- Aug 2018
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pharmd.umc.edu pharmd.umc.edu
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24-48
Choose one. You need to avoid ranges at all costs.
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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.
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frequent
How frequent is frequent? You need to be specific...
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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...).
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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.
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It
What is "it"? You lost me here.
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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.
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renally impaired
Good to consider this...
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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.
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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.
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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....
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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.
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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.
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i
Capitalize.
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while the source
What is it called when you start Abx before the cultures come back?? (Hint: Empiric therapy...)
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8-12 hours
Choose one of these... never give ranges.
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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.
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Continue Tylenol ES
Are you sure? Look at this some more and be prepared to defend your answer.
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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.
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no indication
Look at Bactrim's side effects... is there a specific reason he shouldn't be on bactrim?
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vital signs will return to normal range
Give the normal ranges if you're going to mention this
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get back to his normal daily routine
Excellent! Always mention QoL.
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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"
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fever, rapid pulse
Include the specific goals for these
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pharmd.umc.edu pharmd.umc.edu
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5 mg
You may want to double check this dose and make sure you aren't going to snow your patient.... I usually suggest starting low and going slow with benzos...
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References
I hope you're going to make these complete references before turning this in...
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discontinued
Is there something else you could do in the event of respiratory depression? You don't really want your patient not being able to breathe for a significant amount of time... Hypoxia is pretty dangerous... Is there a way to reverse the respiratory depression effect of benzos?
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phlebitis
Any time you ever mention phlebitis ALWAYS put what to do in the event it occurs... How do you fix it? This is super important for a lot of drugs and a lot of treatment plans that you will write this year.
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ALT (9-52 U/L) and AST (8-39 U/L)
Think about the physiology of this disease state... would you expect an increase in these to be an adverse event of the drug or an indication that your drug isn't working and the disease state is progressing? Just something to think about....
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136 mEq/L, then that means he has hyponatremia, and therapy with lactated Ringer�??s may need to be changed to normal saline
I don't know that you really understand hyponatremia yet or the electrolytes within LR but it's pretty unlikely (almost impossible) that LR would lead to hyponatremia (it has 140mEq of Na in it)... I would think primarily about other electrolytes that are bigger issues (K, Mg...).
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New Drug Therapy
There are other things that happen secondary to pancreatitis and alcohol withdrawal that require additional pharmacologic intervention.... I would suggest thinking about these things.... Hint: Nutrition state, electrolytes.
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Fine needle aspiration
Is this necessary? This is a painful procedure... When should you do this?
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not working
I am confused... Because the goals you mentioned were adequate... So you might be missing a word like "If these values are not met then it might indicate resuscitation is not working"... Re-read this and fix it because it changes your entire plan.
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long-acting
I understand your argument here but I'm going to play devil's advocate... What happens if you give too much diazepam?? It's long acting so the implications of overdosing it are greater than if you were to overdose a shorter-acting such as ativan... Just something you always need to consider for your clinical experiences.
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fluoroquinolone
It might be worth mentioning that FQs have a hefty side effect profile or something too...
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one study
Only 1 study? You could just say that its been proven that carbapenems are better....
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Gram-negative bacteria
Why do you expect Gm- bacteria? Obvious, but these are things the graders like to pick out and its incredibly annoying.
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hydroxyethyl starch
This isn't even really worth mentioning because it's literally never used anymore.... because everyone was dying. If you're going to compare LR to anything else it should be Plasmalyte...
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appears stable
What's your definition of stable?
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decrease BUN
What is your goal for BUN?
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0.5-1
Same thing here. I would stick with UO > 0.5mL/kg/h rather than giving the range.
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65-85
There is usually a very specific goal for MAP... And you gave a range, which I wouldn't recommend in regards to MAP... so I would stick with "MAP >65"
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Continue Pepcid OTC
I don't know what the graders are looking for here... but what I do know is that there has been recent literature posted about the use of H2 Antags in pancreatitis, so you might want to review some of that to have in your back pocket for group. It's pretty interesting stuff.
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Continue Tylenol ES
Is there a risk of continuing this? (Think about tylenol's metabolism... also look at recent literature on tylenol and pancreatitis)... Are his headaches secondary to something else? You always have to consider these things when evaluating a patient and their med list.
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well-being,
Good. Always mention QoL. Faculty loves that.
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pharmd.umc.edu pharmd.umc.edu
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References
Never include the hyperlinks to things... Seriously, get rid of the hyperlink. The URL is enough.
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Monitor lab values
What lab values? Also what happened to your electrolytes? I feel like half your treatment plan is missing...
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antibiotic therapy
Interesting.... I didn't know infection (besides C.Diff) was a an adverse event to Abx therapy.... you need to be specific with statements like this or you will find yourself in a hole you can't dig out of...
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CIWA-Ar scale
What scores are you looking for?
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subjective response
What is this specifically?
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irst two days
Okay and what about after the first 2 days?? How long are your fluids going for? You never specified this so now I have questions.
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oxycodone 10 mg tablet po
Congrats, you have literally just killed this patient via respiratory depression secondary to giving them an opioid and benzo....
Also... is it really best practice to give opioids to an alcoholic? Think about these things....
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Lactated Ringer�??s solution is used to decrease blood urea nitrogen (BUN)
I also have questions about this.... NS decreases BUN too... So does Plasmalyte... You need to find an advantage to using LR over these....
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three times a day
There really isn't a big benefit to how frequent Abx are dosed if the patient is in the hospital..... This might be something you can delete to save space...
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new
Ehhhhh.... It's been on formulary for awhile.... I wouldn't say this. I would just say "Meropenem is equally effective and has a better side effect profile and is on formulary at most institutions"
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produce fewer adverse effects
Give a specific example... What's something that FQs do that you specifically want to avoid....
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two antibiotic drug classes
So there's actually more than just these that can be used... so I would say something like "Carbapenems and FQs are considered the most effective for pancreatitis" and then go from there.
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100 mg tablet po
You need to think about whether or not your patient can tolerate PO meds... if they can, then yeah this is great... but if they have things going on that make PO impossible then this isn't your best option... View the patient's whole situation and make a call.
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Enteral
You need to google this word....
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15 to 30
15 or 30? It can't be both... You must be direct and chose one.
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Goals for treating alcohol withdrawal syndrome also include decreasing alcohol intake and eventually abstaining from any alcohol use long term
Are we actually concerned about this? This is fine to leave but I want to mention that your primary concern is not their long-term substance abuse... but rather their acute illness (aka withdrawal). In the inpatient setting our job is to get them stable enough for their chronic conditions (substance abuse) to be addressed by their primary care physician... We can make suggestions but we are not concerned with their long-term sobriety.
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pharmd.umc.edu pharmd.umc.edu
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Refer ences
Something weird with formatting happened here....
Overall your plan looks good, the 1 page max is hard to hit so if there some stuff that is less important, go ahead and cut it out. But do look into the things I mentioned even if you don't add them to your plan, it will benefit your general knowledge and clinical abilities later down the road...
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fluoroquinolone
There is 1 more super important adverse event with FQs that you're missing (Hint: its a cardio effect). I suggest knowing this and mentioning it and how to monitor and what to do if it happens.
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disulfiram
Please research Flagyl and disulfiram reactions, like actually look into it and research it and read some primary lit... how long would our patient need to avoid alcohol?
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extreme sedation
What do you do if this happens? This is super important...
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magnesium
What happens if these are high... what is your plan if this happens....
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monitored
How often are you going to monitor this?
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blood pressure
Whats the goal? Every value you mention you HAVE to mention a specific goal.
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resolution of signs and symptoms
what are the s/s you're trying to resolve? Also what's the plan if this one doesn't work?
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Calcium
What is your goal and why? How does Ca correlate to severity?
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therapeutic range
What are your therapeutic ranges for these? I know its a hassle but if it wasn't important I wouldn't mention it.
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48 to 72
Which one? When do I want to draw the next labs? At 48 or at 72hr? Specify one.
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decreased tachycardia
what is your goal heart rate?
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3-5
I would say "by 5 days" instead of giving a range...
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Wernicke
How common is this syndrome? I suggest looking into the research into banana bags and thiamine dosing and Wernicke.... You will be smart for group this week and for life in general if you're well versed in these things.
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but after if
I think you have an extra word here...
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intravenous
Also... why is IV preferred for this patient? You need to specify this. It's important.
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banana bag
Fascinating research in the use of banana bags, look into it!
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level of sedation
What is your goal here? What level of sedation are you trying to achieve?
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5 to 10 minutes
Which one? You need to choose one or your nurses may get confused...
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due to alternative
Is there a more specific reason to keep the Bactrim D/C'd?? (Hint: yes there is, but you've got to find it).
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continue Pepcid
Extensively research the use of H2 antags in pancreatitis. Fascinating research out there currently.
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Ibuprofen
Are you sure? Is there risk to utilizing ibuprofen? I'm not sure but I would explore this..
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electrolytes
What specific electrolytes are you concerned about?
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signs and symptoms of dehydration
What are these?
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pharmd.umc.edu pharmd.umc.edu
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References
This part looks great.
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Pepcid,
You may want to research this, its important to note the implications of H2 antagonists in the course of pancreatitis...
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These goals will help MH feel less anxious and more comfortable
Will it solve the pancreatitis? What is the prognosis? You make it seem like your goals for this patient are focused on palliative care with this sentence....
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meropenem
There are more serious ADEs for merrem... you may want to look into these, mention them, and give a plan on how to deal with them if they occur.
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reduce lorazepam
What if your patient goes into respiratory depression? What can you do?
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Adverse Event Monitoring
So are your electrolytes therapeutic goals or adverse events? You need to decide...
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fluid repletion to 500mL/hr
What if your electrolytes get depleted? Adding more fluid would make the situation worse... What's your plan?
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fever
What is your goal temp?
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77-106
Really? This is the inpatient glucose goal? I would look into this...
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Therapeutic Monitoring
What are you going to do if therapeutic goals are not met?
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,
missing a bracket here.
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more effective
How was it more effective? Length of stay shorter? Less morbidity? Give a specific reason....
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no significant differences between phenobarbital and lorazepam
Then why don't I want to use phenobarb? You need to convince me that I want to use Ativan... So give me an advantage of Ativan vs phenobarb...
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lower cost. 10 L
Cost is the only reason?
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pefloxacin
I have literally never heard of this drug.... Pretty sure it's not available in the United States... Wouldn't advise mentioning it.
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one
Just one study? That's not super convincing...
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tablets
Is this the best route? PO isn't wrong, but you need to think about the implications of the routes of drugs in certain conditions. Does pancreatitis cause complications with giving medications via PO route? Can your patient physically take PO medications (i.e. what is their diet? NPO? Tube feeds?). You need to think about the patient's entire picture when thinking about drug administration...
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possibly
Is it associated or isn't it? Be confident.
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systemic complications
What complications? "Complications" is broad... be more specific and list one...
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pharmd.umc.edu pharmd.umc.edu
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4 to 6
4 or 6... be specific.
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influenza vaccine annually. She is also due for her next tetanus (Td) booster
Include dose and route
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pharmd.umc.edu pharmd.umc.edu
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PCV13 is also recommended at this time followed by PPSV23 in
Give the dose and route for any vaccinations you recommend. Otherwise your plan is good!
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pharmd.umc.edu pharmd.umc.edu
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3-valent pneumococcal conjugate vaccine (PCV13), followed by 1 dose of 23-valent pneumonococcal polysaccharide vaccine (PPSV23) at least one year after PCV13
Whats the route and dose of this.
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black tar color
What should she do if this happens... Mention an action to take for every adverse event?? Switch or D/C??
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slow heartbeat
What is slow? Define this... specific HR??
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4-6 weeks
Be specific. 4 or 6. Choose one.
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pharmd.umc.edu pharmd.umc.edu
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pneumococcal vaccine starting with Prevnar13 (PCV13)
Include the dose and route....
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stay within the 130/80 mmHg
Stay within? Or below?
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2 to 4 points
Which one... be specific
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cost around $4-$9
Choose a price and stick with it.
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first line
Good job specifying why its first-line!!
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can be titrated
Whats the titration... may mention this in detail in the therapetic section....
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pharmd.umc.edu pharmd.umc.edu
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Since JP is older than 65 without a previous pneumonia vaccine, we should administer one dose of 13-valent pneumococcal conjugate vaccine (PCV13), followed by another dose of PPSV23 at least 1 year later (CDC, 11). JP should also be administered 2 doses of recombinant zoster vaccine 2-6 months apart (CDC)
What are the routes and doses of these.... Be specific.
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pharmd.umc.edu pharmd.umc.edu
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The annual influenza vaccine is recommended every year. 23 JP should also be given 2 doses of the recombinant zoster vaccine 2 to 6 months apart. 23 PCV13 should be administered followed by PPSV23 at least 1 year later. 23 If there is no record of JP ever receiving the Tdap, administer this vaccination. 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Effects of donepezil, galantamine and rivastigmine in 938 Italian patients with Alzheimer�??s disease: a prospective, observational study. CNS Drugs . 2010 February;24(2):163-76. Doi: 10.2165/11310960-000000000-00000. Reference 17: Donepezil Prices, Coupons and Patient Assistance Programs. Drugs.com. https://www.drugs.com/price- guide/donepezil#oral-tablet-10-mg . 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} #t25_3 { left:331px; top:2601.599962234497px; FONT-SIZE: 12px; FONT-FAMILY: Arial, Helvetica, sans-serif; color:rgb(0,0,0); } #t26_3 { left:50px; top:2634.599962234497px; FONT-SIZE: 12px; FONT-WEIGHT: bold; FONT-FAMILY: Arial, Helvetica, sans-serif; color:rgb(0,0,0); } #t27_3 { left:141px; top:2634.599962234497px; FONT-SIZE: 12px; FONT-FAMILY: Arial, Helvetica, sans-serif; color:rgb(0,0,0); } #t28_3 { left:50px; top:2649.599962234497px; FONT-SIZE: 12px; FONT-FAMILY: Arial, Helvetica, sans-serif; color:rgb(0,0,0); } #t29_3 { left:50px; top:2664.599962234497px; FONT-SIZE: 12px; FONT-FAMILY: Arial, Helvetica, sans-serif; color:rgb(0,0,255); } #t30_3 { left:562px; top:2664.599962234497px; FONT-SIZE: 12px; FONT-FAMILY: Arial, Helvetica, sans-serif; color:rgb(0,0,0); } #t31_3 { left:50px; top:2680.599962234497px; FONT-SIZE: 12px; FONT-FAMILY: Arial, Helvetica, sans-serif; color:rgb(0,0,0); } .text { position:absolute; white-space:nowrap; overflow:visible; } Reference 18: Medicare National Plans Coverage of Alzheimer�??s Drugs for 2018. Alzheimer�??s Association. https://www.alz.org/media/Documents/medicare-natl-drug-plans-coverage.pdf . Published October 12, 2017. Accessed August 13, 2018. Reference 19: Doody RS, Ferris S, Salloway S, Yijun S, Goldman R, Yikang X, et al. Safety and tolerability of donepezil in mild cognitive impairment: open-label extension study. American Journal of Alzheimer�??s Disease and Other Dementias. 2010 March;25(2):155-9. Doi: 10.1177/1533317509352334. Reference 20: Gharaei H, Shadlou H. A brief report on the efficacy of donepezil in pain management in Alzheimer�??s disease. Journal of Pain and Palliative Care Pharmacotherapy. 2014 March;28(1):37-9. Doi: 10.3109/15360288.2013.876484. Reference 21: Berman BD. Neuroleptic Malignant Syndrome. The Neurohispitalist . 2011 January;1(1):41-47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726098/ . Accessed August 14, 2018. Reference 22: Rhabdomyolysis. MedlinePlus. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000473.htm . Updated August 2, 2018. Accessed August 14, 2018. Reference 23: Advisory Committee on Immunization Practices. Centers of Disease Control and Prevention. Recommended Immunization Schedule for Adults Age 19 Years or Older, United States, 2018. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf . Updated: February 2018. Accessed August 14, 2018.
You need to specify route, dose, etc. BE SPECIFIC.
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effects. 1
WOW exciting. Avoid this.
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hypersensitivity reaction,
What are you specifically monitoring??
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rapid decline that is faster than her baseline decline
How rapid? What are you looking for specifically....
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6 to 12 months
Choose one. 6 or 12.
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greater improvements
What kind of greater improvements? be specific
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mild-moderate Alzheimer
How do you know it is mild-moderate
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4 to 6 weeks
Be specific. Choose one. 4 or 6.
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pharmd.umc.edu pharmd.umc.edu
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flu vaccine, a Td booster in about 3 years, 2 doses of Shringrix, and PCV13 followed by PPSV23 one year later.
How will you give these.... route, frequency, dose, etc.
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4 to 6 hours
Which one. be specific.
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4 to 6 weeks
be specific.
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ollow-up within 4 to six week
be specific. choose one.
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another acetylcholinesterase inhibitor such as galantamine or rivastigmine
which one? does one have better SE profile than the other.... be specific....
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MMSE scores
what would you expect the scores to be
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4 to 6 week
4 or 6? Be specific.
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rivastigmine, galantamine, and donepezil
If you mention these here you need specific rationale for each to compare to the one you chose. For example, specify the exact cost of each and specific rationale. Don't be vague here.
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She should also stop taking Vitamin E since it has no proven effect on AD and may increase chances of falls and negative side effects like diarrhea and fatigue.
"D/C Vitamin E due to worsening diarrhea and fatigue"
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he expectation of treatment would be that her cognition would
Revise this. Say what is expected, not what "would be" expected.
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