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!