- Sep 2018
-
pharmd.umc.edu pharmd.umc.edu
-
vaccine
Include routes and doses of vaccinations
-
24-48
Choose one of these
-
5 to 7 day
Choose a specific duration.
-
-
pharmd.umc.edu pharmd.umc.edu
-
Rocky Mountain Spotted Fever (RMSF)
Unless the case pages state this, don't use it! There are many TBRDs... RMSF is only one of them.
-
-
pharmd.umc.edu pharmd.umc.edu
-
Td booster shot
Include routes and doses of vaccines.
-
-
pharmd.umc.edu pharmd.umc.edu
-
Td booster
Routes and doses of vaccinations are needed.
-
24-48
Choose one of these.
-
5-7 days
Choose a specific duration
-
-
pharmd.umc.edu pharmd.umc.edu
-
Rocky Mountain Spotted Fever (RMSF). 1
Unless the case pages specifically say that it is RMSF, don't mention it. There are many types of TBRD and RMSF is only one of them
-
-
pharmd.umc.edu pharmd.umc.edu
-
rocky mountain spotted fever (RMSF)
Don't say this unless it says it in the case pages. RMSF is only one of MANY TBRDs... So I would stick to "TBRD"
-
po bid. 2
Don't use these abbreviations. Say "by mouth every 12 hours"
-
rocky mountain spotted fever (RMSF)
Don't use this. Just say "TBRD"... There are multiple TBRDs and RMSF is just one of them so don't use this unless the prompt specified RMSF
-
-
pharmd.umc.edu pharmd.umc.edu
-
5-7
Don't use ranges. Choose either 5 or 7 days.
-
-
pharmd.umc.edu pharmd.umc.edu
-
influenza vaccine in November 2018
mention dose and route. (0.5mL IM).
-
Td booster
dose and route?
-
Adverse Event Monitoring
In this section mention specific things you're monitoring, the frequency of monitoring, what values would be alarming, and what you would do if these values are met....
I.E. Doxycycline is associated with photosensitivity. KN should monitor daily for sunburn and take caution when performing outdoor acitviities by wearing appropraite clothing (long sleeves and hat) as well as by applying sunscreen frequently.
-
fever
What specific value would you hope to achieve?
-
should be normal
What is normal? What are the specific labs you're looking at and what are the values you hope to achieve?
-
24-48
Choose one.
-
A pregnancy test should also be performed to confirm KN is not pregnant, as Doxycycline can effect fetal developmen
This would adverse event monitoring, not therapeutic.
-
po
"by mouth"
-
4-6 hour
4 or 6... choose one. Don't use ranges.
-
po
"by mouth"
-
Rocky Mountain Spotted Fever (RMSF)
Does she have this or TBRD? Not always the same thing. Only mention the one that is in the case pages.
-
-
pharmd.umc.edu pharmd.umc.edu
-
OTC
Would probably try to mention her APAP again here.
-
influenza vaccination as well as to get a Td booster shot
What doses and routes?
-
ALT, AST, and thrombocytes are not outside of the normal
What values would be alarming? What would you do if this happens?
-
symptomatic improvement as well as signs and symptoms of infection
This would be therapeutic monitoring, not adverse event
-
Steven- Johnson syndrome, Toxic epidermal necrolysis, clostridium difficile diarrhea, hepatoxicity, hypersensitivity reaction, and pseudotumor cerebri
mention signs/symptoms of these that the patient can monitor for since she will not be in the hospital. Mention how often she should monitor for these and what to do if these things happen.
-
Adverse Event Monitoring
How often are you monitoring? What values would be alarming? What should the patient do if these values are met?
-
Therapeutic Monitoring
What about her fever and rash? Should you monitor for resolution of those? How often? What are the goal values? These are the easiest things to monitor so definitely mention them.
-
two to four
Don't use a range. Choose one of these.
-
Rationale
It is helpful to mention why tetracyclines are used over other antimicrobials, and reasons why doxycycline is the best out of all tetracyclines.
-
RMSF
Again, wouldn't mention this since it's not specified in the case pages.
-
Since it hasn�??t been clarified what specific TBRD it is, the amount of days on the antibiotic was based off the treatment for Rocky Mountain Spotted Fever. I chose Rocky Mountain Spotted Fever due to the recent travel to an area known for it and because a study found Rickettsia (which is the causative agent) at every site where they collected tick samples
I wouldn't mention this. Since you don't know for sure it is RMSF, I would avoid menitoning it and just say the duration was based off the duration deemed appropriate for the majority of TBRD....
-
po
"by mouth"
-
-
pharmd.umc.edu pharmd.umc.edu
-
Adverse Event Monitoring
Be sure to always mention what you're monitoring, how frequent you're monitoring, what the alarming values would be, and what the patient should do if these values are met.... Also this section is particular to adverse effects caused by the medication... look at doxycycline's most common side effects and formulate a plan here for these.
-
OTC
Would also mention here any antipyretics or anti-inflammatory drugs your patient is using.
-
influenza vaccine
route and dose?
-
Td 2 booster
route and dose?
-
electrolyte
Which electrolytes? What values would cause alarm?
-
102 degrees
Fahrenheit or Celsius? Don't forget units.
-
should monitor
How often are you monitoring?
-
fever
What is your patient's goal temperature?
-
24-48
Don't use a range. Choose either 24 or 48.
-
Rationale
Good job on this section. The only thing I would think about adding is the reason why tetracyclines are preferred over other antimicrobial classes.
-
-
pharmd.umc.edu pharmd.umc.edu
-
5-14
Change this to whatever you choose above
-
influenza shot
What dose and route?
-
tetanus shot
What dose and route?
-
contains DEET
Be sure to state why this is effective. How often it should be applied. etc.
-
places that are endemic
What places are these? Give an example or two.
-
Adverse Event Monitoring
How often are you monitoring for the adverse effects? Also there are many more adverse effects for doxycycline that are super important you may want to mention.
-
fever is subsiding
What specific value are you looking for here? Temp < ?
-
24-48
Don't use a range. Choose one.
-
Rationale
Be sure to mention why doxycycline was specifically chosen other antibiotic classes such as cephalosporins, fluoroquinolones, etc.
-
5-14
Choose a specific length... don't ever use a range. You can choose 5, 7, 10, 14 days, but just choose one.
-
po or IV
Are you going to put her in the hospital for a tick bite? Don't use IV... Just po and change "po" to "by mouth".
-
-
pharmd.umc.edu pharmd.umc.edu
-
I am starting you on Doxycycline
Technically her doctor is starting her on this medication. Generally speaking you can shorten this section a lot by stating What is doxycycline, what is it for, how should the patient take it, what are some adverse effects, what should they do if adverse effects occur, what should they do if they miss a dose, what are the outcomes they should expect and timeline they should expect them in.....
-
NonPharm
What other nonpharm things can she do? Is there tick repellent she can use? What about your sunscreen recommendations? Is there something she can do for the rash like an oatmeal bath or topical anesthetic?
-
tetanus vaccination
What dose and route? Is this the only vaccination she needs?
-
applying sunscreen
How often? What SPF? Be specific with recommendations.
-
Adverse Event Monitoring
For this section mention the specific adverse event, the specific thing you're monitoring for with that adverse effect, the frequency you're monitoring, and what your plan is if that adverse event occurs. For example "KN should self monitor daily for signs of SJS such as a new rash, if this occurs, she should stop taking doxycycline and contact her physician immediately".
-
Therapeutic Monitoring
For this section. Mention the specific thing you're monitoring, the frequency it should be monitored, the goal value you want to achieve.
-
ever should be within normal range
What is the normal range?
-
AST, LDH, and bilirubin
What goal values are you trying to achieve?
-
complete blood count
What particular parts of a CBC measure infection? You need to mention these along with the normal values that you're trying to achieve. For example "Monitor KN's WBC at follow up in one week to ensure it has normalized (WBC 4-11 goal)." Or something like that.
-
side effects
What side effects? Why do you want to avoid these side effects?
-
since before the 80s. 1 A
This isn't relevant. Just say they're the treatment of choice and then say why they're better than every other medication.
-
here are several brand names for this medication including: Adoxa, Adoxa CK, Adoxa Pak, Adoxa TT, Monodox, Oracea, Vibramycin Monohydrate, and Avidoxy. 3 T
Don't do this. Just put "Begin doxycycline (generic) 100mg tablet by mouth every 12 hours."
There is literally no reason to list out all the brand names and each brand is potentially a different dosage form and strength so just avoid doing this by using the generic.
-
-
pharmd.umc.edu pharmd.umc.edu
-
pill
tablet
-
pill
"Pills" isn't a term you should use... It might not matter now, but you will get in trouble for this later on. Dosage forms include tablets, capsules, solutions, creams, ointments, etc.
-
NonPharm
What Nonpharm things can your patient do? Sunscreen maybe? What about a tick repellent from now on? What about her rash? Are there topical anesthetics she can use? There is A LOT of information that should be in this section that you're missing.
-
updated tetanus shot
What is the dose and route of this? When should the patient receive it? For vaccines always put the dose and route... I.E. Influenza vaccination 0.5mL IM.
-
NSAIDs
What NSAIDs? What dose? Route? Frequency? Is APAP an NSAID? Be specific here. Generic statements will not fly.
-
lab values should continue 24-48 hours into the drug regimen in order to assess the effectiveness of the treatment. 5 If lab values have not improved (AST 10-40, ALT 7-56, Na 135-145 mEq/L, and platelet 150,000-450,000 mm 3 ) along with fever in 48 hours, the therapy should be discontinued
Are these values for monitoring the effectiveness of the drug or the side effects of the drug?? If they're effectiveness, then only put them in the therapeutic monitoring section. If they're side effects, then only put them in the adverse effects section...
-
Adverse Event Monitoring
In this section you again want to specify how often you're monitoring for these things, the specific things you're monitoring, and what the patient should do if those things happen (i.e. call their physician, discontinue the drug, etc.).
-
98.6 degrees Fahrenheit is present
Would you consider 98.9 degrees acceptable? It's better to say "until fever subsides (temperature <x" and then find out what temperature is considered fever.... Almost no one has a perfect 98.6 temperature....
-
continue to be monitored
How often should fever be monitored for? Daily? Weekly? Annually?
-
24-48
Never use ranges... Just say "Fever should subside by 48hrs"
-
Therapeutic Monitoring
In this section you want to focus on specific things you're monitoring to make sure the drug is working... Always mention what you're monitoring, how often you're monitoring it (i.e. daily, every week, etc.), and what your plan is if these values are not met.
-
Rationale
You need to explain why you chose doxycycline over other classes such as fluoroquinolones, cephalosporins, penicillins, etc. You need to specify exactly what makes it the BEST choice for the patient. Generic broad statements such as "is the treatment of choice" are not enough... you need to go into details on WHY it is the best. Mention things like side effect profiles, effectiveness, duration of treatment, cost, etc to prove this. This section should be your longest section because you are trying to justify your choice.
-
nywhere between 5-10 day
"up to 10 days" never use a range.
-
-
pharmd.umc.edu pharmd.umc.edu
-
flu sho
dose and route? "influenza vaccination 0.5mL IM"
-
TDAP booster
What's the dose and route?
-
HCl
Don't need to say this. Just say "doxycycline"
-
-
pharmd.umc.edu pharmd.umc.edu
-
5 to 7
Don't use ranges. Choose one or the other.
-
po bid. 2,
Don't use these. Say "by mouth every 12 hours"
-
rocky mountain spotted fever (RMSF)
Don't say this. Just say "TBRD". There are multiple TBRDs and RMSF is only one of them so only use this if the prompt specified RMSF...
-
-
pharmd.umc.edu pharmd.umc.edu
-
Td booster shot, a varicella vaccine series (possibly), and a flu shot
Give the doses and routes for these... Ex) influenza vaccination 0.5mL IM
-
-
pharmd.umc.edu pharmd.umc.edu
-
NonPhar
You should probably mention your sunscreen recommendations here again. Also is there anything she can do for her rash? Oatmeal bath? Topical anesthetic? OTCs are a big player in pharmacy so there are ALWAYS things you can recommend. Also how can KN avoid future tick bites? Is there a repellent you recommend? Clothing? Etc?
-
Vaccine
Does she need any vaccinations? Consult the CDC vaccination schedules and recommendations for her age group....
-
Adverse Event Monitoring
Always be sure to include how often you're monitoring for these things and who is monitoring... Is the patient self-monitoring daily? Is the nurse monitoring? Is the patient's parent/caregiver monitoring? Things you should consider.
-
wear sunscreen
How often? What SPF? Be specific in your recommendations.
-
hypotension
What is the definition of this? Make sure to always include specific values.
-
signs of renal failure
What signs? Dark urine? Decreased urine? Be specific on what you are looking for.
-
signs and symptoms
Be specific on things you are looking for and how often your patient should be monitored. For example... "KN should self-monitor daily for resolution of fever (temp <'x')"
-
Rationale
So why doxycycline instead of tetracycline? Why is doxy the choice over cephalosporins or fluoroquinolones? Your rationale section should convince the reader that doxy is the BEST choice and should provide reasons why the other drugs shouldn't be chosen. It should be your longest section.
-
side effects
What side effects does it cause? Make sure you rationalize why doxycycline is a better option.
-
5 days following the cessation
Make sure you specify a total duration of therapy. So you could say "for a duration of 5 days" and then follow it with "if symptoms have not resolved in 5 days, KN should notify her physician for extended therapy".
-
twice daily.
This is sort of unspecific. Twice daily can mean a lot of things to a lot of different people. It is better to say "every 12 hours".
-
po
Try not to use this. Say "by mouth" or "orally".
-
tablet
Make sure you specify how many tablets... "100mg, one tablet by mouth every 12 hours" is better.
-
APAP
Say the drug name here and you can abbreviate later.
-
further disease progression
What are you trying to prevent in particular? Hosptial admission? Death? Be specific on what you want to prevent
-
-
pharmd.umc.edu pharmd.umc.edu
-
next few days
How many days is a "few"? Be specific and make sure you tell your patient when they should go back or call their doctor if their symptoms don't improve....
-
OTC
What other OTC/NonPharm products can you recommend? What should KN use to make sure she doesn't get another tick bite? Perhaps think about mentioning some sort of tick repellent? What about her itching/rash? Can she use something like an oatmeal bath?
-
Td booster
What dose and what route?
-
eceive an influenza vaccine
How should she receive this? For every vaccine you mention, always mention the dose and route! So for this it would be "KN should receive influenza vaccination 0.5mL IM."
-
4 to 6
Choose one of these.... Also make sure you don't exceed the max dose of APAP!!
-
o
"to"
-
sunscreen
What kind of sunscreen? What SPF? How often should she apply it? Sunscreen is effectively a drug so make sure you mention specific instructions to how it should be used.
-
Adverse Event Monitoring
This section is specific to adverse effects of your drug therapy. Take a look at the most common side effects of doxycycline and use this section to tell your patient how often she should monitor for what symptoms and what to do if these symptoms occur. "KN should monitor daily for nausea/diarrhea. If these occur and persist for more than 48hrs, KN should notify her physician".
-
5-7
Choose one of these, don't give ranges
-
at each visit
How often is she coming to the doctor? Instead you could say "KN should self-monitor daily for resolution of chills, rash, muscle aches, and fever (temperature goal of x)."
-
complete blood count, comprehensive metabolic panel, and peripheral blood smear to confirm TBRD
What specific tests are you looking for? A CBC contains a bunch of information... what within in a CBC are you monitoring to make sure doxycycline is working?
-
trovafloxacin is no longer marketed or distributed in the United States
Don't use it in your treatment plan then... Like don't even mention it if it's not marketed... There's no reason to.
-
one
Capitalize. Also I would change this and say something like "Doxycycline has been proven more effectively clear rickettsia than azithromycin/trovafloxacin.."
Also I don't know that trovafloxacin is a real drug... I've never heard of it? Make sure it is available in the U.S. before mentioning it in your treatment plan.
-
allergic reactions
What particular allergeic reactions are you trying to avoid?
-
etween around 5-7 days
Choose either 5 or 7 days. Never use a range in your treatment plans because it's not specific.
-
at least 3 days after her fever diminishes and until improvement is noted
You need to choose a specific time frame. Don't ever say "for at least 3 days after..." Instead I would choose a specific amount of time (i.e. 5, 7, or 10 days) and then add a sentence regarding follow-up with her physician if symptoms do not resolve. It is always better to be specific.
-
tablets taken
How many tablets? For example, instead you should say "Begin doxycycline (generic) 100mg, one tablet by mouth every 12 hours for 3 days".
-
twice daily
This is pretty unspecific. It's better to say "every 12 hours" because "twice daily" could mean at 10am and then again at 11am...
-
Patient may continue the use of acetaminophen because it does not interact with the treatment regimen and may help relieve her headaches
It's totally fine to just say "KN may continue to use acetaminophen". You only have to explain things if you're discontinuing them.
-
allow her to take care of her daughter
Excellent to mention the patient's quality of life. Good job!
-
signs and symptoms of TBRD she is experiencing
Just state the signs/symptoms here. Ex) "Goals for KN include relieving fever, chills, muscle aches, and rash". And if you're going to use "TBRD" you need to say what that stands for... "Tick Borne Related Disease (TBRD)" and then afterwards you can just use "TBRD". Always define your acronyms the 1st time.
-
- Aug 2018
-
pharmd.umc.edu pharmd.umc.edu
-
Adverse Event Monitoring
Remember to mention how often you're going to monitor.... What exactly you're monitoring for (specific values or s/s)... what the critical values are... and what your plan is if these things happen.
-
48-72
avoid ranges
-
0-2
I dont think this is right.... a 2 on RASS means your patient is agitated... Review this scoring system.
-
Richmond Agitation-Sedation Scale
Yes. Thank you. Excellent.
-
steady-state concentration of 8-16 mg/L
Is this necessary??
-
24-4
avoid ranges
-
1-4 hours, 3 f
avoid ranges
-
is the most widely used
This doesn't mean it's the best option for our patient.... Give a reason diazepam is better than librium or ativan....
-
electrolytes
What about his Mag?
-
4 mEq/L of potassium
Is this enough to replace your patient's level? Seriously consider this....
-
8-12
avoid ranges
-
24-72
avoid ranges
-
New Drug Therapy
Consider any emergent electrolyte disturbances the patient has... how are you going to correct these? Also are there nutritional deficiencies you need to correct?
-
14 days
Thats a long hospital stay... could you say "continue until cultures/sensitivies return and then de-escalate"??
-
8-12
avoid ranges
-
-
pharmd.umc.edu pharmd.umc.edu
-
Since meropenem is dosed three times daily as opposed to imipenem being dosed four times daily, meropenem was selected
Does this actually matter when your patient is in the hospital? There are other reasons to go with Merrem...
-
insulin for hyperglycemia
What dose? What kind of insulin? How often? If you're going to mention it then you have to mention all of this. Otherwise don't bring it up... (my suggestion).
-
intravenous potassium, calcium and magnesium
In what forms? What doses? What rates?
-
2-3
Dont give a range... also are you going to keep him in the hospital for 2-3 wks?
-
0.5 g three times a day
is this a renally adjusted Abx?
-
-
pharmd.umc.edu pharmd.umc.edu
-
5 to 10 mg in 3 to 4
avoid ranges
-
65-110 mg/Dl
is this the goal for inpatient?
-
MH is persistently vomiting and will not be able to take or
but you said he could continue oral tylenol and pepcid!! Be consistent.
-
continuously infusing imipenem/cilastatin
continously infusing every 6hr doesn't make much sense re word this sentence
-
3 to 4
avoid ranges
-
500 mg intravenously every 6 hours
Is this drug renally adjusted? Is this the right dose? I'm not sure and im too lazy to google it so double check
-
Continue Tylenol for pain management and Pepcid for his PUD
May want to look at these some more... do they cause harm in pancreatitis?
-
-
pharmd.umc.edu pharmd.umc.edu
-
Continue Pepcid prn for nausea
oral med for nausea/vomiting?
-
Serum glucose levels
what are the goals
-
48-72
avoid ranges. what electrolytes specifically? what are the goals?
-
frequent
how frequent
-
24-48
avoid ranges
-
Wernicke-Korsakoff syndrome
Good. Research this before group.
-
electrolyte levels were deficient
What electrolytes are in LR? How much? Is this sufficient for your patient? You added potassium and thats great... but what about Mag?
-
5-10 mg in 3-4
avoid ranges
-
6h
in imipenem renally adjusted?
-
Begin Begin
Error
-
-
pharmd.umc.edu pharmd.umc.edu
-
4-8
avoid ranges
-
48-72
avoid ranges
-
vancomycin
you're right. Vancomycin only really covers MRSA (it actually kind of sucks at general gram + organisms too). Free information.
-
better electrolyte balance
What electrolytes are in LR? How much? is this sufficient for your patient?
-
New Drug Therapy
remember standard drug form... Merrem (meropenem) 1g IV infused over 30min every 8 hr.... Or meropenem (generic) 1g IV infused over 30min every 8hr
-
2-4 mg
avoid ranges
-
250-500
Avoid ranges
-
Continue Pepcid PRN and start back on Pancreaze
Is this the best option? Could these be held until discharge? Pt has N/v... are oral meds okay?
-
-
pharmd.umc.edu pharmd.umc.edu
-
new
Ehhh it's been around for a bit and is actually on formulary at most institutions. Don't know that I would describe it as "new"
-
oxycodone 10 mg tablet
Is this your best option in combo with a benzo? Think about the implications. Also you're giving an opioid to an alcoholic... more implications.
-
IV potassium, calcium, and magnesium
In what forms and what doses and what rates should these be given at
-
48 to 72
avoid ranges
-
5 to 30
avoid ranges
-
-
pharmd.umc.edu pharmd.umc.edu
-
dehydropeptidase inhibitor
This really isn't a big deal because the drugs come together and are administered as one... It's like using Augmentin or Zosyn... Find another benefit of meropenem (theres several).
-
fluids and electrolytes
all of the electrolytes? Look at what electrolytes LR contains and how much of each electrolyte... is this adequate for your patient?
-
begin ibuprofen
Is this the best option? Are you concerned about a GI bleed?
-
-
pharmd.umc.edu pharmd.umc.edu
-
shock
what are the s/s of this? Specific values?
-
on many hospital formularies
This is true but why do hospitals prefer it? You need to give a reason of why it is better than imipenem... is the SE? Cost?
-
predicable
spelling
-
New Drug Therapy
are there any emergent electrolyte disturbances that need to be fixed? What about nutritional deficiencies?
-
15 to 30
avoid ranges
-
Continue taking Pancreaze (pancrelipase) and Pepcid
Are you sure? Can he tolerate oral meds with n/v? Are these necessary to his acute illness or could they be held until discharge?
-
-
pharmd.umc.edu pharmd.umc.edu
-
24 hours after admission
Why wait 24hr?
-
IV potassium, calcium, and magnesium
What forms? What dose? What rate?
-
-
pharmd.umc.edu pharmd.umc.edu
-
Adverse Event Monitoring
How often are you monitoring for these things, what specific values or s/s are you monitoring for? What are the critical values? What are you going to do if they occur?
-
abdominal compartment syndrome and systemic inflammation response syndrome
how do you monitor for these? How often?
-
Therapeutic Monitoring
How often are you monitoring? what specific values are you trying to reach?
-
ever and heart rate should return to normal
what is normal
-
levels
list the levels
-
normal levels
what are these
-
lorazepam
Actually.... Ativan does come IV.... And we use it A LOT. So you need a reason to use diazepam over ativan...
-
vomiting an oral BZD
But you said him taking oral pepcid was fine... be consistent in your plan...
-
similar efficacies
Okay so why did you go with merrem over imipenem? Give a reason for your choice... SEs? Cost?
-
thiamine 100 mg/25 g glucose IV
Look into this more. There's a better formulation. You don't necessarily want to give 25g of glucose when your patient is hyperglycemic...
-
15-30
avoid ranges
-
1 g IV every 8 hours
Is merrem renally adjusted?
-
magnesium 14 mEq
There's a better solution here. Mag Sulfate comes in grams... I suggest looking into this more.
-
IV potassium 102 mEq (2 mEq/kg
What form of potassium? KCl? Kacetate? KPhos? What dose? How much can you give? (Hint: there is max rate allowed per hour....)
-