Why these meds... please help me figure this out.

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Ok. I had a patient this week in rotations and here is his Dx:

HIV

Hep B

Diplopia

GERD.

Can someone please explain to me why

1. Dr.s put everyone on Heparin. He has NO hx of DVT or Pulmonary Embolus. No abd surgery. Nothing.

2. my pt is on Vancomycin and Maxipime. No bacterial infections at all, only viral. In case people don't know: Antibiotics don't treat viruses. Is there some reason that Im missing? And he doesn't have diarrhea... so no C. Diff.

I can't go back to the hospital and ask the doctor for his rationale. Im hoping there's someone more intelligent than me that might could explain this.

Let me know if you have any other questions, I have all his lab tests and the rest of his chart and MAR in front of me.

Specializes in Critical Care.

Heparin is very common for DVT prophylaxis, although you could use SCD's as an alternative or just have the patient walk/stand TID, which has been shown to be as or more effective than either SCD's or 5000unit heparin BID.

While there are some situation where it's considered acceptable to use antibiotics prophylactically, such as aspiration or surgery, immunocompromise itself is not sufficient and would be considered very bad antibiotic stewardship, particularly to pull out the big guns (vanco) without a known bacterial infection, either MRSA or C diff. With the Hep B, vanco use just for the heck of it is particularly bad form due to the potential for liver toxicity, so I'm guessing the Doc must have had a reason (or he's a bad doc).

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Heparin is very common for DVT prophylaxis, although you could use SCD's as an alternative or just have the patient walk/stand TID, which has been shown to be as or more effective than either SCD's or 5000unit heparin BID.

While there are some situation where it's considered acceptable to use antibiotics prophylactically, such as aspiration or surgery, immunocompromise itself is not sufficient and would be considered very bad antibiotic stewardship, particularly to pull out the big guns (vanco) without a known bacterial infection, either MRSA or C diff. With the Hep B, vanco use just for the heck of it is particularly bad form due to the potential for liver toxicity, so I'm guessing the Doc must have had a reason (or he's a bad doc).

These are all reasons I asked in the very first reply....what was this patient in the hospital for?

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I've been busy in simulation lab today... after having this patient, the one we did sim on was easy!

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The fever can be an obvious sign of infection, but it went away on its own before medication was administered. Patient came in on day 3... day 1 and 2 he had fever, day three he did not. Said he took nothing to make it go away. I have a hard time believing that it is an indication of infection. WBC would be low with an HIV patient anyways, right?

Patient presented to the ER with double vision and a headache. After CBC was run, his WBC is very low(1.91; 3.90-10.70). I thought it had to do with the HIV, but maybe not. His history is HIV, HBV, and GERD. Pt was on neutropenic precautions for days 3, 4 and 5. off of them on day 6. Neutrophil and Lymphocytes are low (.69; 1.80-7.70) and (.46; 1.00-4.80) but I thought it might have to do with his Kaposi's Sarcoma. Patient has HIV, not AIDS yet.

Patients Diplopia is a result of cranial nerve 4 palsy. Thats what they were there to figure out, I didn't understand the Vanc though. Really, I didn't understand why a doc would use Heparin either, especially if the pt. can get up and walk twice a day to prevent the DVT. I guess thats why Im not a doctor. The Vanc may have to do with the neutropenic precautions the patient was on.

MY preceptor picked a complicated patient for me because I asked her to, but I had no idea what I was getting myself into. Im thankful for the opportunity to take care of this patient because Im learning a whole lot in a short amount of time. My preceptor only saw his past Hx and current dx...didn't know all the meds and lab values that would come into play! She said she was proud of me for catching something like that and that she hadn't heard of the ethical issue before. I will be following up with my teacher to see what has been done about this and let you all know. I know I sounded really scattered in my OP, but I was just excited that I found a mystery to solve! Who doesn't love a good mystery?

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Specializes in Emergency Dept. Trauma. Pediatrics.

Do you know what the CD4 count was? I know we were taught by the time the patient has the sarcoma they usually are to the point of having actually AIDS. Not always the case but looking at everything you listed I would be interesting in knowing what the CD4 was.

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CD4 T Cell Absolute (thats what it says here on the lab report) says 320; 416-1751. I don't know what the magic number is to call it AIDS, I haven't learned that yet. Im probably gonna go look it up though...

Here is the letter from the liaison at our hospital..

We verified with our pharmacy this morning and they said the heparin that we use is porcine derived. I spoke with the unit manager for 8 West and she is going to speak with the doctor for this patient. She said that a lot of our Neurologists are Muslim themselves or very familiar with the culture and so they will discuss this with the patient before starting treatment. She is not sure about this patient and said that it could have been overlooked but she will make sure that everyone involved is aware.

And now Im nervous to have to go back to the floor. I feel like the nurses/doctors will not treat me well... I don't know... All I was doing was my assigned homework... if he was on your floor, would you be upset with me? I asked my teacher one question and then it snowballed to this. Im feeling like my patient might be mad at me and that maybe I'd be punished with a "not so interesting" patient assignment this time.

Your thoughts please...

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I did some research on it at my patient does have AIDS because KS is present. CD4 could still be 320, but because of the KS, its automatically AIDS. Patient is on prophylactic Vanc because of the threat of Pneumocystis Carnii Pneumonia. His chart says HIV, not AIDS. Does this matter?

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Specializes in Emergency Dept. Trauma. Pediatrics.

I am not sure about how it will be when you are on the floor, but as far as the CD4 count, we were taught under 200 was considered AIDS unless they had the Sarcoma or a few other things, than they would also Diagnose as AIDS.

We were also told that in HIV/AIDS patients, once the CD4 counts were below a certain level, if they were hospitalized for something, Prophylactic Abx are pretty common since their immune systems are so compromised. I was surprised to see Vanco though since that in itself is so hard on the body.

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Don't worry about going back on to the floor after bringing up an issue. You found a legitimate problem and handled it appropriately, so walk on to the floor with your chin up, knowing that your attention to detail may make an important difference in someone's life. ;)

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Is he active, walking around? Up ad lib? This is given to just about every patient on bed rest where I do clinicals also. Being non ambulatory is the rationale we are taught.

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