Include routes and doses of vaccinations

Choose one of these

Choose a specific duration.

Unless the case pages state this, don't use it! There are many TBRDs... RMSF is only one of them.

Include routes and doses of vaccines.

Routes and doses of vaccinations are needed.

Choose one of these.

Choose a specific duration

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

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"

Don't use these abbreviations. Say "by mouth every 12 hours"

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

Don't use ranges. Choose either 5 or 7 days.

mention dose and route. (0.5mL IM).

dose and route?

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.

What specific value would you hope to achieve?

What is normal? What are the specific labs you're looking at and what are the values you hope to achieve?

Choose one.

This would adverse event monitoring, not therapeutic.

"by mouth"

4 or 6... choose one. Don't use ranges.

"by mouth"

Does she have this or TBRD? Not always the same thing. Only mention the one that is in the case pages.

Would probably try to mention her APAP again here.

What doses and routes?

What values would be alarming? What would you do if this happens?

This would be therapeutic monitoring, not adverse event

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.

How often are you monitoring? What values would be alarming? What should the patient do if these values are met?

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.

Don't use a range. Choose one of these.

It is helpful to mention why tetracyclines are used over other antimicrobials, and reasons why doxycycline is the best out of all tetracyclines.

Again, wouldn't mention this since it's not specified in the case pages.

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....

"by mouth"

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.

Would also mention here any antipyretics or anti-inflammatory drugs your patient is using.

route and dose?

route and dose?

Which electrolytes? What values would cause alarm?

Fahrenheit or Celsius? Don't forget units.

How often are you monitoring?

What is your patient's goal temperature?

Don't use a range. Choose either 24 or 48.

Good job on this section. The only thing I would think about adding is the reason why tetracyclines are preferred over other antimicrobial classes.

Change this to whatever you choose above

What dose and route?

What dose and route?

Be sure to state why this is effective. How often it should be applied. etc.

What places are these? Give an example or two.

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.

What specific value are you looking for here? Temp < ?

Don't use a range. Choose one.

Be sure to mention why doxycycline was specifically chosen other antibiotic classes such as cephalosporins, fluoroquinolones, etc.

Choose a specific length... don't ever use a range. You can choose 5, 7, 10, 14 days, but just choose one.

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".

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.....

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?

What dose and route? Is this the only vaccination she needs?

How often? What SPF? Be specific with recommendations.

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".

For this section. Mention the specific thing you're monitoring, the frequency it should be monitored, the goal value you want to achieve.

What is the normal range?

What goal values are you trying to achieve?

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.

What side effects? Why do you want to avoid these side effects?

This isn't relevant. Just say they're the treatment of choice and then say why they're better than every other medication.

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.

tablet

"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.

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.

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.

What NSAIDs? What dose? Route? Frequency? Is APAP an NSAID? Be specific here. Generic statements will not fly.

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...

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.).

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....

How often should fever be monitored for? Daily? Weekly? Annually?

Never use ranges... Just say "Fever should subside by 48hrs"

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.

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.

"up to 10 days" never use a range.

dose and route? "influenza vaccination 0.5mL IM"

What's the dose and route?

Don't need to say this. Just say "doxycycline"

Don't use ranges. Choose one or the other.

Don't use these. Say "by mouth every 12 hours"

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...

Give the doses and routes for these... Ex) influenza vaccination 0.5mL IM

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?

Does she need any vaccinations? Consult the CDC vaccination schedules and recommendations for her age group....

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.

How often? What SPF? Be specific in your recommendations.

What is the definition of this? Make sure to always include specific values.

What signs? Dark urine? Decreased urine? Be specific on what you are looking for.

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')"

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.

What side effects does it cause? Make sure you rationalize why doxycycline is a better option.

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".

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".

Try not to use this. Say "by mouth" or "orally".

Make sure you specify how many tablets... "100mg, one tablet by mouth every 12 hours" is better.

Say the drug name here and you can abbreviate later.

What are you trying to prevent in particular? Hosptial admission? Death? Be specific on what you want to prevent

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....

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?

What dose and what route?

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."

Choose one of these.... Also make sure you don't exceed the max dose of APAP!!

"to"

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.

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".

Choose one of these, don't give ranges

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)."

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?

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.

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.

What particular allergeic reactions are you trying to avoid?

Choose either 5 or 7 days. Never use a range in your treatment plans because it's not specific.

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.

How many tablets? For example, instead you should say "Begin doxycycline (generic) 100mg, one tablet by mouth every 12 hours for 3 days".

This is pretty unspecific. It's better to say "every 12 hours" because "twice daily" could mean at 10am and then again at 11am...

It's totally fine to just say "KN may continue to use acetaminophen". You only have to explain things if you're discontinuing them.

Excellent to mention the patient's quality of life. Good job!

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.

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.

avoid ranges

I dont think this is right.... a 2 on RASS means your patient is agitated... Review this scoring system.

Yes. Thank you. Excellent.

Is this necessary??

avoid ranges

avoid ranges

This doesn't mean it's the best option for our patient.... Give a reason diazepam is better than librium or ativan....

What about his Mag?

Is this enough to replace your patient's level? Seriously consider this....

avoid ranges

avoid ranges

Consider any emergent electrolyte disturbances the patient has... how are you going to correct these? Also are there nutritional deficiencies you need to correct?

Thats a long hospital stay... could you say "continue until cultures/sensitivies return and then de-escalate"??

avoid ranges

Does this actually matter when your patient is in the hospital? There are other reasons to go with Merrem...

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).

In what forms? What doses? What rates?

Dont give a range... also are you going to keep him in the hospital for 2-3 wks?

is this a renally adjusted Abx?

avoid ranges

is this the goal for inpatient?

but you said he could continue oral tylenol and pepcid!! Be consistent.

continously infusing every 6hr doesn't make much sense re word this sentence

avoid ranges

Is this drug renally adjusted? Is this the right dose? I'm not sure and im too lazy to google it so double check

May want to look at these some more... do they cause harm in pancreatitis?

oral med for nausea/vomiting?

what are the goals

avoid ranges. what electrolytes specifically? what are the goals?

how frequent

avoid ranges

Good. Research this before group.

What electrolytes are in LR? How much? Is this sufficient for your patient? You added potassium and thats great... but what about Mag?

avoid ranges

in imipenem renally adjusted?

Error

avoid ranges

avoid ranges

you're right. Vancomycin only really covers MRSA (it actually kind of sucks at general gram + organisms too). Free information.

What electrolytes are in LR? How much? is this sufficient for your patient?

remember standard drug form... Merrem (meropenem) 1g IV infused over 30min every 8 hr.... Or meropenem (generic) 1g IV infused over 30min every 8hr

avoid ranges

Avoid ranges

Is this the best option? Could these be held until discharge? Pt has N/v... are oral meds okay?

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"

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.

In what forms and what doses and what rates should these be given at

avoid ranges

avoid ranges

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).

all of the electrolytes? Look at what electrolytes LR contains and how much of each electrolyte... is this adequate for your patient?

Is this the best option? Are you concerned about a GI bleed?

what are the s/s of this? Specific values?

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?

spelling

are there any emergent electrolyte disturbances that need to be fixed? What about nutritional deficiencies?

avoid ranges

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?

Why wait 24hr?

What forms? What dose? What rate?

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?

how do you monitor for these? How often?

How often are you monitoring? what specific values are you trying to reach?

what is normal

list the levels

what are these

Actually.... Ativan does come IV.... And we use it A LOT. So you need a reason to use diazepam over ativan...

But you said him taking oral pepcid was fine... be consistent in your plan...

Okay so why did you go with merrem over imipenem? Give a reason for your choice... SEs? Cost?

Look into this more. There's a better formulation. You don't necessarily want to give 25g of glucose when your patient is hyperglycemic...

avoid ranges

Is merrem renally adjusted?

There's a better solution here. Mag Sulfate comes in grams... I suggest looking into this more.

What form of potassium? KCl? Kacetate? KPhos? What dose? How much can you give? (Hint: there is max rate allowed per hour....)