1. Last 7 days
    1. References

      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.

    2. Adverse Event Monitoring

      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.

    3. espiratory depression

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

    4. discontinue meropenem

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

    5. may cause

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

    6. stop the meropenem

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

    7. monitored

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

    8. renal function to not get worse

      How is this actually monitored? SCr maybe??

    9. periodically

      How often?

    10. Therapeutic

      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!

    11. 4 to 8

      which one??

    12. (CIWA-Ar) hourly

      Excellent!!

    13. (77-106 mg/dL)

      Is this the inpatient goal??

    14. persistent vomiting

      Excellent! Always consider the whole patient picture!!

    15. efficacy and safety profile.

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

    16. CrCl of 37 mL/min

      Excellent!!

    17. administered alone

      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....

    18. before a blood culture can be taken

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

    19. 250-500 mL/h within the first 12- 24 hours to be the most beneficial

      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.

    20. goal labs and assessments are not met

      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!!

    21. single

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

    22. Another studied showed that lactated ringer�??s solution is preferred over normal saline due to improved outcomes.

      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).

    23. used together

      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.

    24. 10 mg

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

    25. bolus

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

    26. Pepcid

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

    27. (77-106 mg/dL)

      Is this the inpatient glucose goal??

    28. symptoms

      What are these symptoms?

    29. abnormal electrolytes

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

    30. epinephrine

      consider adding time periods to monitor for all. daily?

    31. hour

      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

    32. Tylenol

      double check about tylenol and pancreatits?

    33. New

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

    34. ringer

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

    35. Rationale

      great rationale

    36. reassess fluid

      consider adjusting fluid rate or switching to normal saline

    37. Discontinue Bactrim

      good

    38. infection

      bacterial infection and susceptibility of meropenem

    39. xpectatio

      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

    1. physician

      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.

    2. adjusted

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

    3. renal

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

    4. Monitoring

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

    5. opioid

      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)?

    6. output

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

    7. Alcohol

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

    8. Monitoring

      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.)

    9. pancreatic

      Typo

    10. 8 to 12

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

    11. 50 tablets

      50 tablets?? I would rethink this wording :)

    12. multivitamin

      Route?

    13. Ringer

      Route?

    14. Therapy

      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).

    15. malabsorption

      Is the patient on Pepcid?

    16. References

      Make sure to include in-text citations!

    1. 3 (release of data and materials is prerequisite to publication)

      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/

    2. 0 (no Open Science policy

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

    3. They created a scheme wherein journals would be graded on their commitment to Open Science.

      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

    1. References

      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.

    2. contact your physician

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

    3. respiratory depression

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

    4. antibiotic

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

    5. Adverse Event Monitoring

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

    6. If there are no improvements in MH�??s electrolytes and fluid balance, then the physician should check lab values and make adjustments to MH�??s fluid and electrolyte intake

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

    7. benzodiazepine

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

    8. another carbapenem

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

    9. no improvements

      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.

    10. monitored

      How often?

    11. follow-up culture

      When should this be done?

    12. monitored

      How often?

    13. monitored

      How often?

    14. performed

      How often?

    15. monitored

      How often are you monitoring? Daily? Hourly?

    16. albumin levels

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

    17. potassium

      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...

    18. respiratory status

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

    19. renal, hepatic, and hematopoietic

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

    20. as this is an indication of imipenem/cilastatin�??s efficacy in treating the infection

      Take this part of the sentence out. Save space.

    21. reduced feve

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

    22. Lorazepam

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

    23. treat delirium tremens

      Yes. Excellent mention!

    24. penetrating into the pancreas

      Excellent!

    25. Wernicke-Korsakoff

      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!

    26. banana bag

      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).

    27. brand

      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).

    28. 2mg tablets

      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?

    29. continued for 2 weeks

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

    30. imipenem/cilastatin

      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...

    31. Pepcid

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

    32. adherence

      Is this necessary? Is your patient being treated outpatient?

    33. development of antibiotic resistance

      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.

    34. improving his overall quality

      Good! Always mention QoL!

    35. electrolyte

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

    36. elevated liver enzymes

      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.

    37. immediately

      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.

    38. monitored

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

    39. potassium

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

    40. who chlordiazepoxide

      who "used" chlordiazepoxide

    41. (

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

    42. resume

      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?

    43. electrolytes

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

    1. Yielded with coy submission, modest pride, [ 310 ]

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

    2. Whence true autority in men; though both [ 295 ] Not equal, as thir sex not equal seemd; For contemplation hee and valour formd, For softness shee and sweet attractive Grace, Hee for God only, shee for God in him:

      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.

    3. can

      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.

    1. work

      Never hurts to mention "improved quality of life"

    2. lorazepam

      How frequently would you monitor for this?

    3. 50

      How frequently should you monitor for WBC and temp changes?

    4. Monitoring

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

    5. given

      What route?

    6. should

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

    7. doses

      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.

    8. electrolytes

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

    9. Therapy

      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).

    10. Pepcid

      Oral or IV? He is nauseated and vomiting.

    11. normal

      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.

    1. Goals

      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).

    2. Adverse Event Monitoring

      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....."

    3. signs

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

    4. entanyl

      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?

    5. CT

      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!!

    6. Monito

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

    7. Acute peripancreatic fluid collections and acute necrotic collections may develop less than four weeks after the onset of pancreatitis and pancreatic pseudocyst and walled-off necrosis usually occur more than four weeks after the onset of acute pancreatitis

      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.

    8. Therapeutic Monitoring

      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....)

    9. APFCs

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

    10. 7 to 10

      Don't give a range. Choose one.

    11. Patients with persistent organ failure and extensive local complications should be transferred to the critical care unit

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

    12. signs of sepsis

      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.

    13. and nor source of infection is found

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

    14. greater than 180

      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.

    15. >0.5 to 1cc/kg/hr

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

    16. Transfer to ICU if hypoxia is persistent

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

    17. blood gas analysis

      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!

    18. oxygen saturation

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

    19. >0.5 to 1cc

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

    20. 65 to 85mmHg

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

    21. 24-48

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

    22. Increase fluid resuscitation if BUN levels remain the same or increase

      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.

    23. frequent

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

    24. Rationale

      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...).

    25. Generally

      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.

    26. It

      What is "it"? You lost me here.

    27. Antibiotics

      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.

    28. renally impaired

      Good to consider this...

    29. incidence of SIRS

      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.

    30. New Drug Therapy

      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.

    31. antibiotics

      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....

    32. 1 fentanyl

      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.

    33. TID to QID PO

      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.

    34. i

      Capitalize.

    35. while the source

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

    36. 8-12 hours

      Choose one of these... never give ranges.

    37. 254mL/hr-509mL/hr

      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.

    38. Continue Tylenol ES

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

    39. D/C Pepcid

      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.

    40. no indication

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

    41. vital signs will return to normal range

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

    42. get back to his normal daily routine

      Excellent! Always mention QoL.

    43. Infections caused by pancreatitis is expected to be treated also

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

    44. fever, rapid pulse

      Include the specific goals for these

    1. 15-30 minute

      Don't put ranges. Put an exact infusion rate

    2. 4-7

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

    3. throughout the course

      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."

    4. heart function should be monitored

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

    5. and for the next

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

    6. watching for improvement

      How often will you monitor for these signs of improvement?

    7. Rationale

      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.

    8. actated Ringer

      Why did you choose a crystalloid over a colloid?

    9. injection

      Provide dosage form (injection solution)

    10. level

      levels

    1. Adverse Event Monitoring

      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.

    2. Therapeutic Monitoring

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

    3. a different therapy

      What would that different therapy be?

    4. When taking chlordiazepoxide, hepatotoxicity must be monitored.

      This should go in Adverse Event Monitoring.

    5. hould be monitored

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

    6. lab values must be reassessed

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

    7. compared to normal saline.

      Why did you pick a crystalloid over a colloid?

    8. Rationale

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

    9. we

      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."

    10. class of carbapenems

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

    11. when

      Delete "when"

    12. meropenem

      provide dosage form (IV solution)

    13. Goals of Therapy

      Great!!!

    1. (Sometimes, in the early years, I called these the Service System and the User System)

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

    2. By 1959 1 was lucky enough to get a small grant from the Air Force Office of Scientific Research (AFOSR, from Harold Wooster and Rowena Swanson) which carried me for several years -- not enough for my full-time work, but by 1960 SRI began pitching in the difference.

      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.

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