What is baseline?

What is normal?

What are the normal levels for vitals and CBC that you're looking for?

What symptoms?

okniss

One of the better ones I have reviewed. Good job picking up on things that are important. Just always remember when you're evaluating a patient that their stability is 1st... aka Fluids and electrolytes (particularly K and Mg bc cardiac), then their infection is important bc it's causing the instability, and their comfort is last... Because if the patient is dead, it doesn't matter if they're comfortable.

For everything you mention in this section you need to say how often you are monitoring for it, the critical values you are monitoring, and what your plan is if those critical values are met.

What signs are you looking for? How often are you monitoring for this? What do you do if this happens to MH?

Cool, but now he has CDiff and pancreatitis... what can you do?

How often are you going to assess for these side effects?

What's the plan for continuing to treat his pancreatitis? Is there an Abx you would switch to?

How often? Can you weigh him if he's zonked out on benzos or having seizures from AWS??

How is this actually monitored? SCr maybe??

How often?

What is your plan if MH doesn't improve? Also consider what the plan is if MH's electrolytes are normalizing? His K and Mg are low and you don't have a plan to correct those... He may go into cardiac arrest! YIKES!

which one??

Excellent!!

Is this the inpatient goal??

Excellent! Always consider the whole patient picture!!

In what way is it safer than ativan? Be specific.

Excellent!!

This isn't a good reason. Imipenem/cilastin is kind of like Zosyn (piperacillin/tazobactam)... it comes premixed together and is given together... There's a better reason to use meropenem....

You can just say "used empirically" and save space.

I wouldn't put these ranges. Here I would say "LR needs to be administered at 500mL/hr for the first 12hrs" or something to that effect to rationalize your administration rate.

Are there other things you need to give?? Specifically in regards to his electrolyte and nutrition status?? What is your plan regarding his dangerously low potassium? (LR only has 4mEq/L of K... that's not going to work). What about his Mg? Mg and K are essential to always consider bc of their cardiac effects!!

I would take this last part of this sentence out and just say "LR has shown efficacy with fluid and electrolyte replacement".... save space!

You just stated this in the previous sentence, so save space and don't say this again (just use 2 references for the previous statement).

Be careful with this sort of statement... It almost sounds like a compatibility statement... meropenem cannot be mixed in LR... so I don't know that I would include this part just because there's risk of misinterpretation.

Would you give 10mg as subsequent doses? How often are you planning on giving this?

Is a bolus the best choice? Or would an infusion be better?

Not sure what the "right" answer is here but look at recent literature of H2 antags and pancreatitis... fascinating stuff.

Is this the inpatient glucose goal??

What are these symptoms?

Mention the specific ones you need to correct. (i.e. correcting his hypokalemia, hypomagnesia, etc)

consider adding time periods to monitor for all. daily?

Is that all, probably need to continue fluid replacement for longer than an hour to assure hydration

consider adding KPhos

Add thiamine for alch withdrawl

double check about tylenol and pancreatits?

may want to hit on duration. how long will he get AB? fluid? diazapam.

intravenously (could say at a rate of 500 mL/hr)

great rationale

consider adjusting fluid rate or switching to normal saline

good

bacterial infection and susceptibility of meropenem

consider saying normalize lab values (if you need more space). may want to include: expectations would be to effectively treat pancreatitis (etc) with minimal adverse effects. g

He is in the hospital already, so he may or may not be able to recognize and communicate these issues to his doctors. So, it is up to you to determine how frequently someone should be checking these things for him and what changes should be made if they occur.

Is there a certain number/cutoff that you could mention?

Good! But, what lab value do we use to monitor renal function?

Be sure to mention how frequently all of these should be monitored.

Was he previously taking the Tylenol ES for his HAs? Do we use opioids for HAs? Also, would we want to start an opioid in someone who already has a history of substance abuse (ie. alcohol)?

If you mention this, they may expect you to mention what is considered normal urine output for a patient in this setting.

Like that you mentioned this assessment, but how would I use it in modifying MH's care? What would the score mean?

Be sure to mention how frequently all of these should be monitored. Also be sure to include critical values (ie. the range for WBC, the range for the specific electrolytes you want to monitor, etc.)

Typo

Pick one: either 8 or 12 How long will MH be on the meropenem?

50 tablets?? I would rethink this wording :)

Route?

Route?

Be sure to use the correct format for the drug names. --> Correct naming format (Brand + generic unless using specifically generic version and will write generic name (generic) ex: lisinopril (generic) or Januvia (sitagliptin).

Is the patient on Pepcid?

Make sure to include in-text citations!

Level 2 is actually the required release of data underlying reported findings. Level 3 requires independent verification that shared data and code can replicate reported findings. See here for 6 journals that do that step https://osf.io/kgnva/wiki/home/

0 also include "encouragements" to share data, which have been repeatedly shown to be ineffective.

The TOP Guidelines provide a modular and tiered set of polices that journals or funders can use to implement policies that fit with their norms or resources (higher tiers of course require more resources). See https://cos.io/top

This is one of the better plans I've reviewed, so good job! Just fix the few things that were mentioned. I know it's a long plan, so try to cut some unnecessary jargon down if you can. The major things I noted were that you need to mention a plan for what to do if your adverse events occur or if MH doesn't improve as well as specific frequencies for monitoring.

Is MH in the hospital? This is unnecessary if so.

What are the specific things you monitor for this? RR? O2sat? What's the plan if this happens?

What antibiotic? Not every antibiotic is good for C. Diff.

What is the plan if MH experiences these adverse events? For every adverse event you need a plan on how to manage it.

This is a very generic sentence... I would consider saying "If MH remains hypokalemic after x hrs then y is the plan.."

Should you switch benzos? Or should you just increase the dose or add a 2nd agent?

Why another carbapenem if they cover the same organisms? Are you sure he shouldn't be switched to a different class?

How long should you wait before switching Abx? If he hasn't improve in 24hr are you going to switch? Or are you going to wait a few days? Be specific.

How often?

When should this be done?

How often?

How often?

How often?

How often are you monitoring? Daily? Hourly?

Good thought. However, look into the use of albumin as a monitoring parameter.... is there something better to use?

So you probably are expecting that potassium comes up because you gave LR.... But, LR actually only has around 4mEq/L of potassium... so it's not going to work. You need a plan to replace this (mention it in new drug therapy). A potassium of 2.7 is dangerous...

What is the goal? Also how is anxiety measured and assessed in AWS? There is a tool that is used...

Include goal values and things you're specifically looking for.

Take this part of the sentence out. Save space.

What's your goal temp? also what is the goal WBC?

You should also mention why you chose Ativan over Valium (another common benzo).

Yes. Excellent mention!

Excellent!

This is good. Be sure to look at and research this syndrome and know how common it is, what prevents it, and how well the thing that prevents it works. Will help later in your clinical experiences!

Read recent literature concerning banana bags. Are they best practice? I don't know what graders are looking for here, but being well-versed in banana bags for your clinical experiences will be of benefit. (Note: They are super expensive).

Be sure to use the correct format for the drug names. --> Correct naming format (Brand + generic unless using specifically generic version and will write generic name (generic) ex: lisinopril (generic) or Januvia (sitagliptin).

Is oral the best option? If so, be prepared to mention why oral was chosen in your rationale... Always consider your patient's whole picture, are they able to take oral meds? Is the metabolism of oral drugs changed by their disease state?

You're going to keep this guy in the hospital for 2wks? Reconsider this.

Is this dosing correct? If you've renally adjusted this medication you need to mention that in your rationale... I don't have the case pages so I can't determine if your patient needs renal adjustment...

Look into recent literature about using H2 antags in pancreatitis...

Is this necessary? Is your patient being treated outpatient?

Not super necessary to mention... You're getting into the weeds with this and you can save space by leaving it out. Yes we care about resistance... but we care more about saving this dude's life.

Good! Always mention QoL!

I would mention the specific electrolytes you need to correct (i.e. hypokalemia, hyponatremia, hypocalcemia, etc)

Remove this unless you're going to include the specific goal values... You've mentioned enough that you can save space by mentioning this later and not here.

What should you do if a critical value is met? In order to answer this question, I would assume that the physician is going to ask the pharmacist what their recommendation would be. Also note that MH is already in the hospital, so MH may or may not be able to recognize and communicate these adverse events to a nurse or doctor.

For all adverse events listed, how frequently should MH be monitored?

Was potassium replenishment addressed in New Drug Therapy? If so, is that enough to get MH back into the normal range?

who "used" chlordiazepoxide

May need a closing parenthesis since you have an opening one.

Do any of MH"s current medications have the potential to induce acute pancreatitis? If MH is vomiting, should oral medications be used? Will elevated liver enzymes affect your choice of medications used?

Is correcting electrolytes/fluids a goal of therapy? Which ones are abnormal?

The key word here is submission. This is illustrative of Eve's relationship with Adam.

Milton followed the classic line of his time about the inferiority of women to men. Thus the relationship between Adam and Eve was not that of equals, she was deemed inferior and subordinate to him and he was viewed as closer to God.

You can take the Devil out of Hell, but can't take Hell out the Devil. He is now fully committed on the path of evil.

Never hurts to mention "improved quality of life"

How frequently would you monitor for this?

How frequently should you monitor for WBC and temp changes?

What is your plan if the patient does not respond ideally to your current recommendations?

What route?

Typo - do not need the word "should" here.

Are there any other concerns in patients who present with alcohol withdrawal? What medications could be used to address these concerns? If you find anything, be sure to add to your rationale section.

Will the LR's cause his electrolytes to normalize without using any additional agents?

Be sure to use the correct format for the drug names. --> Correct naming format (Brand + generic unless using specifically generic version and will write generic name (generic) ex: lisinopril (generic) or Januvia (sitagliptin).

Oral or IV? He is nauseated and vomiting.

If you start to get close to 1 page, you may consider taking the critical values/actual numbers out of this section since these really fit better in the therapeutic monitoring section.

I have left a lot of comments that will hopefully direct you towards the right path... Please take them into consideration. Sometimes we get so bogged down in the details we miss really important big picture items and I think that's what has happened here. Remember that your focus for this patient is his pancreatitis 1st and his AWS 2nd. So focus on Fluids/Electrolytes (specifically electrolytes needed in AWS), Antibiotic therapy for pancreatitis, and supportive care for AWS (aka anxiety trx).

This section should include the frequency of monitoring for specific adverse events that are associated with your chosen drug regimen.... Including the specific values and plan of action if it occurs.

For example: A side effect of diazepam is respiratory depression so you would say "Monitor hourly for respiratory depression (RR=<12bpm, O2sat <90%) with diazepam. If this occurs, then....."

What are the signs of hypotension? You need to be specific... Also what are you going to do if this happens?

What else increases risk of respiratory depression? Maybe the dual benzo use? What are you monitoring for specifically (i.e. specific breaths per minute or O2 sat?)? How often are you monitoring for this? What are you going to do if it happens?

This is more therapeutic monitoring than adverse event... Remember your adverse event monitoring should associated with adverse events of the drugs you've chosen to give!!

How often are you monitoring? Hourly, every 4hr, daily?

This needs to be taken out and re-done... I seriously don't know what you're saying.. Instead focus on the specific things you're looking for and when you're looking for them.. and then what to do if they're present.

Good job with the monitoring of general pancreatitis... But what about AWS?? How are you assessing if your patient's AWS is improving or getting worse? There is a specific scale you might want to look at for this... (also goes into assessing how well your Valium is working....)

I don't know what this acronym is...

Don't give a range. Choose one.

Remove this to save space because it's unnecessary...

You need mention specific things you're looking for... I would suggest mentioning WBC that don't decrease, Temp that doesn't normalize, HR that doesnt normalize, etc... but be specific with the values you're looking for with these things.

Would you d/c Abx if they have an infection or would you just de-escalate to a more appropriate regimen??

Greater than 180!! GOOD!! I'm like a proud parent right now because you're the first one who has gotten this. Just remove the "to 200" because you don't want to give a range.

Just >0.5mL/kg/hr.... don't give a range.

Remove this... A lot of times AWS patients are already in the ICU.

I would take this out because you want to do this anyways... Blood gases are super important in assessing patient status especially in AWS... You should be super concerned about your patient's anion gap... And you should know everything about Anion Gaps and Arterial Blood Gases anyways!

What is your goal O2 sat? And at what O2 sat would you need supplemental oxygen?

Just leave it at >0.5mL/kg/hr avoid the range!

I would just say "MAP >65" and leave it be.

Choose one. You need to avoid ranges at all costs.

What are you normal BUN levels? Furthermore, you need to look at what BUN really is... sometimes we see an increase in BUN due to volume overload, secondary to acute kidney injury... so just be aware of this.

How frequent is frequent? You need to be specific...

This section should probably be your longest section. Once you determine your Abx you should add the reasoning here. Also if you determine any electrolytes or other things need to be given then include that as well.

Hint: There are certain electrolytes you should be concerned about in AWS/pancreatitis.... There are also other nutritional factors that come into play when you're dealing with people in AWS (research a bit about the progression of AWS to delirium tremens...).

This is fine but be sure to also consider the risks of utilizing long-acting benzos... I've personally never seen valium used for AWS in the inpatient setting (it's not "wrong" and as long as you have evidence to back it up its fine), but I want you to be aware of this fact for your clinical experiences.

What is "it"? You lost me here.

You need to choose an Abx or regimen to treat pancreatitis and then defend the agent(s) you choose. There are specific Abx that are used for this.

Good to consider this...

Is this a primary lit you found? There are other reasons to choose LR too... Why use it over NS or Plasmalyte? Mention these things.

This section needs major work. You need to state what antibiotics you're choosing, route, dose, frequency. Also consider any electrolytes that may need replacement. Pain is NOT a major focus of this case... So focus primarily on Fluids, Electrolytes, Antibiotics for Pancreatitis, and Anxiety associated with AWS.

What Abx are you starting? What route, dose, frequency, and for how long? This is like the main purpose of the treatment plan.... Please do not turn this in without choosing Abx for pancreatitis....

Is it best practice to give fentanyl and a benzo? What's the risk? Is the benefit greater than the risk? Again, these are things you always need to consider.

Is this the best route for you patient? Always be sure to be conscious about your patient's whole picture... can your patient tolerate oral meds? Is there a reason your patient should be NPO? Does your patient's condition change drug metabolism? These are things you will need to think about for the rest of your life.

Capitalize.

What is it called when you start Abx before the cultures come back?? (Hint: Empiric therapy...)

Choose one of these... never give ranges.

You need to choose 1 rate... and just a hint for life advice, round to the closest bag size (i.e. 100, 250, 500, 1L) because literally no one is ever going to give fluids at a rate of 509mL/hr... that would be ridiculous.

Are you sure? Look at this some more and be prepared to defend your answer.

I don't know what the graders are looking for and this is probably "right", but you should look at recent literature about using H2 antags in pancreatitis... It's fascinating. You'll be smart for group... and life.

Look at Bactrim's side effects... is there a specific reason he shouldn't be on bactrim?

Give the normal ranges if you're going to mention this

Excellent! Always mention QoL.

I would re-word this to "Goals also include resolution of infection secondary to pancreatitis"

Include the specific goals for these

Don't put ranges. Put an exact infusion rate

Don't put ranges. Pick an exact number of days.

The graders usually want you to be very specific with what you will do. They don't like ranges or generalized statements. They usually want to know exactly how often you will monitor for adverse events, not the general statement of "throughout the course of his hospital stay."

How exactly will you monitor his heart function? An ECG, BP, pulse?

Will this be assessed hourly over the next 24-48 hours, every 4 hours, every 12 hours?

How often will you monitor for these signs of improvement?

Excellent rationale. Are there any guidelines on this topic? It is always important to include guideline recommendations as well or at least reference guidelines in the rationale.

Why did you choose a crystalloid over a colloid?

Provide dosage form (injection solution)

levels

Instead of just listing adverse events, it would be better to state how you will monitor for those specific adverse effects and how often you will monitor them. Will you do a physical exam, question the patient, monitor lab values, etc.? This section is about how you will monitor for the adverse events and provide a plan for monitoring them.

Is there anything else you should monitor for to see if the meropenem is working? Cultures, signs of infection, etc.?

What would that different therapy be?

This should go in Adverse Event Monitoring.

How will you monitor these? Are there certain tests you can look at? How often will you monitor them?

What specific lab values are you looking for, and what are the goal levels? How often will you check these labs?

Why did you pick a crystalloid over a colloid?

Are there any guideline recommendations for this? Always include guideline recommendations in rationale.

who is "we"? Maybe just say "Based on the studies above, meropenem, chlordiazepoxide, and Lactated Ringer's solution are the first line treatment based on clinical efficacy, costs, and dosing regimens."

Do any other classes of antibiotics cover these organisms? If so, why didn't you choose a drug from that class?

Delete "when"

provide dosage form (IV solution)

Great!!!

As he does in the Project MAC memo, summer 1963.

Actually, I think Doug has this backwards, at least from what I can see in the archives. SRI did pitch in half of his salary, but that seems to have been the first funding, in early 1960. The AFOSR proposal was submitted in mid-December 1960 and the funding, which allowed Doug to go full-time, kicked in in March, 1961.

It better to call it Extension API

S'inscrire

illimité (small "i" at the beginning cause the typo makes it hard to read with the 2 'l' afterward)

S'inscrire

Abonnements

Accès (without the second "s" at the end)

n (small size instead of capital)

n (small size instead of capital)

SwingLab (without the space between the 2 words)

Lindy Hop (capital "H" for Hop)

Danses de couple (without the "s" at the end)