Goals and Objectives: Psychiatry rotation

Goal #1: Become more competent with history taking and information gathering from the psychiatric patient. Objectives to meet this goal:
– Know what information MUST be gathered, and distinguish it from information that is nice to have
– Further develop skills in rapidly establishing rapport with patients

Goal #2: Be able to recognize and adequately treat extrapyramidal symptoms in the psychiatric patient and be able to rationalize it as pharmacotherapy-caused, rather than from other etiologies. Objectives to meet this goal:
– Achieve goal #1
– Learn how to perform an AIMS assessment in under 10 minutes
– Know other etiologies of movement disorders that are unrelated to pharmacotherapy

Goal #3: Be aware of non-psychiatric considerations for the psychiatric patient receiving pharmacotherapy, and be vigilant of those in the non-psychiatric setting. Objectives to meet this goal:
– Formulate a robust monitoring plan for each patient receiving 2nd/”3rd” generation antipsychotics
– Endeavour to obtain baseline LFTs, ECG, A1c, lipid panel, waist circumference in patients receiving these medications
– Provide patient education to those with insight and judgement into their illness


Reflections on Ambulatory Cardiology

Goal #1: Hone my history-taking skills in a clinic-type environment where access to the paper chart may be limited or non-existent – I think I achieved this. I tried my best to obtain information from previous admissions and clinic visits, but sometimes, a robust symptom and medication history proved to be helpful in deciding further drug therapy. Such as in the case of the patient I had for my 2nd BPMH – a history helped determine that a re-trial of an old medication was the best way forward for her.

Goal #2: Gain a better understanding of practice differences between the acute care setting and the ambulatory care setting. – I think I was kind of surprised as to how, despite the collaborative environment, one has to be self-sufficient in this setting. In terms of info gathering and history taking, it was a different approach. I had to go in and gather pertinent information that, in that moment, could direct future drug therapy.

Goal #3: Be focused on providing patient-specific recommendations and alternatives, in situations where the available evidence is unclear – I was surprised in this setting that there is a LOT of grey. Sometimes what will determine what is the “evidence-based” recommendation is what the patient has tried – an “n = 1” of sorts. Anticoagulation peri-ablation was also a controversial area of practice. Now that the ablation has taken care of the afib (hopefully)…does the patient still need Eliquis for life?

C3.2 R5: Perform and document a “Best Possible Medication History (BPMH)” (#2)

For this BPMH, this was an unfortunate 64 year old woman who previously had tried propafenone pill-in-the-pocket and sotalol up to 120 mg PO BID for a rhythm control strategy in atrial fibrillation, with concurrent metoprolol for rate control (had symptomatic recurrences up to 1-2x a week). She was recently switched to flecainide 75 mg BID + diltiazem 120 mg BID a week ago. She felt extremely unwell, nauseous, and faint and went into Emergency, where she was found to be in Afib with RVR. She had an overnight stay in hospital and was discharged on different medications. She reported to the A-fib clinic the following week for an expedited follow-up. On Pharmanet it showed all 3 antiarrhythmic medications she has tried, plus a couple of rate control agents. I took a BPMH from her in person and gathered that she was taking:
– Apixaban 5 mg BID for stroke prophylaxis (she was almost 65, shared decision between care provider and patient to anticoagulate)
– Metoprolol 50 mg BID for rate control
– Levothyroxine 75 mcg daily for post-thyroidectomy hypothyroidism
– Estrogel 1 pump applied every other day + Prometrium 100 mg QHS for menopausal symptoms
– Avamys nasal spray 1 spray daily PRN into each nostril

I garnered from patient interview that she had tolerated the sotalol best, and had the least recurrences (1-2x a month) while on it. She had tried metoprolol alone in the past for rate control which was ineffective. Her ECG in clinic showed she was in sinus rhythm and her ventricular rate was 82, and her BP was 146/73 (higher than usual measurements at home). From this information I presented my recommendation to the electrophysiologist to restart her on sotalol 80 mg BID and discontinue metoprolol (as sotalol at lower doses displays more beta-blocking activity – higher doses >80 mg BID is where class III antiarrhythmic activity kicks in). The patient was amenable to this plan as well as she wanted to avoid side effects at the expense of experiencing AFib episodes 1-2x a month.

ADS – Parenteral and Enteral Nutrition

One of the scenarios that I found myself scratching my head over the past few months on rotation is this: what are the pharmaceutical implications for a patient receiving TPN or enteral nutrition (EN)? Does it matter? Is there a difference? Do we need to care, as pharmacists?

Spoiler alert – Yes, we do. 

Some take-home points:
– Don’t overcomplicate. TPN = EN except by delivery system
– There are tons of different kinds of tubes depending on entrance and exit points. For pharmacists, we just have to make sure it goes down the thicker lumen
– 25 kcal/kg total calories –> divide 50% carbs, 30% fat, 20% protein
– Carbs and protein roughly are 4 kcal/g; fat is 10 kcal/g
– The commercially available MVI and Micro +6 concentrate will do the job for vitamins and minerals
– As a pharmacist, for a clogged EN tube, you can save the day by recommending Cotazym (make sure it’s NOT enteric-coated – 1 capsule should do it given through the tube), but you should give it ASAP before the clogged stuff becomes hard rock!
– A lot of things such as nausea, vomiting, constipation are blamed on the tube. Do not succumb to this temptation, and reassess for other causes (medical conditions, MEDICATIONS, procedures)

ADS – Antifungal Review

This was an imposing topic with lots to cover – it’s great that there weren’t any pictures of Mucor spp. infections – not for the weak of stomach!

In a way, I find mycoses therapeutics to be more straightforward than bacterial infection therapeutics – however, monitoring is more complex with the antifungals, what with therapeutic drug monitoring added to the mix. It was helpful for me to review the risk factors associated with invasive candidiasis, as empiric fluconazole is started on some patients destined for ICU, but it’s always a judgement call whether empiric antifungal coverage is warranted.

Overall, it was a good overview of antifungal susceptibilities and empiric treatment – I had certainly forgotten some of them since undergrad (and I had barely seen any fungal infections during my time on the AMS service).

ADS – Delirium

Delirium is linked with higher mortality, and delirium can complicate a patient’s stay. I had encountered delirium a few times before on rotation, and I remember one previous resident’s project was comparing prescribing practices between first-gen antipsychotics and second-gen antipsychotics for delirium on a general medicine ward. I knew delirium had negative clinical outcomes associated with it (a patient on my CICU rotation was delirious for nearly the entirety of his CICU stay), but what I gained from the ADS was a way of assessing delirium, from hypoactive, hyperactive, and mixed.

More importantly, as is a common refrain during residency – try to find the cause! I look forward to applying these skills when I get out there as a staff pharmacist, and also on my Psychiatry rotation.

ADS – CV Preparation

I have written many a resume before residency. I remember for Science Co-op, sending them out in hopes of catching an employer’s eye. I had heard of the term “curriculum vitae” before but never truly grasped the difference between the two. I am in no ways a seasoned veteran of the professional world, but I couldn’t help saying to myself – why was I not aware of this? It also made me reflect – what would I put on my CV?

What I think was striking was that I thought that a CV was purely academic – however, in a field of similar candidates, maybe it’s the non-academic, non-professional stuff that sets you apart.

I now have a framework by which to form a CV – I’m sure the skills acquired through this seminar will serve me well for future opportunities that may arise in my career.

C3.2 R5: Perform and document a “Best Possible Medication History (BPMH)” (#1)

This was a 61 yo male from out of Vancouver, followed by the A-fib clinic, whom I was following up with regarding refills for his spironolactone and candesartan. Past medical history significant for persistent AF (CHADS2 = 1), CHFrEF, mitral valve replacement (2006), current smoker (2-3 cigs/day), and obstructive sleep apnea.

From Pharmanet —-> verified with patient over the phone:
Warfarin 5 mg tabs filled  —————-> taking 5 mg daily for stroke prophylaxis
Bisoprolol 10 mg daily —> taking 10 mg daily for rate control and HFrEF
Carvedilol 25 mg BID x 14 emergency supply filled 30 days ago ——-> no longer taking, was taking both bisoprolol and carvedilol. Counselled he was correct in taking only bisoprolol as it proved superior for his rate control over carvedilol (from chart).
Candesartan 16 mg AM + 8 mg PM ——-> taking 24 mg PO QAM for HFrEF
Spironolactone 25 mg daily ——–> taking 25 mg daily for HFrEF
Amiodarone 200 mg tabs last filled in Nov 2017 ——–> no longer taking. 

No OTCs/NHPs were taken by the patient. Home BP 120-130/80, HR 75-90 (rate controlled), no dizzy spells, shortness of breath. Able to carry out ADLs on his farm. Refills were provided for candesartan 24 mg PO daily and spironolactone 25 mg PO daily for 3 months from the clinic and faxed to his pharmacy. Conversation was documented on AF clinic records in patient’s chart.

Goals and objectives: Ambulatory Cardiology (Atrial Fibrillation clinic) rotation

More cardiology!

Goal #1: Hone my history-taking skills in a clinic-type environment where access to the paper chart may be limited or non-existent. Objectives to meet this goal:
– Have a robust process to obtain a relevant, focused history pertaining to atrial fibrillation
– Have therapeutic alternatives figured out beforehand to direct questioning of the patient
– Know common adverse reactions to all anti-arrhythmics used in clinic

Goal #2: Gain a better understanding of practice differences between the acute care setting and the ambulatory care setting. No real objectives, just soak it all in and ask tons of questions.

Goal #3: Be focused on providing patient-specific recommendations and alternatives, in situations where the available evidence is unclear. Objectives to meet this goal:
– For the landmark trials for A-fib rate/rhythm control and stroke prophylaxis, don’t just read the latest trial but understand the context in which the newest trials were published.
– Be able to rationalize drug therapy decision-making with both references to the literature, patient-specific factors, and permutations for various alternatives.

Reflections on Cardiology

I could talk about how I met or didn’t meet my goals that I outlined before the rotation…but I feel that this rotation taught me a lot both in the sense of developing one’s knowledge base and also growing as a clinician in general.

What I’m referring to is applying the evidence that you have, even when it’s not the best evidence. Towards the 3rd and 4th week of rotation (it’s always near the end, isn’t it?), I found myself realizing that no matter how many placebo-controlled, n = 10,000, published-in-the-NEJM trials you have – there will always be the daily clinical situation which will make you stop in your tracks and force you to extrapolate to your patient….even when the evidence can’t answer the question you want answered. As pharmacists, I feel like we always want to fit our patients into boxes. “Would he be a HOPE-type patient”, “do we want to COPERNICUS him”, “does PIONEER-AF PCI apply to her”… when it’s really about taking the years and years of context in which the study was done, integrating the new findings, and then making a decision based on the weight of evidence. I felt that at least for the first couple of weeks, I may have strayed away from that. I was so determined to know the trials, know the NNTs, know the inclusion and exclusion criteria, that I lost sight of treating the patient in front of me sometimes.

But that’s okay. I realize it’s all part of clinical development. And I think I’m better off now realizing this and learning from it. Off to the A-fib clinic next week!