New Year, New Rotation

Tuesday was the first day of my mental health rotation, after 2 months of vacation! 

It’ll take some getting used to having a set schedule again, but I’m ready to be back. 

Psych medications in general are weakness for me, so I’m looking to get the most 

out of this rotation. I’ve already learned a few things today.

• Olanzapine and quetiapine are FDA approved for bipolar, but not PTSD.This 

is important when looking at nonformulary consults for atypicals andverify whether 

or not the patient has either disease state.

• Ziprasadone – one side effect of antipsychotics in general is the metabolic syndrome. 

This medication needs to be taken with a high fat meal in order to absorb…so metabolic 

syndrome + high fat meal? Not the best combination. Plus this medication is dosed BID, 

which can affect compliance.

• Symptoms to be looking for for bipolar vs PTSD: With bipolar, the patient will 

experience manic episodes, and can go without sleep for days and then crash and 

sleep for days. For PTSD, The patient will have nightmares and feel the need to 

“sleep with a gun” for example, and will want to go to sleep, but can’t. These are subtle 

differences to watch out for.

• Citalopram: can prolong QT interval, and the max dose was recently changed

 to 40mg/day.

• Tramadol: can cause seizures.

• Bupropion: high seizure risk, has a black box warning for this. Not for patients 

with history of seizures, head trauma, alcoholics (d/t seizing during withdrawal), 

and bulimic patients (d/t electrolyte imbalances).

• 5 traditional mood stabilizers: if a patient needs a mood stabilizer, then one or 

a combination of the following should be tried before anything else: lithium, 

valproic acid, carbamazepine, oxcarbamazepine, and lamictal. The latter 4 are also 

anti-seizure medications.

• New medical abbreviations: SI/HI: suicidal ideation or homocidal ideation. 

MST: military sexual trauma (form of PTSD)

• DSM-IV Multiaxial Classification
          o  Axis I: Diagnosis of psych issue as an infant, child, or adolescent. 

Examples include delirium, dementia, amnesia, substance-related, schizophrenia, 

mood disorders, anxiety, sexual/gender identity disorders, eating/sleep/impulse-control/

adjustment disorders.
          o  Axis II: Mental retardation and personality disorders. Examples include: 

paranoia, antisocial/narcissistic/avoidant/dependent/and obsessive compulsive disorders.
          o  Axis III: General medical conditions
          o  Axis IV: psychosocial and environmental problems – things that affect 

diagnosis and treatment of Axis I and II problems.
          o  Axis V: Overall function, noted as the GAF (global assessment of function).

• Delusion – a false belief that one firmly holds.
          o  Bizarre: a delusion a patient has that would be culturally implausible.
          o  Delusional jealousy: delusion that sexual partner is unfaithful.
          o  Erotomanic: delusion that someone (usually of higher status) is in love with individual.
          o  Grandiose: delusion of inflated worth, etc.
          o  Persecutory: delusion that patient is being attached or conspired against.
          o  Somatic: delusion dealing with function of body.
          o  Thought broadcasting: delusion that thoughts are being broadcasted.
          o  Thought insertion: delusion that thoughts are being inserted into patient’s head.

• Hallucination – sensory perception of reality.
          o  Auditory
          o  Gustatory
          o  Olfactory (usually of decaying fish or burned rubber)
          o  Somatic
          o  Tactile (ex. Formication – something is crawling under skin).
          o  Visual

• Mood ~ climate as affected ~ weather

The Jury is STILL Deliberating

The title of this post comes from one of the education sessions I attended at Midyear this year. So, the JNC-8 was supposed to come out last year or the year before, and is now set to be released next year in 2012 (hopefully!). The session was presented by two pharmacists - the first one was discussing all the major articles published about hypertension in that last few years - papers that the JNC committee cannot ignore when releasing the latest guidelines. The second speaker went over cases. I thought this talk was very interesting, and jotted down the following notes.

*The guidelines used today for hypertension come from the JNC-7 (published in 2003) and the AHA Scientific Statement (published in 2007). 

*BP goals:

• JNC7 states: <140/90, and <130/80 for patients with DM or CKD. 
• AHA states: <140/90, and <130/80 for patients with DM, CKD, and/or an increased CAD risk. 
• The diabetes goal being lower is interesting - because according to the speaker, this isn't really evidence-based medicine. The ACCORD trial (done in DM patients) for example, compared a SBP goal of either <140 or <120. The primary endpoints were stroke and MI. Results - more meds were needed to reach SBP <120 and no difference between primary outcomes (p = 0.20). I believe there was a study that showed that patients with proteinuria of 300-1000mg (probably signifies diabetics) had better outcomes when their blood pressure goals were lower. In the HOT trial, blood pressure goals were also studied. In the diabetic population, there were better outcomes with a DBP <80 rather than <90. However, the latter was a subgroup analysis. This is important to consider in my opinion, because diabetic patients are likely already on a couple medications. Is adding more blood pressure medication to reach a lower goal blood pressure worth it if it's not truly evidence-based?

*Treatment schemes:

• In 2003
• If a patient had compelling indications other than hypertension, then specific BP meds would be prescribed (ex. comorbid disease DM, then ACEI/ARB, or post MI, BB, etc.).
• Non-compelling indication stage 1 HTN: HCTZ first line usually, or ACEI/ARB/CCB/BB
• Non-compelling indication stage 2 HTN: 2-drug combo of any of the above with HCTZ as one of the choices. 
• In 2007 (AHA Scientific Statement) 
• If a patient had compelling indications, then no change to above.
• Changes to non-compelling indications: BB were taken off the list and no preference to HCTZ. 
• The ACCOMPLISH trial was a study that looked at combination HTN medications - CCB/ACEI vs. HCTZ/ACEI. The trial was stopped early because the CCB/ACEI combination was significantly better than the other combination. This may have been one of the reasons to take away the preference for HCTZ. 

*ACEI/ARBS

• How are these two different?
• ACEI: dry cough, more data, less expensive. 
• ARB: no dry cough, less data, more expensive; however, 2 generics are supposed to be coming out in 2012, so the use of ARBs may increase. 
• the ONTARGET trial studied the effects of ACEI alone, ARB alone, and combination ACEI/ARB. The results showed increased renal dysfunction, increased incidences of hyperkalemia, with no added benefit. This is why we don't see the combination used very often (except in severe CHF or proteinuria). 

*Chlorthalidone and HCTZ

• If a patient is on HCTZ, and has resistant HTN (on 3 or more meds not at goal OR on 4 or more meds at goal), then consider switching to chlorthalidone. 
• Also, something that the speaker said about HCTZ caught my attention - I've always thought that 25mg/day of HCTZ was maximum that should be recommended - and that anything above causes increased hypokalemia with no benefit. The speaker, however, encouraged going up to 50mg/day HCTZ or adding another agent if BP wasn't at goal with just HCTZ. I haven't completely made up my mind about this, but it's something to look into. 

*What We MAY See in JNC8

• BB as second line therapy or just for compelling indications. 
• Goal SBP <140 for ALL patients, with specific individual goals between patient and PCP. 
• The HCTZ vs. chlorthalidone issue
• ACEI or ARB with CCB as first line combination therapy
• Tailored recommendations for the elderly with HTN.

Long Time No Talk

So…it’s been a while! But, to be fair, my last rotation ended on October 31, and I haven’t been on rotations since. I get back to it on January 2 at a psychiatric ambulatory care site, which I’m looking forward to. So what exactly have I been doing since then…?

1. I started a job with Fry’s pharmacy! I did the bulk of my training in November, which included a week of computer work, and then 80 hours of in-pharmacy training. Now, I’m working 12 hours a week until rotations begin again, and then most likely 8 hours/week after that. This is my first real experience with community pharmacy as an employee, which is crazy since I’m a fourth year student.  But, it’s better late than never. My favorite part of the job is counseling patients. It’s amazing how much I remember (and don’t remember) about certain medications. This also gives me a reason to go back into lexicomp and pull up specific counseling points for different drugs, especially the ones that keep coming up. For example…

Antibiotics in General (most of them)…

• Each dose should be taken with food to increase absorption and decrease GI upset (which is the main side effect)
• Take entire prescription (even if you feel better)
• Talk to your doctor if your condition worsens or dose not improve upon completing the prescription
• Can decrease the effectiveness of birth control (Use back up form of contraception to be safe)
• The pharmacist at my training store also emphasized having yogurt included in the patient’s diet while on antibiotics (but not within 2 hours of the medication). This is to help with digestion.
• For tetracyclines specifically – no dairy, vitamins, antacids 1 hour before and 2 hours after the medication.

Steroids in General…

o        Take with food

o        Can increase blood glucose (so careful in patients with diabetes)

o        Can cause water retention, but this goes away after the course of treatment

o        Can make people moody

o        Can cause early morning insomnia

o        If patient becomes puffy, then PCP needs to be called

Beta Blockers…

o        Can cause dizziness

o        Can cause coldness of the hands and feet

o        Can cause water retention

Ace Inhibitors…

o        Can cause dizziness

o        Take with food

o        Can cause the dry cough

o        Need to get potassium checks

Pain Medications in General…

o        Can cause dizziness and drowsiness

o        NO alcohol due to additive effects

o        Can cause constipation (so offer ideas on some OTC products to help with this, encourage increased fiber in diet)

o        For combination products, watch the Tylenol intake

I also had to do ProAir a few times…

o        Go over how to use an inhaler (prime it – 4 test sprays into the air before the first time of use or if it hasn’t been used in over 2 weeks). When using the inhaler, exhale first, and then inhale deeply while pushing down the inhaler and hold your breath for 10 seconds. Wait 60 seconds between puffs.

o        If also using this with another inhaler, use your proair (albuterol) first, so it opens up your lungs. This will make the other inhaler more effective. 

I’m sure I’ll be asked to counsel on a lot of other meds, but that will come with time. I also sent in my immunization certification from APhA to the state board of pharmacy. I think this will make it official for me to start giving immunizations at Fry’s! My least favorite part of community pharmacy has to be all the insurance claims – this is the part that makes me shy away from the community setting. It becomes more about who owes who money rather than patient care at times. Other than that, it’s the perfect part-time job for now J.

2. I’ve been busy preparing for residency applications. Everyone now a days is encouraging students to apply to about 12 programs, since it’s become so competitive, so that’s exactly how many I’m applying to! At this point, I’ve got my letter of recommendation writers lined up, my CV updated, and a table with specifics for each program/when things are due. Now, all I have to do is actually apply! I was hoping to get everything done by the 17^th, but we’ll see how that goes. I made my finalized list after attending Midyear – which really pushed me towards some programs, and made me eliminate others. I would highly recommend anyone fourth year student who wants to do a residency to go. It’s worth it! And it was in New Orleans this year, which was a blast.
   
   
3. In addition to absolutely loving pharmacy, I love to dance! My sister, myself, and four of our friends founded UofA Om Shanti, which is University of Arizona’s Bollywood Dance Team in 2008. Since then, we’ve competed in competitions in LA, Berkeley, and New York…plus do tons of local performances. Just last month we won first place in New York, which qualifies us for the BIG competition called “Bollywood America,” which is coming up in a few months. I’ve also been busy with this since my break began on October 31^st.

I should have more rotations-related posts about what I’m learning once I start again in January. Until then, I’ll have summaries on what I read in all the pharmacy journals I need to catch up on!

"Suga, Suga" (...how you get so fly)

...My diabetes medications review! I made this list during my last rotation, since I felt like I was all over the place with my diabetes medications knowledge. Enjoy!

Types of Insulin – insulin is safe in pregnancy

Rapid-acting – for meals eaten at same time as injection

• Humalog (Lispro): 15-20mins/3-5 hours
• Novolog (Aspart): 10-20mins/3-5 hours

Short-acting – for meals eaten within 30-60mins

• Humulin or Novolin (Regular): 20-60mins/5-8 hours
• Velosulin: 30-60mins/2-3 hours

Intermediate-acting – half day or overnight (combo with rapid/short)

• NPH: 1-2 hours/18-24 hours
• Lente: 1-2 hours/18-24 hours

Long-acting – about a full day (combo, if needed, with rapid/short)

• Lantus (glargine): 1-1.5 hours/20-24 hours
• No peak time, delivered at a steady level
• Levemir/Detemir: 1-2 hours/up to 24 hours
• Peak time 6-8 hours

Pre-mixed – twice with meals

Oral Medications

Actos (pioglitazone) – thiazolidinediones (^insulin sensitivity and secretion)

• Maximum 45mg/day, Start 15-30mg/day
• ADR: liver problems (2.5x ULN)
• Contraindications: CHF III-IV (BBW)
• Well tolerated in older adults, don’t cause hypoglycemia, okay for renal dysfunction

Janumet (sitagliptin/metformin) – sitagliptin increases levels of incretin, decreases sugar from liver, metformin restores body’s response to insulin, decreases sugar from liver

• Maximum 100/2000mg/day

Metformin – restores body’s response to insulin, decreases sugar from liver

• Contraindications: renal dysfunction (CHF?)
• Perks: has also been shown to decrease LDL and TC, weight loss, less hypoglycemia  
• ADRs: GI, lactic acidosis (d/t OD or renal dysfunction)

Sulfonylureas (chlorpropamide, glyburide, glimepiride, glipizide) – increase insulin release

• 1^st and 2^nd generations
• ADR: hypoglycemia, weight gain

Meglitinides (repaglinide and nateglinide) – similar to sulfonylureas

• If patient can’t use sulfonylureas, same weight gain as sulfonylureas, possibly less risk of hypoglycemia.

Alpha-glucosidase inhibitors (acarbose and miglitol) – block complex carbs to monosaccharides (slows glucose absorption)

• ADR: GI very common

DDP-IV inhibitors (gliptins) – regulates enzymes involved with glycemic control

• No risk of hypoglycemia and weight-neutral (from UpToDate); however, safety of these drugs has not been established for long-term use. Also expensive, and need to be adjusted in renal insufficiency.

Subcutaneous Medications

Byetta (Exenatide) - ^incretin to ^insulin

• BID with breakfast and dinner, Abx/BC with lunch
• ADR: N/V/D/GI/decreased weight
• Contraindications: T1DM, Renal, Pancreatitis, pregnancy

Victoza (liraglutide) – increases insulin, decreases gastric emptying, decreases glucagon, GLP-1 analog

• BBW for thyroid tumor
• Another one in this class is exenatide, but it is BID injections (should not use with CrCl < 30ml/min)

"So will you be getting your master's next?"

I'll get to how my current rotation is going, and all the wonderful things I'm learning. But first, I wanted to take a second to explain the title of this post! Last week, we had a huge dinner party at my parent's house - aunties and uncles I hadn't seen in a long time were there, and we were all catching up. They were asking questions about my life..."Soo, when are you getting married?!" (umm, not quite even engaged yet)..."Are you working now?" (nope, still a student)..."So, will you bet getting your master's next?" (....WHAAT?!). This last question was what really got to me. But only for a second. I realized that the older generation (actually, the majority of people) know a pharmacist as an RPh (which I believe is a bachelor's degree). They don't know that a Pharm.D. degree is what current pharmacy students are getting...a doctor of pharmacy degree, and includes more clinically oriented courses. Anyway, instead of actually blurting out the initial "WHAAT?!" I explained that there would be no more schooling after this (yay!), because it is a doctorate degree, and that I'll be doing a residency because I'm passionate about a clinical career. The transition to pharmacists being seen as clinicians will take time, which is why it's so important to educate anyone and everyone around you about what it means to be a pharmacist.

Anyway, enough preaching. So my current rotation site is great! The clinic rotation was relaxing, since I wasn't busy all the time. Now that I'm back in the hospital, and the rotation site is custom to having pharmacy students, it's been nonstop. My preceptor is SO smart, and she's literally a super star on rounds. She just graduated from pharmacy school 2 years ago, and is already the trauma pharmacist at the hospital I'm at. Very impressive. I have a few tasks to do everyday:

1. Dialysis patients - I print out the list of patients on dialysis at the hospital, and make sure their medications are all renally dosed - the major ones I look for are the antibiotics. I've taken it upon myself to make sure there aren't any drug-drug interactions too - and I catch them fairly often. The major ones I keep finding are simvastatin with amlodipine and diltiazem. Since the guidelines changed, the max dose of simvastatin with amlodipine is 20mg, and with diltiazem is 10mg. There are others, but these are the most common ones that keep coming up.
2. Epidemiology reports - This is a print out of completed culture and sensitivitie reports for patients in the hospital. My job is to look at the clinical picture of the patient, and make sure they're on antibiotics/antifungals if needed, and if they're already on something, then to make sure they cover the bugs that grew out. I've made many interventions doing this so far. For example, we had a patient who was on day 18 of cefepime and day 12 of vancomycin. The patient had not had a fever in days, and did not have a white count. So I went to the chart, and looked at progress notes - and the plan was to discontinue the antibiotics on a certain day, but it was never done. So, finally...10 days later, they were discontinued. It bothers me when patients are getting medications when they're not getting any benefit from them - then it just becomes unnecessary chemicals in the body. Another intervention was when I identified a patient with MDR Enterobacter and a Staph haemolyticus wound infection who was on the wrong abx. I was able to talk to the physician and change the patient to the correct antibiotics. Today, one of my patients' C.dif result came back negative. She was on prophylactic Flagyl, but was never discontinued - so I made sure it was gone before the end of my work day!
3. Coumadin teachings - we get a print out of all the patients on coumadin in the hospital. The students are responsible for doing these coumadin teachings, since it is such a serious medication. They're very redundant, but it's been fun talking to patients. 
4. Vent rounds - Every Wednesday, the pulmonary doctor volunteers to come in and go through her patients on vents with the respiratory therapist and the pharmacist. I tag along too, since my preceptor is this pharmacist. So far, I've presented patients at two vent rounds - I make sure there's DVT and stress ulcer prophylaxis, PRN sedation and pain medications, make sure they're on the correct abx, etc. 
5. Go on rounds - I around on trauma rounds every Monday and Thursday. It's a sad hour in my opinion, since a lot of these patients are young. However, it's a great learning experience - I listen to see what kinds of issues my preceptor brings up, and 9/10 times, her suggestions are followed through. Everyone on the team, including the head trauma surgeon, is always interested to hear my preceptor's opinion, which makes me happy :D. 


By the time I've gotten through all my patients, dealt with the issues that I found while going through the charts, and finish my teachings...it's time to go home!

And...It's a Wrap!

I haven't updated in forever! Wrapping up my last rotation, moving back to AZ, settling back into Chandler, and starting my new rotation has  all been a little crazy :). The following is what I had typed up on my last week of rotations at the clinic in North Carolina...

Day XVIII.

• Patient #1 – 65 y/o woman on HCTZ 12.5mg/day, Evista 60mg/day, and Lotrel (amlodipine/benazepril) – not sure about the dose. This was what was listed on her profile. Her blood pressure was 140/90. I asked her what her BP readings were prior to starting her medications and she said about 160/100. So, it was helping her. However, she hadn’t had her labs done since 2009, when her cholesterol was high (she refused statins at the time). She actually had a few misconceptions about statins – that they decrease good cholesterol and make people put on weight like crazy and require weekly blood draws (the latter 2 were her friend’s experiences). She said instead, she has been taking niacin everyday. She also takes vitamin D and calcium randomly, and ASA whenever she “doesn’t feel so good.” I told her that her friend may have experienced those things (maybe or maybe not from the statin), but that thousands of people do benefit from the drug. But, I also said that I won’t be making any recommendations to the doctor until her blood work was updated. I also mentioned that she should be taking a baby aspirin everyday for overall heart health.
• Patient #2 – 60 y/o woman with history of depression. She’s on alprazolam, citalopram, carvedilol, HCTZ, fish oil, multivitamin, and pravastatin. Her blood pressure was under control – 108/76, as well as her cholesterol. I also asked about over the counter medications. Now, I’ve noticed something interesting when I ask this question. Usually, when I ask, “So, what kind of OTC medications to do you take,” they’ll say none. Then, I’ll say, “So, if you ever have a headache or something, what do you take?” That’s when they’ll say either ibuprofen or Tylenol. If I ask how often, the patient will usually say once in a while, which I’m not concerned about. However, this patient, after saying “no over the counter medications” initially, ended up telling me that she does take Tylenol everyday – about 1-2g/day. Statins…liver….Tylenol…liver…I recommended getting her LFT’s checked.
• Doctor’s question – if a patient has diabetes, and renal dysfunction, and refuses insulin, what are my options? First, I asked what exactly the creatinine clearance was (42ml/min). My first response to this was – Januvia 50mg/day, need to decrease down to 25mg/day if CrCl falls below 30ml/min. Another option is Amaryl (glimepiride) – can start at 1mg/day and increase up while monitoring glucose. Also, the glitazones are an option. The patient was prescribed Januvia.

Day XIX.

• Patient #1 – talked to a patient on lisinopril/HCTZ, simvastatin 40mg/day, actonel once a month, baby aspirin, Allegra, pantoprazole, and flonase. We basically just went over all of her medications. My contribution to her health was to get a magnesium level, since I found out she had been on the pantoprazole for about a year.
• Patient #2 – 50 y/o male on amlodipine 5mg, Lipitor 20mg, flomax 0.4mg, and HCTZ 12.5mg. I recommended starting this patient on a baby aspirin, since he does have high blood pressure and cholesterol. He said he would buy some when picking up his prescriptions J.

Day XX.

• We had a patient come in to be seen – she said her job is to teach nurses and doctors about medications, etc. However, when I started talking to her, I was surprised that she did work in the health care field. Her AIC 3 month ago was 12%, her blood pressure was 190/112, and she had gained weight since the last time she was seen. She said she was taking all of her medications. When I asked her when she was taking them, she said she takes her first dose at 12pm and her second dose at 5pm (most of her medications were BID dosing). I recommended that she take her 12pm dose in the morning when she wakes up/with breakfast. Taking her medications 12 hours apart may help her. I still have my doubts about compliance, but she claims she is. Anyway, she’s coming back next week after she gets her labs done, and said she would ask for me. She may be hardcore dieting and exercising this week to get her labs to look a little better, but her AIC will tell the truth about what she’s been doing the last few months.  

Day XXI.

• Didn’t have a lot of patients come in today, but was asked about the interaction between PPIs and clopidogrel (theory is PPIs decrease effectiveness of clopidogrel, so more adverse CV events are possible). So, I looked into the COGENT trial (Clopidogrel and the Optimization of Gastrointestinal Events Trial). In this study, 3700 patients were randomly assigned to clopidogrel, ASA, omeprazole OR clopidogrel, ASA, placebo. Results – fewer patients had GI events with omeprazole (significant), and the CV events were similar with both (no significant differences). Apparently, the only real interaction is between clopidogrel and omeprazole, and the other PPIs are okay. If this comes up again in the future, I’d recommend switching to a different PPI – but if this isn’t possible, I’d bring up the results of the COGENT trial. With the results of this trial, my opinion is that omeprazole is also safe.

I’m sitting here on my last week of rotations, and just wanted to take a second to reflect on my experience here. First off, I think I had an extremely unique rotation – as I’ve said before, this clinic has never had a pharmacy personnel of any kind working here. I didn’t have a pharmacist preceptor to “second” my recommendations, so I went to the literature to double check many times. Many of the nurses hadn’t even heard of a Pharm.D. I came here with the goal of educating not only patients about their medications, but also my coworkers about the awesome-ness of pharmacy. Something that I’ve been interested in lately is collaborative practice agreements. It’s when a clinical pharmacist (nowadays, I’m sure a residency is required) and a physician sign a contract – and pharmacists can prescribe medications for certain disease states. For example, I emailed a few clinical pharmacists in North Carolina, and one in particular said she even has her DEA number and can prescribe controls and antidepressants. Anyway, basically when a patient comes into a clinic to see a physician, and that patient is diagnosed with a disease state covered by the contract (usually diabetes, hypertension, hyperlipidemia, GERD), then that patient’s care is transferred to the clinical pharmacist. From this point on, with respect to this disease state, the clinical pharmacist is in charge of prescribing that patient’s medications, writing labs, and seeing them at follow up appointments. Honestly, even if I could just do this for DM, HTN, and HLD, I’d be content. These three disease states are major risk factors for further health complications, and I would be fulfilled if I could be a part of preventing any of these complications. I’m talking to one of the pharmacists I emailed over the phone in the next few weeks to ask her questions, get her input on a few things. So, I’ll update on that as soon as that conversation is over.

As far as leaving NC and this clinic – it’s been an amazing experience. My preceptor told me she considers me as one of her daughters, the nurses said they would miss me, and the doctors said they appreciated my “pharmacy consults.” Having my Phoenix rotation canceled to make room for this one was a real blessing. With that said, I’m ready to be in a hospital again, and see how the next hospital is different from my previous hospital rotation :).

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)     :)