Yesterday was my day to present in Vancouver. Prior to presenting in Vancouver I had practice giving this presentation at VGH and at the pain clinic. I think that I was well prepared and have gained experience making a good case presentation with a clear PICO question and review of evidence to support my decision.  

Pain Case Presentation

Evaluation Form February 2010

This therapeutic session covered the practical approach to dosing phenytoin and digoxin and dealing with digoxin toxicity. I learned the criteria for using digibind in acute versus chronic digoxin toxicity (acute: >10mg, Sr K >5mmol/L, life threatening arrythmia/ chronic: >12.8nmol/L, Life threatening arrythmia). I also learned how to load a patient with phenytoin by both IV and PO routes and when to draw levels (IV at 4 hrs to see if in target, Maintenance at 4 weeks to see if at Css).

Today we talked about VTE prophylaxis and treatment. We discussed some of the risk factors that put medical patients at risk of a VTE or PE during their hospitalization (immobility, cancer, obesity, hypertension, pregnancy, estrogens etc.). We also discussed the many therapeutic options to prevent and treat a DVT and the evidence to help direct decision making. We also made a table listing all of the options with advantages and disadvantages. For example some advantages are: UFH is easily reversible, warfarin is oral and reversible with vit K and LMWH requires no drug monitoring. Some disadvantages include: fondaparinux is irreversible, dabigatran is dependent on renal function and expensive and warfarin requires INR blood work. We then used this information to solve a case of a patient with an evolving diagnosis.

In today’s session on fungal infections we focussed on discussing the mechanisms of action, pharmacokinetics and spectrums of activity of the different antifungal agents and then applied the knowledge to two cases. The classes of medications we discussed included: Echinocandins, azoles, pyrimidines and polyenes. I learned that the azoles have the broadest spectrum of activity with posaconazole  having the most coverage. AmB is also very effective for candida species and Cryptococcus and the echinocandins are best for aspergillus and candida infections.  We also discussed the differences in absorption for the azoles and how voriconazole is best absorbed on an empty stomach which is the opposite of posaconazole which is best absorbed with a high fat meal.

I really enjoyed Friday’s case presentations. There were two pediatric case presentations, one case presentation was about clonidine in aggression and the other was on osteomylitis in a 6 week old infant. Both of these cases highlighted the difficulty of finding evidence in the pediatric population; however, they were able to extrapolate information from adult and animal studies to support their therapeutic choices.

Today we saw pictures of some of the signs of endocarditis such as osler’s nodes, janeway lesions, ruth spots and splinter hemorrhages. We also discussed two cases, one was an IVDU with a mitral valve prolapsed with regurgitation and the other was a patient with a mitral valve  replacement. In 70% of IVDU the organism is staph, in this patient we started treating with vancomycin to cover for MRSA.  When we were given the culture results the patient had MSSA so we changed therapy to cloxacillin 2g q4h for 2 weeks (right sided uncomplicated).  The second patient had an MRSA from a prosthetic heart valve so we gave vancomycin and rifampin for 6 weeks but chose not to add gentamycin because of the patients chronic renal failure. In both cases the patients start date of their duration of treatment would be from the first culture negative day. Finally, we discussed the monitoring points for efficacy and safety while on vancomycin and rifampin.

Efficacy: Monitor Temp, RR, HR, BP q 4h until stable then q shift change, Malaise/lethargy, blood cultres/WBC/ neuts q 2days, skin rash/myalgia

The pre-readings for this therapeutic session were very helpful to not only use when on rotation in the NICU but to use in general medicine. This lecture helped to remind us to ask young hospitalized females if they are breastfeeding so we can give advice on discharge about breastfeeding after their procedure or after addition of new medications during their hospital stay.  Some of the topics we discussed included the use of analgesics and codeine in breastfeeding. We also talked about other medications such as antibiotics, antidepressants, oral contraceptives and antihypertensives in breastfeeding.

During my toxicology rotation I worked up numerous paper cases and was able to listen in on some live phone calls. Some of the paper cases I worked up included a valproic acid overdose, a benzodiazepine and antipsychotic overdose and an ingestion of ethylene glycol. Some of the phone calls I listened in on included: a child who ate a cigarette, a child who drank a glade plug in and an adult who was bitten by a spider. Listening to the phone calls and gaining practical knowledge about toxic and lethal doses of drugs and how to manage acute toxicites was very interesting and will be useful for my acute care and pediatric rotations.

Assignment #2 Toxicology cases

Assignment #3 Cases and Notes

Assignment #4 Illicit drug notes

Today I attended a therapeutic talk on aminoglycosides. Today’s talk was based on interpreting levels and making an educated guess to change the dose or duration and predict the level you want. For example, in a patient with a peak just in range and a high trough extending the interval from 8 to 12h would get the desired trough of < 2mg/L. Also increasing the dose slightly would maintain the desired peak. We also talked about a systematic head to toe approach for toxicity and efficacy monitoring. For example, with aminoglycosides the head to toe toxicity monitoring would be dizziness, tinnitus, decreased hearing, fullness in the ears and a rise in serum creatinine.

I attended the second set of case presentations yesterday. These presentations were very good! A variety of topics were talked about including: PE prophylaxis, anticoagulation in cardiac wall abnormalities, acetaminophen overdose and lithium overdose.  From attending these case presentations I am learning how to prepare  for my own presentation and I am also getting a review of the literature surrounding difficult clinical questions.