Sunday, November 11, 2012

Rotation #5: Generalist (Adult)

Posted by Kristen Gardner at Sunday, November 11, 2012

I just completed my 5 weeks of the general medicine rotation at UMHS. LOVED it! I strongly believe in the decision by the Experiential Training Office to have this be a mandatory rotation for all students for the following reasons: 

1. It allows you to focus on core clinical services: pharmacokinetics, renal dose adjustments, anticoagulation, appropriate antibiotic use, anticoagulation education, and TPN (although this is just picking up in the adult generalist side).

2. It challenges students to handle a high patient load of ~30 patients daily which is nothing considering the generalists cover at least twice that number.

3. You get very familiar with the computer systems used and navigating your resources available. And you learn the documentation procedures.

4. I liked interacting with so many pharmacists and gaining their perspective on a number of things. You have your primary preceptor but other one cover for them and join your talks and are available to answer your questions if needed.

I do not want to reiterate what other students have said about this rotation as their descriptions were very good. So some specifics- I know we all like details! My journal club/topic discussion was on Stribild, a new HIV treatment, and review of HIV/AIDS management. I also delivered a patient case presentation on a patient dx with a pulmonary mold infection, Aspergillus fumigatus, and worsening of heart failure in the context of numerous other complications per normal given we are at UMHS. The preceptors led various topic discussions such as IVIG, geriatrics, pain, C. diff, and infectious disease which were useful.

What I did to stay organized

1. I printed off the patient overview from theradoc (not sure what this is technically called) to have a basic reference of lab values, meds, cx, crcl, age, allergies, etc. I would NOT print one out for every patient daily- just every time a new patient was admitted.

2. I printed off the theradoc roster of patients for each team for which I was responsible. I would write in a few phrases for why the patient was there to help me remember all 30+ patients! I would also write what I wanted to follow (BP, renal function, glucose, Cx (UCx, BCx, etc), pain med use, etc depending on high priority problems and therapy the patient was receiving. On the left side column I would write what my recommendations were or what I wanted to discuss with the attending (for non-rounding services) or the medical team (for rounding services). I would use the bottom to remind myself of what I need to follow-up on before leaving for the day or to keep track of doses given in the case of pharmacokinetic monitoring or pain regimens.

3. I would complete as much documentation as I could as I was going through and working up patients. Documentation includes, new starts, education, and summaries for anticoagulation, goal troughs for vanco, IV vanco/aminoglycoside follow-up, adding/deleting new flags from theradoc, reasons for using restricted antibiotics, pharmacokinetics, heparin drip follow-up, etc.

Common Interventions

1. specific therapy for infections

2. IV --> po switch for antibiotic regimens

3. Metabolic monitoring for patients on antipsychotics

4. Renal dose adjustments

5. Optimizing antibiotic regimens (ABW, frequency)

6. Citalopram --> lexpro switch for elderly patients on high dose citalopram + EKG > 500 + omeprazole 20-40 daily or BID

7. Optimizing pain regimens and adding therapy to prevent constipation

8. Reducing unnecessary use of IV meds

9. Warfarin dosing and scheduling

10. Optimizing enoxaparin dosing

11. Restarting anticoagulation after procedures

I hope you all enjoy this rotation! 

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