Internal Medicine Rotation

Preceptors Contact Information:

Karishma Deodhar, PharmD, BCPS Phone: 317.880.9539

Clinical Pharmacy Specialist- Internal Medicine Cell: 847.840.7343
Email: karishma.deodhar@eskenazihealth.edu

PGY1 Resident: Maha Muzaffar, PharmD Cell: 317.448.8858

Email: maha.muzaffar@eskenazihealth.edu

Rotation Description:

Clinical pharmacy services with an inpatient general medicine service. Daily activities will include
participating in medicine team rounds, medication reconciliation, patient education, pharmacokinetics,
topic and patient discussions, and interactions with other health care professionals. The application of
therapeutic principles and pharmacokinetics, as well as problem identification and solving,
documentation, communication skills, and drug information skills will be emphasized daily.

Objectives:

1. Participate in multidisciplinary rounds and interact with other health care professionals as the
drug expert and main contact point for pharmacy services
2. Collect appropriate information about the patient (through patient interview, patient records,
and other healthcare professionals)
3. Develop a method of monitoring patients daily
4. Assess the appropriateness of medication therapy, including but not limited to the following:
indication, effectiveness, safety, adherence
5. Complete medication history from patient including prescription, OTC, and herbal medications
6. Gain an understanding of common disease states seen in patients hospitalized on a medicine
service
7. Demonstrate knowledge of underlying mechanisms of actions of drugs used in this setting as
well as adverse effects and monitoring parameters
8. Review medications profiles and develop a patient specific pharmacotherapy plan based on
assessment of disease state, drug therapy, and monitoring parameters
9. Provide drug information to other health care professionals
10. Prepare and lead at least one topic discussion for fellow students and preceptors

Expectations:

Professionalism: Please treat other health care professionals, patients, and team members with respect.
Remember, you are representing the pharmacy department, your school, and yourself. Any acts of
incivility such as rude, disruptive behavior, threats or damage to property will not be tolerated. Failure
to comply with the following is grounds for failure of the rotation:

1. Eskenazi Health Policies regarding universal precautions, HIPAA, and dress code

2. University Policies regarding academic integrity/plagiarism, drug/alcohol abuse, and attendance

Preparation: A reading list for topic discussions will be provided. Please bring articles and any notes or
handouts to each topic discussion. Students will be expected to pre-round with the preceptor daily

Documentation: Students will be expected to complete medication histories and reconciliations on all
patients and document these in the Epic system. Students will also be expected to document any
anticoagulant or other medication education they provide to the patient. Students may also be asked to
document recommendations for anticoagulant dosing, TDM, IV to PO, or CrCL adjustments using the
pharmacy check off columns.

Topic Discussions: May be in a group of other clerkship students or one on one with the preceptor.
Students are expected to be prepared for all topic discussions including having read the required
readings (see reading list) and worked up any patient cases. The student will be responsible for
preparing one of the topic discussions which he/she will present to other students or preceptors. This
will include preparation of a 2-3 page handout with blanks and work up of a patient case. References for
this topic discussion will be provided, however additional materials may be used if necessary. All
references must be cited appropriately.

Evaluations: Preceptor and student will provide each other feedback at least once a week. Students will
complete a midpoint and final evaluation which will be discussed with the preceptor (evaluations maybe
formal or informal).

Rounds:

1. Rounds will be with a teaching team. Team members typically consist of:
a. Staff (Attending) Physician
b. Resident Physician (usually in 2nd or 3rd year)
c. Interns
d. SubIntern “Sub-I” (4th year medical student)
e. 3rd Year Medical Students
2. Please be respectful of other members of the team as this is also their time to learn.
3. Rounds typically start around 0830 daily but may vary depending on patient census, call
schedule, and attending preference and may be conducted at the bedside or in the team room.
4. Students will discuss patients with preceptor daily prior to the start of rounds. (see attached
information)
5. Any recommendations should be discussed with the preceptor, but the student will make these
recommendations directly to the team
6. Students will be responsible for researching and communicating any drug information questions
that arise during rounds. Information must be reviewed by preceptor prior to communication
and communication should be done in a timely and appropriate manner, specific to the situation
(in person, phone call, email, etc)

Call Schedule:

Medicine teams take call every 5 nights.

On-Call: The team will admit up to 7 patients throughout the day

 Post-Call: Busy day - the team will work to formalize better therapy plans for patients newly
admitted and previously admitted.

Short Call: The team will admit up to 3 new patients throughout the day and will leave in the early
evening.

Holdover: Busy day (like post call but worse). The team will take on 4 new patients that were
admitted by the overnight team.

Pre-call: The team will try to be offsite by 1300 in anticipation for on call the following day. Team
will try to discharge patients to make room for new ones the next day

Patient Discussions:

1. Students will meet with preceptor to discuss the patients they are following

2. Students will start by following 3 patients and will add more patients daily as deemed appropriate by
the preceptor for the student’s level. The goal is to follow half of the service by the end of the month
(approx 7-8 patients)

Topic Discussions:

Please see topic discussion calendar for topic discussion schedule

Other Information:

Grading: Grading will be performed according to the format outlined in the University Clerkship Manual.

ID Badge: Students will receive an ID badge during orientation. This should be worn at all times

Secure Chat: Students are required to be available by secure chat or cell phone M-F 0800 – 1630. Secure
chat communication should remain professional at all times

Cell Phones: No texting or phone calls are permitted during patient care or discussions with the
preceptor (unless approved by preceptor). Cell phones may be used as a drug reference or to
communicate with preceptor but should be kept on silent.

Absences: In the event of an unexpected absence from the site, for any reason, the student is required
to contact the preceptor (must actually SPEAK WITH the preceptor (cell 847.840.7343) prior to 8:00 am
on the day of the absence. Failure to do so will result in a documented warning and an unexcused
absence. The second time will result in failure of the rotation. If there is an expected absence which is
known to the student prior to the start of the rotation, the student is required to contact the preceptor
in advance to discuss the absence. Preceptor must also be notified if student will be late and provide
approximate arrival time.

NOTE: The student is required to make up absences according to the guidelines outlined in the PharmD
Clerkship Manual, unless otherwise approved by the preceptor.

Dress Code: Dress is professional (i.e. no jeans, open toed shoes, sneakers, or revealing clothing) or navy
blue scrubs. All clothing, including white coat with name tag (must be worn at all times), should be clean
and ironed (if necessary). Please be mindful of others in regards to fragrances (some patients or
coworkers may be very sensitive/allergic). Students who are dressed inappropriately may be asked to
leave (resulting in an unexcused absence).

PPE: Students will don appropriate personal protective equipment as determined by hospital, university,
or infection control policies. Students are expected to comply with hospital masking policies. PPE
requirements may include gowns and gloves (depending on patient isolation status). Students will not
be expected to enter rooms for patients who have tested positive to Covid.

Confidentiality: Students will have access to personal private information during the course of this
rotation. All information must be kept STRICTLY confidential. Students shall not discuss patient
information in any public areas (including cafeteria, hallways, elevators, etc.) or with friends or family.
Students will remove all patient names and identifying information from case records retained by the
student or distributed in presentations. Students will be expected to comply with HIPAA regulations. Do
not leave patient information clearly visible or accessible to anyone unrelated to relevant patient care
activities.

Popcorn: No popcorn may be popped at any time in the shared workspace or any other Eskenazi Health
microwave. Popcorn may be provided from home or purchased from the Ingram Micro Mobility
Marketplace.

Preceptor Unavailable: If I am unavailable due to PTO, comp day, or other obligations the student will
be provided with a plan for the day as well as designate another preceptor who will be available to
answer questions and serve as backup.

All rules and regulations for rotations set forth by the student’s college apply while on rotation at
Eskenazi Health.

Other Contact Information:

Decentralized pharmacist contact information

3. Main pharmacy (317.880.4400)

4. St. Margaret’s Outpatient Pharmacist (317.880.4525)

By signing this form, you are acknowledging you have read the syllabus, understand the responsibilities,
and are committed to completing the above items.

Student’s Signature __________________________________ Date: _____________

Preceptor’s Signature _________________________________ Date: _____________

Appendix 1

Pre-Round Data to Collect

Please come to pre-rounds prepared to discuss the following information on each patient. At a
minimum, collect the italicized items.

1. List of inpatient medications including knowing what was changed/added/stopped, day of

therapy when appropriate, and use of pertinent prn medications
2. Creation of a list of each patient’s top 3 problems, and an adequate work up of each problem
3. Medication history and reconciliation (you may collect this post-rounds if it requires calling an
outside pharmacy or talking with the patient)
4. Past medical history
5. Any significant events in past 24 hours (surgeries, imaging, new medications)
6. Vitals when pertinent
7. Labs or monitoring parameters that need attention
8. Creatinine clearance (please note trends)
9. Pertinent radiologic or other diagnostic tests
10. Culture results and antibiotic sensitivities
11. Chief complaint and working diagnosis of the problem
12. For patients on vancomycin, calculated patient kinetics
13. Potential treatment plan and interventions you would like to make (see potential list in
appendix 2 for ideas)

Patient Presentation Flow

1. Initial Presentation (goal = 8 minutes)

a) Name, age, gender

b) Chief complaint (CC) and history of present illness (HPI)
c) Past medical history (PMH) and pertinent social history
d) Medication reconciliation (home medications) – (limit to pertinent information)
e) Vital signs
f) Pertinent labs, microbiology, radiology, study results
g) Diet status
h) DVT prophylaxis assessment
i) Assessment of the patient’s top 3 problems & plan to address treatment plan for top 3 problems

2. Follow-up Presentations (goal = 4 minutes)

a. “One liner” (name, age, gender, CC)

b. Prioritized problem-based presentation that should include only the information that is
pertinent to that problem:
i. Vitals
ii. Labs or monitoring parameters (CrCl, electrolytes, levels, etc)
iii. Imaging or results of other diagnostic tests
iv. Culture results and antibiotic sensitivities
v. Assessment and plan including potential interventions you would like to make
Example:

CM is a 45 yom who presented 2 days ago with shortness of breath

Problem (list should be in order Subjective and Objective Assessment

of severity) Information (no need to repeat
old information daily, stick to
new data)
CAP Patient is no longer febrile but
is on 2 L of O2.
Other vital signs are normal
WBC down to 10
Resp culture is still pending
Qtc 437
CXR: infiltrate on RUL
- Is the current therapy
effective and safe?
- What information are
you basing this on?
Plan
- What changes, if any, do
you recommend to the
current therapy?
- Is there anything else
that needs to be
monitored?
Patient is currently on day 2 of
ceftriaxone 1 g IV daily and
azithromycin 500 mg PO daily.
Ceftriaxone is appropriate
coverage for gram negative
bacteria and strep pneumo. IV
antibiotics are appropriate since
patient is still needing
supplemental O2. Azithromycin
is appropriate to empirically
cover for atypical bacteria.
Plan: Continue current empiric
antibiotics until more culture
data available. Can add stop date
after next dose of azithromycin.
Create a plan on when to switch
patient to PO. Pick what
antibiotic and dose you would
choose. Continue to follow
temperature, WBC, and culture
results, CrCl, and QTc.

Appendix 2

Types of Drug Related Problems

1. Medication with no medical indication

2. Patient has medical conditions for which there is no medication prescribed
3. Medication prescribed inappropriately for a particular medical condition
4. There is no lab ordered to assess safety of the medication (ex: Qtc for azithromycin)
5. Immunization regimen is incomplete
 6. Current medication therapy regimen contains something inappropriate (dose, dosage form,
duration, schedule, route of administration, method of administration)
7. There is therapeutic duplication
8. Medication to which the patient is allergic has been prescribed
9. There are adverse drug or device-related events or potential for such events
10. There are clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test
interactions or potential for such interactions
11. Social, recreational, nonprescription, or nontraditional drug use has interfered with medication
therapy
12. Patient not receiving full benefit of prescribed medication therapy
13. There are problems arising from the financial impact of medication therapy on the patient
14. Patient lacks understanding of medication therapy
15. Patient not adhering to medication regimen.

Potential Questions from Preceptor

Note: It is not expected for you to know all the answers for these questions. In the case that you are
unsure about a question, it is encouraged that you review current literature and research an answer
to present to the preceptor on the following day.

• What were the patient’s home medications?

o Was this regimen appropriate?
o Was the patient adherent to his home regimen?
o Are there any home medications the patient currently is not on? Why?
o Are there any social concerns that would prohibit appropriate drug adherence?
• Does every medication have a corresponding indication?
o Why did we choose that medication for that indication? Could a different drug be used?
o What is the pathophysiology or rationale for that drug?
o Is the current regimen the most cost effective?
o Is the current regimen the safest option for the patient?
o Are there any therapeutic duplications?
• Are there medications with no corresponding medical condition?
o What is your plan with addressing medications with no corresponding medical
condition?
• Are medications and doses appropriate for this patient’s indication?
o Is the patient prescribed something he is allergic to?
o What is the appropriate dose for this disease state?
o Do we need to titrate the medication up or down? How quickly do we do that?
o Are medication doses appropriate for this patient’s renal/hepatic function? Think – what
is the risk of under/overdosing the patient when you want to make an adjustment?
o Does a dose adjustment today make good clinical sense?
• What are the monitoring parameters for the current drug regimen?
o What are the clinical and laboratory monitoring parameters?
o How soon would we expect a change in either of the above?
• What are common side effects of the current drug regimen?
 o Might a problem be caused or exacerbated by a current medication?
o What changes could you suggest if that is the case?
• What did we do yesterday to change drug therapy that we need to monitor (clinically, with
laboratory data, or for side effects) for today?
• Are there any drug interactions (consider drug/drug, drug/disease, drug/food, drug/lab)?
o Are they clinically significant?
o What would be an alternate management plan?
• Are there any IV drugs that can safely be switched to PO route?
o What is your basis for that decision?
o What is the dosage conversion?
• Are the antimicrobials appropriate for the suspected/proven infection?
o What bugs are we treating? What is the spectrum of the antibiotic we are using?
o Is it the most narrow spectrum agent that could be used for that indication?
o How many days has the patient been on therapy that covers the suspected/confirmed
infection?

Appendix 3

General Chart Review Workflow

• Notes Tab
o H&P (usually resident or intern notes provide the most detailed information)
▪ CC/HPI and PMH
▪ Problem list
• Summary Tab
o Overview
▪ Vitals
▪ Ins and Outs
▪ Active medication list
o Labs (will only display results, not pending labs)
o Micro (usually updated around 0900)
o Glucose (choose “all” interval)
o MAR (medication administration history)
o Daily Monitoring
o Other useful tabs may include (antimicrobial monitoring, anticoagulant monitoring,
diuretic monitoring, ONC facesheet, TPN monitoring – for electrolyte replacement)
• Chart Review
o Imaging and Cardiology Tests (such as TTE/TEE and EKG)
o Procedures
o Labs – can see if labs have been drawn and are pending (will be listed as “active - in
process” as opposed to “needs to be collected”)
• Notes (again) – for information that is usually new later in the day
o Updated team progress notes (however usually contains information you already heard
during rounds)
 o Consult team notes
o Social worker and case manager (look for any barriers to medication compliance, health
literacy, social situations, and placement)
• Orders
o Active inpatient medication list
o Active lab and diet orders
o Home medications
• Hand Off Communication (should update daily)
o Summary: can use the phrase “.com” to populate a hand off note template (can only
seen by other pharmacist personnel) used by most pharmacists to take notes but also
communicate follow up plans to other pharmacists over the weekend, coverage, or if
the patient transfers to another service
o Components of the “.com” phrase are listed below:

To Do/Monitoring:

CC:

PMH:

Problems:

VTE Px:

Med Rec:

Dispo:

▪ To Do: reserved for action items for other pharmacists or education not needed
▪ To Do – On Call: free space, can use this area to note down list of home medications for ease of
comparing
▪ Sticky Notes
o You can also use the sticky note feature on the far-left corner of the patient chart screen
to keep a running tab of helpful notes for yourself