First clinical rotation complete!! The CTU was awesome, the medical team was receptive, and the St. Paul’s pharmacists were welcoming of us residents. Although the intent of the rotation was to keep it focused on developing a process and not so much delving into therapeutics, I found myself learning a lot through working up various patients. Already by the end of the rotation, I felt like I was just hitting my stride in information gathering, and have begun to crystallize a process in formulating plans. What I still need to work on overall is creating concrete and executable plans for all the medical problems that my patient has, although prioritizing them has not been a challenge as of yet. So, how did I do on my goals?
Goal #1: Holistically incorporate radiographic findings and be able to apply them to rationalize diagnoses to better develop a pharmacotherapeutic plan – I believe I have met this goal. I did look up any terms I did not understand, and used reasoning from a diagnostic test (a CXR) to rationalize that what I was seeing (in one of my patients who had CHFpEF and a query pneumonia) was more likely a pneumonia and as such should be treated based on those findings and her symptoms. This helped me better understand the medical team’s plan.
Goal #2: Become proficient at performing medication reconciliation, and proactively take action to resolve any discrepancies – During this rotation I did not get to take part in an observed medication history. However, given the characteristics of some of my patients, whether there is a language barrier, or medical literacy was low (so they did not know what they took/why they take medications/how often each medication is taken), or uncooperative patients, I became better at taking focused medication histories for the information that I most urgently needed. One example was planning a discharge for a patient who took various traditional Chinese herbal products. This patient was also on warfarin, so I had to take a quick history of her NHPs and determine if any of them interacted with it. In my future rotations, I look forward to being involved with reconciling medication histories alongside the physicians.
Goal #3: Be able to work up a relatively simple patient (<6 medical conditions) in under 3 hours – I don’t think there was a patient that I had who had <6 medical conditions during Clinical Orientation! Such is the life in CTU. However, I found that with each subsequent workup, I became more efficient in gathering pertinent data. I look forward to working on my efficiency further and being more efficient in getting up to speed on medical conditions that I may not have seen before. I did keep therapeutics notes in a notebook and wrote down things I may need to unpack later.
All in all, it was an enriching rotation and I look forward to continuing to build and refine my process.
When to NOT bridge warfarin with LMWH following a procedure (low risk)
– Laprascopic surgery
– Dermatologic procedures
– Ophthalmologic procedures
– Bone marrow aspirate and biopsy, lumbar punctures
CSF findings that would raise suspicion of viral encephalitis (not meningitis)
– Increased WBC but <250/mL
– Increased protein but <150 mg/dL
– Normal glucose (decreased with herpes simplex)
– RBC usually absent, but positive in HSV-1 or if contaminants present
Gram-negative bacilli may be divided into fermenters and non-fermenters.
Fermenters can be found in GI/GU: E. coli, Proteus mirabilis, Klebsiella spp.
Non-fermenters (skin, resp, GU): Pseudomonas aeruginosa, Acinetobacter spp., Legionella pneumophila
Acinetobacter susceptibilities follow Pseudomonas susceptibilities closely!
And while I’m at it..
– Neisseria gonorrhoeae
– Neisseria meningitidis
– Moraxella catarrhalis
– Haemophilus influenzae
Some causes of an elevated lactate include:
– Decreased renal function
– Comorbid liver disease
– Decreased tissue perfusion, hemodynamic instability (like sepsis)
– Active alcohol abuse
– Decompensated HF
– Hypoxic state
Myelodysplastic syndromes – risk and prognosis measured by DIPSS score, taking into account (one point each): age >65 yo, leukocytes >25, Plts <100, required transfusion, circulating blasts 1% or above, unfavourable karyotype, fever/sweats/wt loss preceding Dx. High risk DIPSS is for a score of 3 or above.
– DIPSS factors into decision making for drug therapy. High risk = allogenic HCT is favoured. Low risk = symptomatic care such as DNA hypomethylating agents, transfusion, G-CSF, or darbepoeitin may be favoured.
– Iron chelation therapy post-transfusion initiated if ferritin is constantly elevated >1000, AND pt is stable (no comorbid infections), DIPSS low risk (0-1) may favour iron chelation.
Looking forward to my first foray into patient care this residency year. I will be working with Dr. Michael Legal and I will be paired up with my fellow resident, Puneet (follow the link to his blog!). I hope that I will develop somewhat of a foundation to tackle my next clinical rotation, which is oncology…and should be a steeeeeep learning curve indeed.
Goal #1: Holistically incorporate radiographic findings and be able to apply them to rationalize diagnoses to better develop a pharmacotherapeutic plan.
Objectives to meet this goal:
– Look up any words that do not make sense on a dictated interpretation of any radiographic investigations
– Present any radiographic findings as: what was found, and why that points towards a diagnosis (or why not)
Goal #2: Become proficient at performing medication reconciliation, and proactively take action to resolve any discrepancies.
Objectives to meet this goal:
– Obtain a relatively simple BPMH (5-10 medications +/- 1-2 OTCs) in under 10 minutes
– Be able to rationalize to my preceptor any action to resolve discrepancies
– Be able to write a succinct (<1 page) clinical note in the patient record on a MedRec clarification
Goal #3: Be able to work up a relatively simple patient (<6 medical conditions) in under 3 hours.
Objectives to meet this goal:
– Develop a flow to gathering information, starting with the chief complaint and HPI first
– By the end of the rotation, develop my personal workup sheet for further clinical rotations
– Continue to keep a notebook outlining conditions I do not know and to be transcribed to electronic form later (repetition solidifies knowledge for me!)
Goal 1 was borne out of a weakness that I found during my hospital rotation in undergrad based on feedback I received, and goals 2 and 3 were due to them being necessary competencies I must carry forward in my residency training. I look forward to starting my clinical rotations!