Reflections – General Medicine

I can’t believe how quickly this rotation flew by! I’m very fortunate to have been able to work with such a supportive preceptor and health care team at the Short Stay Medical Unit (SSMU).

These were my objectives for this rotation:

  1. Develop and strengthen my systematic approach to assess and work up patients
  2. Develop my ability to clearly and concisely document my soap notes and important patient interactions
  3. Develop my ability to effectively perform therapeutic drug monitoring on medications such as vancomycin, aminoglycosides, digoxin and anticoagulation
  4. Develop my ability to practice antimicrobial stewardship (e.g. assessing when therapy can be narrowed, for IV to PO stepdown)

During this rotation, my preceptor helped to build on my approach and when I presented on my patients, he would help map it all out on the whiteboard. This made it easier for me to view my patient as a whole and connect their medications to their indications and medical conditions. The importance of matching medications to medical conditions, vice versa was emphasized with this rotation. Additionally, I feel that I was able to improve on my documentation, especially on my soap notes for therapeutic drug monitoring (e.g. for vancomycin). Unfortunately, I was not able to get much experience with monitoring of digoxin or aminoglycosides. I was able to see various patients with pneumonia, and had more experience assessing for narrowing of therapy and IV to PO stepdown.

C3.2 R5: Reconcile a patient’s medications on DISCHARGE #2

ID: VT is a 60 yo male admitted with carbamazepine-induced SIADH

Prior to admission, his P’net stated that he was on:

  • Ketotifen 1mg PO HS
    Patient unaware of indication or medication
  • Ramipril 10mg PO daily
    For high blood pressure control
  • Tamsulosin 0.4mg ER daily x 7 days
    For benign prostatic hypertrophy 
  • Carbamazepine 400mg PO twice daily
    For tonic clonic seizures

Upon discharge from the hospital, reconciled his medications and went over the following medications, side effects and overall plan, etc.:

I. Medications PTA that have been stopped:

  • Ketotifen 1mg PO HS
    No clear indication or need for medication
  • Tamsulosin 0.4mg ER daily
    Received a TURP during hospital admission 

II. Medications PTA that have been continued with no changes:

  • Carbamazepine 400mg PO twice daily
    Plan is to cross-taper carbamazepine with levetiracetam as an out-patient with the seizure clinic. Emphasized the need to continue carbamazepine while waiting for an appointment

III. Medications PTA that have been continued with changes:

  • Ramipril 10mg PO daily

IV. Medications that are new start in hospital

  • Levetiracetam 500mg PO twice daily

V. Medication Adherence

  • Importance of going to his community pharmacy as soon as possible to get his medications filled
  • Counsel to follow up and visit his family physician as soon as possible


C3.2 R5: Reconcile a patient’s medications on DISCHARGE

ID: WA is a 65 yo male admitted with anascara and stage 5 CKD
(same patient as:

Upon discharge from the hospital, reconciled his medications and went over the following medications, side effects and overall plan, etc.:

I. Medications PTA that have been stopped:

  • Hydralazine 25mg PO TID
  • Metoprolol 25mg PO BID
  • Digoxin 62.5mcg PO daily

Plan is for heart failure therapy to be reassessed as an out-patient by the heart function clinic and renal dialysis clinic (new start to hemodialysis in the hospital).

II. Medications PTA that have been continued with no changes:

  • None

III. Medications PTA that have been continued with changes:

  • Furosemide 40mg PO daily has been increased to 80mg PO BID

IV. Medications that are new start in hospital

  • Calcium carbonate 1250mg (elemental calcium: 500mg) PO TID with food
  • Replavite – 1 tablet PO once daily
  • Insulin glargine – 12 units SC at bedtime

Plan is for diabetic therapy to be reassess as an out-patient by the diabetic clinic. Concerns with discharging patient on regular insulin due to regimen complexicity. 

V. Medication Adherence

  • Emphasized importance of medication compliance even when patient is feeling asymptomatic
  • OT assessed need for blister pack – discussed blister packs and the value of using them. Patient OK with discharge prescription stating blister packing.
  • Advised to follow up with family physician as soon as possible and to bring medication calendar to his general physician and all new clinic visits


C3.2 R5: Reconcile a patient’s medications on ADMISSION #2

ID: WA is a 65 yo male admitted with anascara and stage 5 CKD

Confirmed: NKDA

Adverse drug reactions:

  • Sample medication (unable to verify) for volume overload from his physician.
    • ADR: “water blisters” and shingle-like reactions on both of his feet

According to Pharmanet, his most recent refills were in Jan, 2016. When going through the medications, gathered information as to his understanding, efficacy and safety of his medications

  • Hydralazine 25mg – 1 tablet PO TID
    Started around October 2015 at twice daily. Had light-headedness and dizziness, especially when moving around
  • Furosemide 40mg – 1 tablet PO once daily
    Stopped temporarily by self as he did not notice any swelling. Restarted it about a month PTA as he noticed increased swelling.
  • Digoxin 62.5 mcg – 1 tablet once daily
    Ran out of refills but not stopped by doctor.
  • Metoprolol 25mg – 1 tablet twice daily
    SEs: dreams and nightmares at night infrequently. They are disruptive to his sleep, but tolerable. Stopped temporarily by self as felt asymptomatic but also restarted it about a month PTA.

Additional medications:

  • Vitamin D 1000 IU once daily – recommended by dietician PTA
  • Acetaminophen as needed for pain
  • Ibuprofen as needed for pain, when pain is not received with acetaminophen
    • Advised and explained to patient about avoiding NSAIDs due to his CHF and CKD

Barriers to medication adherence:

  • Finds it difficult to get appointment from doctor to get refills
  • ?Understanding of his medications and indications


C3.2 R5: Submit an ADR report to appropriate authority

Submitted an ADR report through the Fraser Health Intranet


  • Click on PSLS on FH intranet
  • Click “Enter a Safety Report”
  • Report “Adverse Drug Reaction”
  • Updated ADR on Medi-tech and Medi-net


Adverse Drug Reaction: Euglycemic DKA and fungal UTI

Suspected Medication: Canagliflozin 300mg PO once daily (has been on it x 1 year)

  • s/s: progressive nausea, vomiting, tachycardic
  • At time of admission: anion gap metabolic acidosis with bicarbonate of 11, anion gap of 13, pH of 7.14 and CO2 of 23 on VBG.  capillary blood glucose was 12.7.  Beta hydroxybutyrate at 6.6
  • Normal lactate in the context of metformin use at 1.8.
  • Blood glucose ranged from 6 to 10 during hospital stay (Sept 9 to 12)

Treatment of reaction:

  • Invokana and Metformin was held on Sept 9, 2016.
  • Insulin IV infusion with potassium supplementation was started for DKA from Sept 9 to Sept 11/16, and was transitioned to insulin sliding scale for remainder of stay.
  • On Sept 10/16, patient looks well and on Sept 12, 2016, he feels near normal.
  • Upon discharge on Sept 13, despite being asymptomatic, beta-hydroxybutyrate is still elevated at 0.7
  • His fungal urinary tract infection was treated with fluconazole 200mg daily for 14 day (as out-patient)

Patient Info:
Other Medications he was on:

  • Clarithromycin 500mg by mouth twice daily for presumed tonsilitis (Filled Sept 6 for 10 days)
  • Metformin 1000mg by mouth twice daily
  • Tramadol 37.5mg/Acetaminophen 325mg – 1 to 2 tablets by mouth every 6 hours as needed
  • Acetaminophen 650mg – 2 tablets twice daily
  • Vitamin D and Vitamin B12


Relevant history and pre-existing medical conditions:

  • T2DM since 2010 (HbA1c 6.8% on Sept 11/2016)
  • Not a smoker, No alcohol


C3.2 R4(c): Clarify a medication order with a prescriber #2

ID: TAS is a 37 yo male (wt = 134 kg) admitted with PE and DVT

  • Currently bridging from IV heparin to warfarin for PE/DVT Treatment
  • Original order was for: warfarin 10mg PO once daily x 3 days

Patient’s labs are as follows:

Aug 31 Sept 1 Sept 2
INR 1.0 1.0 1.8
Warfarin 10mg 10mg

On Sept 2, there was a 0.8 jump in INR. Based on the half-lives of clotting factors, the increase by 0.8 is likely due to the peak effect of 1st 10mg dose. Generally, when there is an increase greater than 0.5, we could consider withholding or decreasing the dose.  If the 3rd 10mg dose is administered, the INR may exceed our therapeutic range of 2-3.

Clarified with the prescriber if she would like to decrease or withhold the dose.

Order written:

  1. Please discontinue previous warfarin order.
  2. Warfarin 2mg PO x 1 dose today – MD to reassess tomorrow.

FYI: Follow up

Sept 3 Sept 4
INR 1.6 1.9 2.2
Warfarin 8mg 8mg


C3.2 R4(c): Clarify a medication order with a prescriber

ID: DMP is a 57 yo female admitted with DKA, secondary to stopping her diabetic medications 6 months ago

She was treated with an IV insulin infusion which was discontinued yesterday. At that time, she was put on insulin glargine 14 units SC once daily, insulin sliding scale and re-started on metformin 1000mg PO twice daily. She went back into DKA and her IV insulin infusion was re-started later that day.

Clarified with prescriber if he wanted to hold insulin glargine 14 units SC once daily, insulin sliding scale and metformin while patient was on infusion. Prescriber confirmed that he wanted to hold metformin and insulin sliding scale, but not insulin glargine. (Some evidence that if putting a patient on basal insulin while on insulin infusion can increase success of them getting off insulin infusion. Since patient has already failed to come off insulin infusion, he wanted to leave the glargine on).

Pharmacy Clarification Order:

  1. Hold Metformin PO while on insulin infusion
  2. Continue with Lantus as ordered.

C3.1 R4(e): Perform & document a vancomycin or aminoglycoside pharmacokinetic interpretation

Sept 6: Dosing

ID: AIA is a 30 yo female [163cm (5 feet 4 inches), 66.3 kg] admitted on for meningitis (Listeria).

ID consult – orders to:

  • Discontinue dexamethasone, acyclovir, ceftriaxone and vancomycin
  • Continue Ampicillin 2g IV Q4H x 20 days
  • Start Gentamicin 100mg IV Q8H x 5 days – Pharmacy to dose

4 day history of severe headache, neck pain, diffuse myalgias, multiple episodes of emesis throughout the day, mild sore throat and rhinorrhea.
x cough x photophobia x fevers/chills

Sept 6/2016
Vitals: Temp 36.4,  BP 98/59,  HR 69,  RR 18,  O2Sats 98% RA

↓ WBC (Sept 5: 11.1 → Sept 6: 9.5)
eGFR: >120mL/min/1.73m2 (stable)
↓ sCr: (Sept 4: 49  → Sept 5: 40 → Sept 6: 35)
Calculated CrCl (CG): 217.46 mL/min


  • 02/09: Lumbar puncture – CSF: No growth
    CSF WBC: 471 (H), Cloudy appearance (Tubes 1+2), CSF RBC 12(H), Neutrophils 6%, Glucose 2.5 (N), LDH 31 (H), Total Protein 2559 (H)
  • 02/09: Lumbar puncture – CSF: Viral Cx, Fungal Cx, Mycobacterial Cx Pending
  • 03/09: Blood Cx: No growth after 48 hours incubation
  • 04/09: Lumbar puncture – CSF: Pending
  • Sent cultures off-site for PCR: Listeria Meningitis


  1. Is this drug indicated?: Yes
    IDSA 2004 Guidelines: Aminoglycosides could be considered in addition to Ampicillin or Penicillin G for Listeria monocytogenes
    Sanford’s: Listeria meningitis: Ampicillin 2gm IV Q4H + gentamicin 2mg/kg IV loading dose then 1.7mg/kg IV Q8H
    Treat for 21 days.
    ID consult – determined that gentamicin should be added on for synergy
  2. Is the dose appropriate?: Yes
    Usual conventional dose is 1-2mg/kg/dose every 8 hours (5mg/kg/day divided every 8 hours falls under this range). Sanford’s provides a dose of LD of 2mg/kg IV then 1.7mg/kg IV Q8H.
    LD determined to be unnecessary by ID.
    ? Duration of 5 days for synergy
  3. Is the dosing interval appropriate?: Yes
    based on sCr and age, every 8 hours is appropriate

IBW (kg) = 45kg + (2.3*4) = 54.2 kg
DBW (kg) = IBW + 0.4*(66.3-54.2) = 59.04kg
ABW is 22% greater (<25%) than IBW → use IBW to calculate dose (if >25%, use DBW)

5mg/kg/day * 54.2kg = 271mg/day → ~90mg IV Q8H

  • Gentamicin is available as 40 mg/mL solution (80 mg/2 mL vial) and premixed minibag (60 mg/50 mL NS, 80 mg/50 mL NS, 100 mg/100 mL NS, 120 mg/100 mL NS)
    ∴ ↑ to 100mg IV Q8H

100mg IV Q8H

  • Falls within 1-2mg/kg IV Q8H conventional dose (54.2-108.4mg IV)

P: As discussed with MD,

  1. Gentamicin 100mg IV Q8H x 5 days (1st dose given at 1715)
    ∴ dosing times – 1715, 0115, 0915
  2. Gentamicin Peak Concentration  (Target: 8-10 mg/L for meningitis)
    – 30 mins post 30 min infusion of 0915 dose (3rd dose)
  3. Gentamicin Trough Concentration (Target: 1-1.2mg/L for synergy)
    – 30 mins prior to 1715 dose (4th dose)

Dosing times slightly changed and 2nd, 3rd doses wer given at 0030 and 700


  1. Please change gentamicin dosing times to 700, 1500, 2300
  2. Gentamicin peak concentration at 1600 today (30 mins after the 30 min infusion ends)
  3. Gentamicin trough concentration at 2300 today (30 mins before the 2300 dose)

Sept 8:

Vitals: Temp 36.4, BP 101/65, HR 69, RR 18, O2Sats: 97% RA (stable)

WBC (Sept 7: 9.5 → Sept 8: 9.1)
↑ sCr (Sept 7: 42 → Sept 8: 56)
Calculated CrCl (CG): 135.91 mL/min


  • 07/09: Lumbar Puncture – Preliminary: No Growth
    CSF WBC: 293 (H) ↓, Appearance Clear/Colourless (on all tubes), CSF Glucose 4.7 (H), Total Protein: 213 (N)


  • Gentamicin Peak: 4.9 mg/L
  • Gentamicin Trough: < 0.5 mg/L


  1. Is this drug indicated?: Yes
    See above.
  2. Is the dose appropriate?: Yes
    See above.
  3. Is the dosing interval appropriate?: Yes
    Stable renal function, Q8H still appropriate
  4. Are all the doses given on time?: Yes
  5. Was the level drawn at steady state?: Yes
  6. How is the patient doing?:
    Overall, patient is clinically improving on his antibiotic therapy.
  7. Any side effects?: Renal function is stable. No changes in hearing.

As her lumbar puncture has significantly improved, her gentamicin therapy will only be continued until discharge (likely only 3 days therapy total). Another serum drug concentration is not required.

Resources for AG:


C3.1 R4(e): Perform & document a vancomycin or aminoglycoside pharmacokinetic interpretation

ID: 42 yo female admitted for query septic arthritis/deep tissue infection/myositis

Current Abx Therapy:

  1. Pip/Taz 3.375mg IV Q6H
  2. Vancomycin 2g IV Loading Dose x 1 dose on August 31 1530
    Currently on 1g IV Q12H (at 330, 1530)

Vital Signs (Sept 2/16): Temp 37.4, BP 119/79, HR 99, RR 18, O2 sats 95% RA
(receives APAP PRN for pain)

↓ WBC (Aug 31: 22.2 –> Sept 2: 10.5)
↓ sCr (Aug 31: 98 –> Sept 2: 45)
↑ eGFR (Aug 31: 62 –> Sept 2: 118)

Micro: MRSA screen pending. Blood Cxs on Aug 31/16 are negative.
Urine Cxs + For E. Coli 90 mega CFU/L

Vanco trough level: 6.2 mg/L (target 15-20mg/L)
– drawn 30 mins prior to Sept 2 330 dose (4th dose, including LD)


  1. Is the drug indicated?: Although patient is improving (decreased WBC, afebrile, improving overall) and is tolerating vancomycin (urinating well, no compliants, sCr stable), cultures are still pending.
  2. Were all the doses given on time?: All doses were given on time
  3. Was the level drawn at steady state?: Trough level was at steady state (pre-4th dose)
  4. Was the level drawn appropriately?: Level was drawn appropriately 30 mins prior to the 4th dose
  5. Assess the level: Vanco trough level = 6.2, which is below target

P: As discussed with MD:

  1. Discontinue previous vancomycin IV orders.
  2. Increase vancomycin to 1.25g IV Q8H – next dose due at 1530 today
  3. Vancomycin level on Sept 3 at 1500 (30 mins prior to 1530 dose)
  4. Will continue to monitor: renal function, temperature, pain/swelling, WBC, CRP
  5. Pharmacy will continue to follow and adjust dose accordingly. MD to reassess need for vancomycin.

Rationale for vancomycin 1.25g IV Q8H:

  • Improving renal function requires increased frequency (Q8H) to ensure concentrations stay above vancomycin’s MIC
  • Following linear pharmacokinetics:
    • Would expect that we would need to target a daily dose of ~5500mg
      (~1800g IV Q8H)
  • Although we want to ideally target 15-20mg/L, the benefits of ~doubling the dose to target 15-20mg/L likely won’t outweigh the risks (e.g. risk of accumulation
    → increased risk of nephrotoxicity and ototoxicity) when the patient is already improving at a significantly sub-therapeutic level.
  • Therefore: ↑ dosing frequency and ↑ the dose by 250mg (minimum dosing increment)
  • Keeping in mind: patient improving at sub-therapeutic level may indicate that patient is improving on other antibiotic therapy and that coverage against MRSA may not be warranted. Pharmacy should follow up with MRSA screen.