Wednesday, April 19, 2006

DoRo

Day 19:

When rounding, medical students are expected to present their patients' status to the rest of the team in a relatively formal manner, running through all the important details of a particular case (e.g., a patient's subjective complaints, the history of his present illness, pertinent lab values, your physical exam findings, assessment, plan, etc.). If you know your patient well and don't fumble the delivery of said information, you come out of presenting a patient feeling pretty good. But the fear of screwing up, at least for me, always causes a slight adrenaline rush just prior to the attending physician calling out, "Who has room 215?"

This morning I was presenting a patient I admitted the previous day, a 41 year old African American male with a one-day history of hemoptysis (coughing up blood), shortness of breath, left sided flank pain, and significant crackles in the left lower lobe of his lungs. His past medical history was significant for AIDS, coronary artery disease, myocardial infarction, deep vein thrombosis, and a host of other ailments. A fairly fit-looking guy, he appeared ten years younger than he actually was, and his demeanor suggested a youthful spirit still resided within his body.

So when I began presenting this gentleman's case earlier today, I felt like I was nailing all the particulars pretty well; when the attending physician asked what his lipid levels were, I had the ones drawn from last November ready. The supervising resident threw a couple softball questions my way, and I swatted them down with no problem too. But out of the corner of my eye throughout this whole process, I could see Dr. K, our Pharm.D., just waiting to pounce with a question of her own. And sure enough, just as I thought I had made it into the clear, she probed, "What antibiotic is he on right now?" Phew, easy question, I thought. I told her we had started him on Levofloxacin 500 mg. Then she posed the follow-up: "And what effect should you be concerned about with this patient regarding his dose of Levaquin, given that he's also on Coumadin? Surely you remember from pharm?"

Hmmm... no, I surely didn't. I ventured a guess about the cytochrome P450 system, at the same time (correctly) thinking that wasn't what she was looking for. She gently pointed this out, and went on to talk about the effect this particular drug interaction can have on a patient's INR (his was therapeutic at 2.78, but after a three-day course of the antibiotic, it might double, she said, launching into a discussion of vitamin K metabolism, anti-coagulation factors, and so forth). "Just something to be aware of," she finished.

Not quite "pimping," by any stretch, but man, I wish I could have gotten that question right. Impetus to hit the books, I suppose.

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