Today we discussed delirium and some of the ways we can approach helping patients with delirium. As a pharmacist I should try and predict the patients risk factors for delirium prior to, or on admission to the hospital (alcohol use, age, medications, pain etc.). I should then try and prevent delirium by modifying these risk factors (CIWA protocol, nicotine replacement, changing high risk medications etc.). In addition, I need to be able to recognize the acute onset and signs of delirium such as day/night reversal, agitation, altered LOC and disorganized thoughts so that I can identify patients with delirium. If a patient develops delirium, non-drug measures should be used first to orient the patient (clock, calendar, pictures from home, glasses, hearing aids etc.). Finally, if it becomes necessary appropriate intervention such as antipsychotics can be used short term.

I really enjoyed attending the first set of case presentations in Vancouver. The three topics presented where pheochromocytoma, liver disease and CAP. I think that it is really beneficial to attend case presentations as I learned about a rare condition (pheochromocytoma) and the literature behind the recommended therapy. I also had the chance to see the kinds of patients that other residents have been looking after and was able to learn about these patients, their disease states and the effects the pharmacists recommendations had. 

Today we finished working up our case of a patient who got acute renal failure and then ended up with chronic renal failure. During the last two lectures we talked about medications that need to be adjusted or avoided in renal failure and then how to manage chronic renal failure. To start off,  our patient had normal renal function; however, he had many factors that put him at risk of renal failure such as hypertension, diabetes, age over 65  and taking hydrochlorothiazide. When he became ill with an infection (another risk factor) and was given numerous antibiotics that affect renal function such as gentamicin, vancomycin and cephalexin his renal function rapidly declined. During this first session we talked about the reasons for his rapid decline in renal function and what could have been done to avoid this. Today we talked about how to manage his chronic renal failure (CrCl 20mL/min).  We talked about the benefits and costs of medications, for example using calcium carbonate versus Sevelamer to bind phosphate. We also discussed non-drug measures to help this patient with his chronic renal failure such as quitting smoking, exercising and certain diet restrictions such as limiting protein, salt, fluids and dairy (for phosphate content). Finally, we also discussed weighing the benefits and risks of starting medications in patients with low CrCl and how to calculate appropriate CrCl values based on patient specific values.

See One45.com for objectives

Today’s therapeutic session on depression touched on a number of topics relating to diagnosis, therapy and monitoring of depression. The pre-quiz was very inclusive and created good conversation. Some of the questions we answered included:

What are the 3 phases of depression? Acute (6-12wks), Continuation (4-6mo), Maintenance (1-2 yrs)

What other syndrome has overlapping symptoms with serotonin syndrome? NMS

List 4 possible augmentation strategies: Antipsychotics, Stimulants, Buspirone, T3 etc.

 Objectives/Activities- Understand the importance of communication and the tools used. 

 

- This week’s focus was on the importance of communication. To fulfill this objective I made four charts on antacids, ophthalmic antibiotics & anti-inflammatories and cough & cold. The key purpose of these charts is to use them in the dispensary when a physician orders a product by brand name and the pharmacist is unsure what the product’s ingredients are. These charts are meant to be easy to navigate, to the point and communicate what is really important. 

 

 Therapeutic Interchange Program Antacids

Sessional Objectives

1. To demonstrate the application of knowledge by working through 3 case studies and developing a pharmacy care plan focusing in on pain management.
   1. Information gathering – acquire additional information needed to solve the DRP.
   2. State the DRP accurately and concisely.
   3. Develop desired outcomes or goals of therapy.
   4. Consider options

Make a recommendation that is best for the patient, including a monitoring plan for effectiveness and safety.

In today’s session I learned about how to assess patients for chronic pain using the ABCD not E and F questions (Ask, Behaviour, Characterize, Depression, Function). These questions allow you to determine the type of pain patients have and determine their daily function. We also made a quick chart to make dose adjustments or determine roughly what dose a patient would need when switching opioids. For example Tramadol and Codeine are equivalent at 100mg and morphine is 1/10 at 10mg and oxycodone is 1/2 of this at 5-7.5mg and lastely hydromorphone is about 1/2 of this at 2mg. We also discussed 3 cases with patients with arthritic, neuropathic and nociceptive pain.

Session Objectives

 Goal: To review the pre-session objectives and apply the knowledge and principles learned from the pre-readings in a case format.

Objectives/Activities

1. Review the answers to the pre-session “Take Home Quiz”
2. Answer the therapeutic question – “Should the daily dose of acetaminophen be less than 4g per day?”  (time permitting)
3. Case studies

During this lab session I learned how to interpret lab tests to differentiate between the kinds of liver disease. For example if a patient has a 2:1 ratio of  AST: ALT and an increase in GGT their liver function is most likely due to alcohol use.  I also learned to be more suspicious of patients with many ADR’s. One of our case studies had a patient with many intolerances to pain medications and it turned out she was unable to metabolize many of these drugs because of her liver failure so they were ineffective or caused side effects.  As well, I have already had a chance on 7N to apply this knowledge.  Today one of my patients had a low bilirubin which was attributed to her low RBC’s (bilirubin is a by product of RBC breakdown) and a low albumin (could be caused by protein loss from poor kidney function).

Objective- To familiarize the resident with collection & reporting of laboratory tests that are relevant for the assessment of patients with common infectious diseases caused by bacteria.

This session familiarized me with the lab information available on Power Chart. We discussed 3 ways to determine sensitivity of antibiotics, how to interpret these results and use them to make clinical decisions (eg. Sensitive to Cefazolin includes 1st gen cephalosporins so po cephalexin is ok too).  As well, we discussed 3 cases and determined what types of lab tests would be useful to order for each situation and why they were needed.  For example, one patient had a UTI so a CBC & differential, urinalysis and urine culture was appropriate. In addition, we discussed what was involved to collect suitable lab samples. For example, antibiotics should not be given before the specimen is collected and a blood culture involves 2 sets of blood drawn 10 minutes apart (with each set having samples drawn from different arms).

Objective 2A- Establish a relationship with the patient & other health care providers on the multi-disciplinary team.

Objective 2B- Establish a patient database – Information Gathering

Objective 2C- Drug-related Problems – Identification &  Prioritization

Objective 2D- Solving Drug-related problems – Establish Desired Outcomes, Determine Options, and Recommendation 

This week I gained experience in physical assessments and interview skills. I leared 4 techniques for the physical assessment portion: inspection, palpitation, percussion and ascultation. I practiced these techniques with the other residents on the respiratory, cardiovascular and gastrointestinal systems. I also practiced prioritizing DRP’s and writing SOAP notes based on information gathered in patient interviews (observed one interview in ER and one in Psych). This week, the emphasis was on seeing and interviewing the patient to get the “whole” picture before making recommendations. Finally, another part of direct patient care is working with other health care professionals. This was reviewed through some basic readings and discussions, along with some role playing to practice solving difficult situations.

Upon completion of the Evidence-based practice sessions participants should be able to:

• Formulate answerable clinical questions
• Compose an efficient information search strategy
• Define the terms and statistical parameters used in evidence based practice
• Demonstrate a systematic approach to health science literature evaluation
• Interpret and apply literature evidence to patient specific drug-related problems
• Demonstrate 3 methods whereby computer technology can help pharmacists keep up with new health sciences literature
• Understand the issues surrounding conflict of interest and the pharmaceutical industry

Hilary PICO Presentation