 mEq of potassium.This isn't actually a whole lot per bottle, but it could be a significant amount if the patient drinks a ton in a day.

Electrolytes
At the end of certain days we have "family rounds," where the three students doing the acute care rotation and our preceptors sit around and discuss some interesting patients. Instead of presenting a patient case last Friday, I decided to discuss the calcium-phosphate equilibrium (which, let me tell you, is an exhausting topic). So calcium and phosphate are important for our bodies to function, and it's important to have the right amount of both. Parathyroid hormone and Vitamin D both act to increase the amount of calcium (PTH tells osteoclasts to bring down bone to bring Ca into the blood and tells the kidneys to excrete more phosphate and reabsorb more Ca into the blood, and Vitamin D absorbs more Ca from the intestine into the blood). The main thing I was explaining last week was how kidney dysfunction relates to Ca-PO4 equilibrium. If a patient's kidney function decreases, then two important things (among others) happen: there's more phosphate in the body since it's not being excreted, and vitamin D isn't being turned into its active form by the kidneys. The decreased vitamin D means there's decreased absorption of calcium from the intestines into the blood, and of course, less calcium in the blood. This signals PTH that there isn't enough calcium in the body, and activates osteoclasts to break down bone to take care of this disequilibrium. The increased phosphate in the body also causes secondary hyperparathyroidism, which also leads to the activation of osteoclasts. In the long run, this cycle can lead to osteomalacia. Also if the calcium x phosphate product is >55, you would want to consider treating the patient with calcimimetics, vitamin D analogs, lanthanum, etc. The whole spectrum of what happens is definitely more complicated than this, and this explanation serves as a summary :).

Infectious
Last week we had a review about sepsis and neutropenic fever. First of all SIRS (systemic inflammatory response syndrome) is defined as 2 out of the 4: fever of <38'C, tachypnea, tachycardia, leukocytosis/leukopenia. Sepsis is SIRS + infection. Severe sepsis is sepsis + end organ dysfunction (altered mental status, liver failure, intubation, heart dysfunction, etc.). Septic shock is severe sepsis + hypotension DESPITE adequate fluid resuscitation. Antibiotics and vasopressors would be given until the Mean Arterial Pressure > 65 (MAP = 1/3SBP + 2/3DBP). Neutropenic fever has to meet two definitions - neutropenia (ANC < 500), and fever (temperature of 101'F once or 100.4'F sustained).

Imaging
During rounds, I constantly hear about MRI/CT/Ultra sound, and wanted to get a better idea of what each one has to offer. A CT shows fine slice images of the body, but it uses radiation (can also do spiral CT, which is a 3-D image). An MRI does not use radiation, and the pictures from this time of imaging are also very useful for diagnoses; however, no magnets or implanted medical devices can be in the vicinity of the scan. An ultra sound also doesn't use radiation, but it's not as clear for highly dense areas, such as big bones, in the body.

Recommendations
Friday (7/1): Patient came in with a GI bleed, and was given pantoprazole 80mg IV for gastric protection. The attending looked right at me and asked what, if anything, the patient should be on as an out patient. My recommendation was omeprazole 40mg BID (this patient's situation was serious regarding GI bleeding and ulcers). This was the dose that was ordered.

Tuesday (7/5): Patient came in with unstable angina, and I recommended that the patient's ibuprofen be D/C'd due to the risk of vasospasm, and also to start nitroglycerin sublingual PRN for chest pain.

Anyway, my next management conference is coming up on July 22. I'm looking for a topic...something that would be useful for pharmacists to know about drug therapy for any disease really (well, preferably a topic that would pertain to the older VA population), and something with a couple legit journal articles to analyze. Any suggestions would be appreciated :)!