It’s Valentine’s Day, time for those three little words…thyroid stimulating hormone! 

Thyroid stimulating hormone (TSH), plays an important role in thyroid function and consequently metabolic function. It is the most common lab measurement ordered to determine thyroid function (and with low thyroid function, where would you get the energy to make dinner for your sweetheart?).

One of my learning goals was to look at diagnostic tests and their role in medication management. Originally I was thinking of diagnostic imaging however the diagnostic value of TSH measurements in acutely ill patients has resurfaced time and time again during my clinical re-orientation. This was especially true in patients previously diagnosed with hypothyroidism.

On your floor, a patient with previously controlled hypothyroidism was admitted through the ER where  a TSH was ordered. The TSH is low however there are no signs or symptoms of clinical hyperthyroidism…at least none that cannot be explained by another mechanism. Do we dose adjust the levothyroxine?

Now, I do not claim to have all the answers to this question but it was helpful for me to create a short write-up and to create a table of how I would approach TSH (and FT4 if available) measurement with what I now know today. This includes patients believed to be euthyroid prior to admission. I would love feedback from others to know how you approach this.


Adverse drug reaction, a ghost of yesterday past…

I was involved in the care of a pleasant, elderly patient with a high number of comorbidities, admitted post-fall with CHF, liver disease with abdominal ascites and hepatic encephalopathy, Afib, leg chronic leg ulcers secondary to venous insufficiency with a historical ADR to furosemide (list incomplete!). She was being treated with an increased dose of metolazone and spironolactone in hospital for ++ abdominal ascites that would not drain mechanically. Her renal function declined below CrClIBW of 30mL/min and spironolactone use was no longer safe in this patient.

Rather that presenting the problem alone (spironolactone was unsafe at CrClIBW < 30mL/min). I was able to investigate the ADR to furosemide in more detail to determine if it was “off the table” as an option for symptom management. The family had expressed the wish to avoid furosemide if alternatives are available but what if there were not? The reported ADR was hearing loss. By talking with the family I discovered she had previously been stabilized on furosemide for 10 years with no adverse reaction. Following an incident of ++ edema three years previously, she was reportedly instructed to increase the dose of furosemide to 4 times her regular amount. In the days following the dose increase, she experienced reversible hearing loss in her left ear. She was admitted to hospital and treated with corticosteroids. Reversible and non-reversible hearing loss/deafness is a side effect of furosemide when administered by IV push or IM. Her husband believes she was taking furosemide 40mg PO daily and her dose increase would have been 160mg (unverified by pharmanet).

Conclusion? It appears that the sudden furosemide dose increase was responsible for the ADR rather than the medication alone. Given that spironolactone is not a safe medication to use with her current renal function, low dose furosemide could be a suitable alternative given it was titrated very slowly with close monitoring of her hearing (in addition to other monitoring parameters). In the end, the acute on chronic kidney injury which related temporally with increased diuretic use improved by decreasing the diuretics to pre-hospital doses. Her journey is not over and there may be a time in the future that furosemide use could be considered.

Take home for my learning: Diagnosis and treatment is often a moving target with co-morbidities complicating drug treatment. This sometimes requires re-evaluation of past therapies.

Two week re-orientation complete!

During my 2 weeks on an acute medicine ward at VGH, I had the opportunity to work with patients with a variety of clinically interesting conditions and pharmaceutical care needs. These included infectious diseases such as an abdominal abscess, urosepsis in patient with hypopituitarism and another with complicated cellulitis of the legs. Multi-organ damage was common in this patient group. One who stood out was admitted post-fall with hepatic encephalopathy, liver disease with abdominal ascites, CHF, atrial fibrillation, leg chronic ulcers secondary to venous insufficiency with a historical ADR to furosemide (yes, this was one patient and I will talk about the ADR in more detail in another post).

Throughout these busy weeks (snow and all!) I was able to meet my rotation specific goals with the assistance of my preceptor. The last week included a mock oral exam which I was able to complete in the 2h time period. More than this, I am excited to be back in the residency. I am thrilled to be involved with the interdisciplinary team again with the patient right where the patient belongs, in the center!

Speaking of organ systems and comorbidities, on to nephrology…

Clinical Re-Orientation

Following an eight-month leave of absence to focus on my health, the Island Health Residency program is accommodating my return. A two-week re-orientation to clinical pharmacy has been planned prior to my final two rotations. I am excited to re-orientate to residency life and I am grateful for the opportunities provided. Since re-orientation to the hospital environment and patient care is the goal, I will be focusing on my midpoint learning goals and objectives relating to the patient work up process. Following an absentee, I will be responsible for successfully completing an oral exam, as I was earlier in my residency. Working towards this and my career as a clinical pharmacist I will focus on my foundation and the following mid-point learning objectives in this re-orientation rotation:


I will consistently develop a thorough, patient specific, pharmaceutical care plan (e.g. within two hours) and be able to effectively communicate this plan both verbally and in writing.

  • Efficiently collect and interpret relevant clinical and laboratory information.
  • Conduct patient interview times (less than 20mins) through the use of efficient, targeted questioning.
  • Create a medical problems list in order of priority.
  • Identify all DTPs and provide recommendations and alternatives for each.
  • Communicate patient clinical status and drug therapy recommendations efficiently to my preceptor and other healthcare professionals.
  • Prioritize patients who would most benefit from a comprehensive work-up.
  • Manage “problem orders” on an acute medical ward.
  • Conduct PK antibiotic assessments on an acute medical ward.
  • Use resources effectively to answer DRPs.
  • Create timed scenarios by week 2 to prepare for the oral assessment.


I will be able to write effective chart notes containing all relevant lab values and pertaining information at an appropriate length.

  • Demonstrate the ability to write concise, descriptive chart notes by the end of this rotation.
  • Communicate comprehensive medication assessments in patient charts.


I cannot predict more than anyone the learning curve ahead of me. I can commit to giving it 110%.

Back on the bike and heading to the ROADs!



Reflecting back on a fabulous 4 weeks of clinical orientation, I hardly believe how far I have come! During this rotation I have begun to develop many foundational skills allowing me to build a ‘patient database’. These include navigating through charts, systematically collecting lab data and relevant information from resources I previously did not realize were available. I had the opportunity to conduct patient interviews, to practice a review of systems (ROS) and write targeted SOAP notes. I have to admit that filtering all of the available information and completing a patient work-up in a 2-hour time frame remains a challenge for me but I am optimistic that this will improve over the course of my residency year.

Clinical orientation allowed me to identify targeted areas for improvement. I am hopeful that practice during my upcoming ambulatory rotation will sharpen my DTP identification skills and improve my ability to rationalize specific recommendations.

Start with the Patient, End with the Patient

In one of my patient interviews physical/visual assessment of the patient was particularly useful. The patient was experiencing a muscle jerking reaction that began in hospital. It appeared to be either an ADR or a reaction to her uncontrolled pain. She had not been receiving any doses of metoclopramide prn, a medication known to cause EPS in some patients, and the reaction appeared to be either pain related or potentially an opioid induced myoclonus. After speaking with the physician, we decided that her pain needed to be controlled but with a different drug. The hydromorphone CR was switched to a fentanyl patch with break through hydromorphone doses to be reassessed. I look forward to following up with this patient to assess the efficacy and safety of my recommendations.

Through this experience, I was able to work with the physician to tailor drug therapy for this patient and provide valuable information as a clinical pharmacist. I further realized that as part of an interdisciplinary team, my assessments and recommendation are valued and expected by other members of the team.

Update: Patient is doing well and was up for physio. Pain is under control (4-5/10 was her tolerable pain level) and the myoclonus, drowsiness and sedation have resolved.

Clinical Orientation

As I complete my second week of clinical orientation I have been able to apply the didactic instruction and modeling from week one to my first few patient work-ups. These lessons included comprehensive information gathering to create a patient database, patient interviewing skills and physical assessment. The logical head to toe manner gave me a template and facilitated the beginning of creating my own process of patient information gathering and assessment.

The need to quickly and systematically collect data was reinforced given the large volume of patients and their daily change in acuity. Now that I have been through this process, my goal for the next two weeks of clinical orientation is to continue to develop my skills and to complete patient work-ups in 2 hrs. This will help prepare me before my mock oral exam at the end of clinical orientation and for my internal medicine rotation.