This is ridiculously low... He might go into cardiac arrest... Are you replacing this? (Hint: Look at LR and how much potassium it contains, do you think this is adequate to keep your patient from having cardiac issues?)

How frequent are you monitoring these? What values are you monitoring?

What are these signs? And what are you going to do if it happens?

You need to consider your patient in your rationale... What's his renal function? Did this make a difference in the dose you chose? What's his diet status (NPO, tube feeds, PO, etc) and does this make a difference in your choices?

Is this exclusive to liver disease or does this also happen in pancreatitis or acute alcoholism? I like Ativan as a choice, there are many more reasons Ativan is good.

You need to mention that this is why you chose it over NS...

Please look at how much of each electrolyte LR has... Is this enough to cover your patients needs?

Which one? Don't use ranges.

Can your patient tolerate oral meds with his nausea/vomiting? If so, this is fine... Just defend this option in your rationale.

What electrolytes are you trying replace? What is your plan for this? LR? Probably not going to work for some of them... look at LR and how much of each electrolyte it contains...

No. Stop. Don't do this. 1) You need give 1g every 8hr, not 1g over 8hr.... totally different 2) Merrem isn't compatible with LR so don't use LR to dilute merrem... BAD. 3) you can give merrem 1g every 8hr (diluted with NS, but you don't have to mention this) over 15min while you're simultaneously giving LR at a rate of 500mL/hr.... Essentially you're creating an IV piggyback or giving it in a separate line works too. Just general knowledge you need to know.

Can your patient tolerate his oral meds with N/V? Something to consider in every patient you encounter.

Inpatient?

You need to work on this section. How often would you monitor for each Adverse event? What critical values are you looking at? What are you going to do if that critical value is met?

What value do you want?

Don't give a range.

There is specific tool you may want to use for monitoring of these symptoms....

What is the goal? (Hint: inpatient goal)

Changed to what?

Which one? Don't give a range.

What electrolytes? What values are you looking for? Are you sure this is the right monitoring frequency?

Don't give a range. Just say a value. Also is this the normal range for Urine output? Double check.

What levels are you looking for?

So why did you choose it and not merrem? You have to give a reason for selecting it instead of merrem....

Why do you need to give IV drugs?

There is another reason we theoretically give thiamine to people with AWS... Research thiamine use in AWS.

Given

Excellent!

Always be cautious about this. You did great giving supplemental K above and not just relying on LR to fix it (LR only has 4mEq/L of K which would not be enough for your patient). Always be weary about how much of each electrolyte is in your fluid....

Keeping him in the hospital for 10 days? Or can you plan to de-escalate to oral Abx at some point and send him home? Things to consider.

Consider your patient's renal function... I don't know what it is but Abx are renally dose adjusted so if he has renal impairment then this dose may be wrong.

This is the only reason to d/c them?

What are these complications?

What are normal? Pick out the important ones here... you don't have to list all of these. Being able to pick out important lab values is super relevant.

This is too specific. You need to state goal levels, BP >90/60... or MAP >65 is good.

Good. Always mention QoL

Technically you're giving anticonvulsants in the form of benzos... So you might want to specify that anti-epileptics (i.e. keppra, phenytoin) are not necessary....

Hmmmm... You're using symptom-triggered benzo dosing so are you really preventing seizures? Or just prepared to treat them if they occur? Think about these things.

Choose one... don't give a range.

How often? Continuously? Hourly? Daily?

How much time?

What if he has respiratory depression? Do you still want to give it? Or hold it? Intubate him? Give some flumanezil? I need specifics.

How often is regularly? Around the clock? Hourly? Daily?

How often are you monitoring for this? It's totally chill to say "MH should be monitored continuously..."

What critical value are you concerned about?

What are the critical values of these? Also sepsis is a deep hole so be careful...

How often?

How often are you monitoring?

What do you do for these? How often are you monitoring for these?

Hypermag isn't an issue? Might want to make sure.

By how much? Also this is overdose of LR and you should probably specify that...

What are the values for these?

Also fun note and more free knowledge... Alcohol typically causes metabolic acidosis and you haven't even mentioned that factor in your plan. Or how Anion Gaps are used in monitoring resolution... Fun items.

What's the critical value for this and respiratory distress? What would you do about these things? Keep giving LR? Switch? I need direction...

Good but what do you do if this happens?? For every adverse event or set of adverse events you need a plan for how to proceed....

What values do you want?

Which one? There's a large difference in 5mg and 10mg... You're risking snowing your patient here.

Excellent!

Not your best option. If you have a culture and sensitivities then you're Abx should be based on those. Also, Vancomycin is only good at covering MRSA (not typical of gut) and it kind of sucks at all the other Gm+ organisms.... I know you didn't learn anything in that antibiotics course so I'm offering this information for free.

And provide sensitivities right? What if it's Gm- but the organism is resistant to merrem?

Define this... If patient has kidney issues at baseline how would you assess that creatinine is "normal"? Hint: There is a specific increase of SCr over a specific amount of time that may be helpful...

How? What are your critical values? How do you adjust based on these?

How often is regularly? every 2hrs? Daily?

Good. But what are you specifically monitoring hourly? Urine output? CBC? BMP?

What are the critical values for these? How do you know if his fluid replacement is working based on these?

How often?

Excellent!

Why is IV important? In the first section you said you could keep Pepcid OTC (oral)... so why can't you do oral Librium here? Be consistent in your plan. I agree IV is better (pt has n/v and should probably be NPO)....

Fine here, but is this always a good thing? Just something to always consider in general.

What other drug classes?

This is true, almost every facility carries Merrem. Also consider any side effect differences between the two products.

What else happens with Mg deficiency? Think about these implications... They're pretty major.

Are you sure that LR has enough of each of these to normalize your patient? Be cautious here.

Are there other electrolytes besides Mg you are concerned about? Look at how much of each electrolyte LR contains and determine if this is going to be sufficient for your patient... Also consider any potential nutritional deficiencies that may be related to pancreatitis/AWS...

I would make this a new sentence and state "LR is associated with reduced sys inflammation in comparison to NS"... Save space where you can.

Can he tolerate oral meds? Something to always consider in every patient...

Excellent.

are you going to keep this guy in the hospital for 14 days?

Don't give a range... give a specific amount of time... How fast can you safely infuse mag?

Yep but is there an association between tylenol and pancreatitis as well? Would this also be grounds for d/c?

What are the specific goals?

Consider your patient's baseline SCr... If a patient has CKD it is highly unlikely that their baseline SCr would ever be <2... These are just things to consider.

Renal function is usually monitored via a specific % or amount of increase in SCr over a specific amount of time....

How are you monitoring this? Respiratory depression? What's the specific values you're looking at? Is there a scale or lab value?

How often are you monitoring for each ADE? What labs of s/s are you monitoring for? What are you going to do if these things occur?

How is this monitored? Are there specific lab values?

How often? Specific...

When is the patient considered chronic?? What oral therapy?

Could you increase dose instead of switching? What's the value in switching...

How often are you checking this? Is there a specific tool to use??

How often?

What is it??

For each thing mentioned... you need to state how often your monitoring it, what the critical value is (normal range, etc.), and your plan if it is not met (aka if therapy isn't working...)

What are the goal levels for these?

Be sure to specify what the normal ranges are...

And probably based on susceptibilities.

Why did you choose that specific dose of thiamine?

Excellent!!

Same sentence as above, delete it. Also should be ADE monitoring, not rationale.

Same sentence as above... delete it.

This should probably be in the Adverse event section and not rationale...

You need to carefully consider how much of each of these electrolyte LR contains... For example, it only has about 4mEq/L of K... Is that going to be enough? Consider this and consider if further replacement of these electrolytes is necessary....

Excellent!

If there's no difference in outcomes why did you use merrem and not imipenem? Be sure to clarify this.

What route? IV or IM? I know what you mean but you need to have a route for every drug.

Is this the best route? You said above that the patient can tolerate oral meds... furthermore your patient has an IV line... so could you give it that way instead of sticking him again?

What is this range?

Okay, so let's prioritize here... What's MH's #1 issue at the current moment? Probably pancreatitis (fluids/electrolytes/Abx)... And #2? Probably AWS (anxiety/nutrition/electrolytes)... That's a lot to conquer in 1 page... Remember that our #1 focus on the inpatient side is getting the patient stable enough to discharge him... the rest of the stuff we should let his primary care physician tackle.

Again, the physician wants our opinion... what do you think? This happens on rounds all the time, so have an answer...

But the physician is asking us... So what do you think needs to happen in regards to pain and nutrition?

So why not just take 2 pepcid OTC?? These are the same thing basically.

You should also look at recent literature about H2 antags in pancreatitis. Not sure if its relevant for this treatment plan, but it is relevant for life in general.

Consider your patient's current status... can he take oral drugs? If so, then great. But you must always consider these factors and be prepared to rationalize them.

Excellent.

Excellent mention.

What is baseline?

What is normal?

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

What symptoms?

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)

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).

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.

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.