Missing the obvious

“Can you take a look at Mrs. Smith’s meds? She is a new admission to our retirement home. We don’t have a lot of history and she is having constant loose stools. She came back negative for Celiac disease, also trying out a diary free diet right now. But nothing seems to work. She is withdrawn.”

“OK. Let me take a look.” I said, then I proceeded to look at a print out of her medications…

“Is she on any excessive bowel regimen?”, I thought.  Nope, not on any laxative.

“Did she recently start on metformin?”, I thought again. No. She is not diabetic.

“Did she recently start on a cholinesterase inhibitor?” No. She scored perfect on the MMSE, a test we use to assess for cognitive impairment.

I scanned over the list of medications… nothing seemed out of the ordinary. I didn’t know what it could be. “Let me take a look at her chart”, I thought.

I flipped open the big heavy binder, a stack of papers was hanging there under the admission tab. It appeared to be her discharge summary notes from the hospital. She was discharged with C-diff infection and needed to complete a course of antibiotic.  WHAT?

“She had C-diff?” I asked.

“Oh yes. That was January.  She completed her antibiotics already.”

I continued to flip the chart… then I came across a prescription receipt from Shoppers Drug Mart. It was dated about 2 weeks ago. It was for clindamycin. WHAT? WHAT?

“She received clindamycin?” I asked.

“Oh yes. She fell and had a scratch over one weekend. Went to emerg and they thought she might have had some cellulitis. She has an allergy to Penicillin so they gave her clindamycin.”

“This is the same hospital that discharged her earlier with a C-diff diagnosis”, feeling perplexed but needed to confirm.

“Oh yes.”

I was screaming inside my head but I remained composed. “Hmm….maybe you want to order some C-diff toxin screen tests.”, I suggested.

“Actually, maybe you want to get an order to restart her antibiotics ASAP.”, I suggested again.

Then, I wanted to drop everything, washed my hands and ran out of that place, literally STAT.






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My name is Cynthia Leung and I am a practicing pharmacist in Kingston Ontario, Canada. This blog is for me to share my ideas, opinions and perspectives on how medications are used in our health care system. Note that these posts are my own opinions and do not represent the opinions of my current or former employers and / or organizations that I may belong to. Any possible case scenarios described in my posts would be modified to maintain patient confidentiality. This blog is not a platform for professional advise for patients or health care providers and the content is not meant to support any clinical decisions or replace professional opinions. Also the images are either taken or created by the author, or adapted with permission. I hope you will enjoy reading my posts!

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