347 Matching Annotations
  1. Sep 2018
    1. booster shot

      the graders will want the vaccines that are needed to be recommended in dosage and site of administration. For example, 0.5 mL IM

    2. Rationale

      Excellent job! Best rationale I have read all day. Continue to write your rationales like this, and you will do well on this section!

    3. Patient Counseling

      You should include the name of the medication and the strength as well.

    4. Your fever should start to subside within 2 days of beginning therapy. 1

      Good! Always include when the patient's symptoms will start to improve. Graders always look for that.

    5. You may experience a few side effects, such as diarrhea, nausea, vomiting, photosensitivity, and cold symptoms (sneezing, runny nose, and congestion)

      All of this can and should also be included in the adverse event monitoring section. They are adverse events of doxycycline. It is necessary to mention here in the patient counseling section too though

    6. KN should avoid direct sunlight

      Based on this statement, you clearly know that phototoxicity is a side effect of doxycycline. You should discuss phototoxicity in the adverse event monitoring section.

    7. OTC

      Are there any OTC products that you would recommend? Anything to help with itching or rash like an oatmeal bath or topical anesthetics?

    8. dverse effects

      This section is all about discussing the adverse effects that you will ask the patient about and assess. You need to include how frequently you will monitor for those adverse effects as well.

    9. Adverse Event Monitoring

      I think you missed the point of this section. This section is all about discussing how you will monitor for adverse effects of doxycycline itself. Look for some common side effects of doxycycline. For each side effect that is clinically relevant, common, and important to monitor for, you need to include how you will monitor for those adverse effects (lab values, questioning the patient, physical exam, etc.) AND your plan for what you will do if any of these adverse effects of doxycycline occur.

    10. Therapeutic Monitoring

      When should the patient start to improve? You need to include when symptoms should start to resolve

    11. The following lab values should be evaluated for normalcy after therapy is completed

      Good job including goal lab values and a specific time that you plan to evaluate them.

    12. Depending on laboratory results, the current therapy would be completed or modified

      This is very vague. You should be very specific with which lab values you will look at and how you will modify treatment based on those results.

    13. misdiagnosed or may still be afflicting the patient. 1

      If these lab values are still abnormal and you think they were misdiagnosed or uncured, what are you going to do? Will you continue doxycycline or take another approach?

    14. complete blood count, comprehensive metabolic panel, and examination of peripheral blood smears

      You need to include goal lab values for all of these

    15. 2-3 weeks

      Pick a specific time

    16. clinical evidence

      What sort of clinical evidence? You need to be specific, this is a bit too vague.

    17. 5-7 days,

      You should pick a specific number of days. Graders will deduct points for putting ranges. Be specific.

    18. Acetaminophen is not contraindicated with the drug

      This is fine and I'm not saying you should discontinue acetaminophen, but for future reference, you should also consider whether the current meds are the best choice for the patient or if the current meds would have any problematic side effects for the patient in the case, not just whether it is a contraindication with the drug you are choosing.

    19. physically feel better is important,

      You should make a statement on how her getting better would impact her life (like allow her to return to work, get back to daily routine, care for her daughter, etc.)

    20. decrease (>100.4°F) and all laboratory values would be in normal ranges.

      You need to state what the normal ranges are for the specific lab values you are going to look at. Also, you should state the normal or goal temperature rather than the temperature she currently has.

    1. If KN did not fall within these ranges, a change in medication would need to take place.

      I don't have the case pages to know, but I don't think that altered sodium and thrombocyte levels are side effects of doxycycline. I'm assuming the patient already has altered sodium and thrombocyte levels? If so, if these levels don't return to normal after taking doxycycline, then this is more appropriate in the therapeutic monitoring section since it isn't an adverse effect of doxycycline, but is more indicative that doxycycline isn't working effectively.

    2. adverse effects

      Be specific in what adverse effects she should be looking for and reporting.

    3. fever after 48 hours

      This is more appropriate for the therapeutic monitoring section. It isn't an adverse effect of doxycycline.

    4. Adverse Event Monitoring

      I think you kind of missed the point of this section. This section is about monitoring for side effects of doxycycline. So what are some common side effects of doxycycline itself that you should monitor for? For each of the side effects you mention, you need to include a plan for what you will do if that side effect occurs, how often you will monitor it (and how you will monitor for it). You also need to state at what point the side effects are too severe that you would discontinue doxycycline. I feel like some of the things you mentioned in this section are more applicable to the therapeutic monitoring section. You did a great job providing specific lab values though!

    5. Evidence

      What kind of "evidence" would you be looking for that would indicate these adverse events are occurring? You need to be specific in what symptoms or signs you are looking for and how you will look for them (physical exam, questioning the patient, etc.). You also need to include how often you will monitor for these.

    6. lood panels should be taken, paying special attention to her platelet levels

      You need to include goal lab values for the CBC and platelets.

    7. considered

      Would you also consider discontinuing doxycycline and starting another antibiotic?

    8. another serum test and blood panel

      If this is the 2nd set of tests, after what time period is the first evaluation occurring?

    9. serum sodium level

      After what period of time should her sodium and thrombocyte levels return to normal? And how often will you check the levels?

    10. fever,

      You need to include goal/normal temperature

    11. should subside

      When should they subside? 24 hours, 1 week, 3 days?

    12. Patient Counseling

      You need to also include when the patient should start to notice improvement in symptoms

    13. r milk

      Double check the milk. I know it shouldn't be taken with calcium

    14. OTC/Vaccine

      Would you recommend any OTC products? Also, you absolutely must address vaccines that the patient needs. Is she due for a flu shot, Hep B, Tdap, pneumonia, etc? If she is up to date on all vaccines based on her immunization history and age, then you need to at least state "the patient is up to date on all vaccines, so no vaccines are needed at this time." The graders will ALWAYS be looking to see if you address vaccines in this section.

    15. require blood monitoring

      Are there any other reasons why doxycycline is preferred over chloramphenicol? Like efficacy?

    16. bacteriostatic

      Bacteriostatic isn't always a good thing though. Sometimes bactericidal is preferable. How does the fact that doxycycline is bacteriostatic make it a preferred treatment option here? I'm just not convinced that this is a relevant point to make

    17. poosible

      spelling

    18. New Drug Therapy

      While there is nothing wrong with what you wrote, it may be better worded if you said "Start KN on doxycycline monohydrate (generic) 100 mg tablets. She will take 1 tablet by mouth twice a day. She will continue this for seven days."

    19. serum sodium level to be somewhere between 135-145 mEq/L and her thrombocyte level to be between 1.5x10 8 - 4.5x10 8 cells/mL

      Excellent! Good job providing specific therapeutic goals and goal ranges.

    1. Patient Counseling

      You also need to include how soon the patient should expect to feel better. And be sure to mention what the patient should do if they forget a dose.

    2. diarrhea

      Why didn't you include this in your adverse event monitoring section? If diarrhea is an adverse event that the patient may commonly experience, then it needs to be in the adverse event monitoring section too.

    3. On the first day of treatment, take 1 tablet every 12 hours for a total of 2 tablets in one day. 3 For the following days, take 1 tablet around the same time every day until there are no pills remaining.

      Put this sentence up at the top of this section where you say "you will need to take the medication exactly as directed."

    4. esophagus and stomach irritation.

      Why didn't you include these adverse effects in your adverse event monitoring section? They should be included there as well

    5. exactly as directed

      You need to direct them how to take it. Tell them the exact dosing of it.

    6. OTC

      Any other OTC products you would recommend for this patient?

    7. There are currently no licensed vaccines for the prevention of TBRD in the US

      This section is not meant to discuss vaccinations against the particular disease you are treating. This section is about recommending any vaccinations that the patient needs based on their immunization history and current age, like influenza, pneumonia, Tdap, Hep B, etc.

    8. patient-reported symptoms

      Patient-reported symptoms of what? How often will you monitor for symptoms and do a BUN analysis? Why are you only analyzing BUN if there is inaccurate dosing? Shouldn't your dosing be correct?

    9. uncommon

      Uncommon, but should you still monitor for them? If so, how often will you monitor for them and how will you monitor for them? What will you do if these adverse events occur?

    10. adjust the dose of doxycycline

      Adjust the dose up or down?

    11. signs and symptoms

      How will you monitor that all of their signs and symptoms have diminished? You need to include how you will determine if they are having signs and symptoms and how often you will assess them.

    12. If the patient does not meet treatment goals, hospitalization may occur

      If the patient isn't meeting treatment goals after how long? 1 day, 1 month, 1 year? Would you consider switching antibiotics as well, or just hospitalize them?

    13. fever reduction

      What is your goal temperature?

    14. at next visit

      When will this next visit be?

    15. until no tablets remain

      How many days will this last? You need to provide a specific duration of therapy

    16. Goals of Therapy/Previous meds

      Excellent!

    1. fever

      provide a goal or normal temperature

    2. Patient Counseling

      You also need to include how soon the patient will start to notice improvement in symptoms.

    3. getting less side effects.

      It would sound better if you said "and help manage any side effects."

    4. than before

      Delete

    5. After you take it, do not lie down for at least 30 minutes. 3

      You should consider adding the side effect associated with this recommendation to your adverse event monitoring section.

    6. your doctor tells you

      You are the one determining the length of therapy, not the doctor.

    7. NonPharm

      You need to provide non-pharm recommendations as well. These are lifestyle things that the patient can do to avoid further infections or that can help with the current infection. The oral antihistamine is considered the OTC part of this section, but doesn't meet criteria for the nonpharm part of this section.

    8. Adverse Event Monitorin

      For each adverse event, you need to provide a plan for how you will manage it and when you will decide to discontinue treatment with doxycycline due to the severity of adverse effects. If the patient is having an allergic reaction, what will you do?

    9. pancreas problems

      How common is this side effect? I would focus on including the more common ones.

    10. a few days

      Say a specific # of days. This is too vague

    11. photosensitivity

      How will you monitor for phototoxicity?

    12. he follow-up visit.

      When will this follow-up visit be? You need to include a specific time (like in 3 days, 1 week, 2 weeks, etc.)

    13. CBC, hepatic transaminase levels, and serum sodium levels

      Good, but you need to include goal or normal lab values for these tests

    14. Rationale

      You need to say why you chose doxycycline over other members of the tetracycline class of antibiotics. You need to be sure you compare doxycycline to other tetracyclines and doxycycline with other classes of antibiotics.

    15. if fever begins

      Doesn't she already have fever? I don't have the case pages, so I'm not sure, but from what I remember she already has fever.

    16. Continue APAP 500 mg po prn HAs

      I would take out the abbreviations since you have plenty of space left.

    17. To treat KN

      This is a sentence fragment. You need to make this a complete sentence. Say "Goals of therapy are to treat KN..."

    1. therapeutic monitoring of doxycycline

      There is a simple test to monitor for efficacy in a patient on doxycycline for TBRD. It is something that a patient could even do outpatient related to one of her symptoms

    2. same time every day

      need to tell the patient exactly how they are going to take the medication. For instance, you will take x pills by mouth x times per day for x days

    3. This medication will only treat bacterial infections, so it will have no effect on viral infections.

      This is irrelevant to the patient case

    4. avoid throat irritation and ulcers

      There is another counseling point that is very important to help avoid throat irritation and ulcers that has to do with avoiding lying down for a certain amount of time after taking the medication

    5. Counseling

      need to tell the patient what the medication is called from the beginning instead of starting to use the name halfway through

    6. NonPharm

      Strong nonpharm recommendations

    7. because it has almost been a year since

      Flu shot recommendations are for each flu season and don't have to do with needing one spaced out by a year.

    8. Tdap

      The graders like to have a dose when suggesting vaccines and to put either SQ or IM

    9. Adverse Event

      You hit on some more serious adverse effects, which is important. Are there any more common adverse effects you would like to monitor for?

    10. As long as all of KN�??s values stay within normal range

      The graders will want you to have a plan for what you will do if these adverse effects occur

    11. sings

      signs

    12. GFR

      altered GFR is generally not related to hepatotoxicity

    13. WBC counts remain elevated

      Would you suggest an alternate agent at this point? How long with elevated WBC would you suggest the patient be hospitalized or try an alternate agent?

    14. 3.5-10.8

      there should be units for these

    15. 1.7-7.5. 8 If

      there should be units for these

    16. periodically

      Graders like to see an actual frequency in the monitoring sections, even if it is not something that is set in stone in the literature.

    17. BCBS

      Very smart to look at affordability in rationale. Good job

    18. adverse events

      Do you have any examples of which adverse effects are at a higher risk with minocycline?

    19. most effective and safest tetracycline drug available

      If you have any specific numbers on this, it would make your rationale ever stronger

    20. 5 to 7 days

      Generally, the graders do not like ranges. They want you to choose that specific duration of therapy.

    21. APAP

      Remember that interactions with therapy can be more than just an interaction with the drug chose; it can also be an interaction with a monitoring parameter.

    22. resolve entirely

      Will the other symptoms not resolve? If they too are expected to resolve, don't call out only some of the symptoms

    23. . KN is experiencing a

      Make this one sentence so it is completely clear that these are the signs and symptoms the patient is experiencing.

    1. wice a day

      be sure to say by mouth

    2. doxycycline

      the grader will want you to explain to the patient how it will work in a broad sense. Is it it attacking the pathogen or bug that is causing this infection?

    3. 3 days

      the patient is going to be given a prescription with a defined number of pills in it, so you need to make the decision what that duration is and then explain it to the patient.

    4. 30 minutes after taking it.

      Great counseling point; explain why the patient needs to do this.

    5. Rickettsia infection

      You can tell the patient what the infection is but also tell them what probably caused it so they know if there is anything they can do to prevent these in the future.

    6. Monitoring

      For all monitoring, you need to say how often you will be monitoring for these things. It may not always be set in stone in recommendations from the literature, but you need to choose something.

    7. NonPharm

      For an acute infection, this section is not so much about overall wellness but what to do during the infection and maybe also how to decrease the chance of getting this infection in the future. For instance, maybe rest would be good for the patient as they recover. For the future, what can be done to prevent tick bites?

    8. year

      You need to complete this thought. If you believe the patient needs a flu vaccine, recommend a flu vaccine rather than just stating a fact.

    9. booster

      Graders like to see more specifics here, such as how many mL the vaccine is and is it SQ or IM?

    10. be continued

      It may not interact with the treatment option but could it "interact" with one of your big monitoring parameters?

    11. recommended

      Is this recommended while the patient is still acutely ill? If not, don't put it in the treatment plan.

    12. include

      One aspect that the grader is going to need to see in this section is what will you do if these adverse effects occur. Some of them could require an alternate agent to be chosen where others could be where you simply suggest giving care for those adverse effects but therapy with doxycycline can be continued. It's one of the harder parts of the monitoring section but is something graders really care about.

    13. need for supportive therapy

      I would more say that if the patient is experiencing the adverse effects listed just prior to this, she would need to be hospitalized for further treatment and supportive therapy.

    14. Adverse reaction

      For every one of these adverse reactions listed, you need to put the values that would show they are an issue or the signs and symptoms to monitor for. So generally, you don't want to put all of them in there, but look for the ones to monitor that are common or concerning.

    15. H

      no need to capitalize this; it makes the list look copied from Lexicomp

    16. urea and creatinine

      You are going to need to put the ranges for urea and creatinine that would be concerning for renal issues.

    17. doctor

      The grader is going to want you to suggest what to do if treatment does fail. Do you suggest a new agent, IV formulation of doxycycline or do you have an alternate diagnosis that could be suspected to which you have a plan to treat?

    18. 5- 7 days

      Based on your therapeutic monitoring section, it seems that treatment success has fever subsiding within 48 hours, so I would give the definitive duration of therapy of 5 days if this is the case

    19. subside within

      You did a good job talking about treatment failure, but you will also want to talk about what defines treatment success

    20. fever

      as silly as it may sound, graders are going to want you to define a fever; give the specific body temperature

    21. outpatient

      This makes me think you need to completely delete the sentence about IV doxycycline in the "new drug therapy" section

    22. antibiotics

      You should cover how the tetracyclines are superior to other classes of antimicrobials already. When you specifically talk about doxycycline, the grader is going to want you to compare it to other drugs in the tetracycline class, like tigecycline, minocycline, tetracycline. Basically, what sets doxycycline apart from the others in its class to make you choose it.

    23. Tetracycline-class antibiotics

      The grader will want you to directly compare the tetracyclines to other classes of antimicrobials. This means if your source is saying that the tetracyclines are the only class that are active against all pathogens that can cause TBRD while other classes have gaps in coverage, mention that directly. If tetracyclines as a whole have more therapeutic success than other classes say that.

    24. agents

      agents is usually used for drugs pathogens may be a better term here

    25. 100 mg given intravenously twice a day is indicated for patients who are more severely ill

      the grader is going to want you to make a decision if the patient is severely ill. If the patient's symptoms would be defined as severely ill, just mention the IV dosage. if the patient would be defined as able to have the oral treatment, only mention that one.

    26. APAP

      Write out acetaminophen

    27. deadly.

      if death is such a concern, this should be listed as a goal of therapy along with those other symptoms that are listed. Goals of therapy are not just alleviating current symptoms but also preventing further complications, which in this case, seems to be death

    1. Guidelines for the Diagnosis and Treatment

      GOOD!!! Always include guidelines

    2. severe side effects

      What would these side effects be? How would the patient know if she was having a severe side effect?

    3. If you are become pregnant

      How old is this patient? Is she of an age that is likely to become pregnant? I don't have the case pages to know her age, so just checking to make sure this is relevant for this particular patient.

    4. NonPharm

      you need to include nonpharm recommendations as well. These are lifestyle recommendations, like wearing long-sleeves, avoiding wooded areas, etc.

    5. up to date

      Isn't it flu shot season too?

    6. ommon side effects

      You are missing several of the required criteria for this section. You need to include 1) how you will monitor for these adverse effects (physical exam, questioning the patient, let work etc.) 2) how often you will monitor for them. 3) You also need to include at what point the adverse effects become too severe that you will discontinue treatment with doxycycline.

    7. as also proven essentiality in preventing

      Re-word, this doesn't make much sense how it is worded

    8. Therapeutic Monitoring

      After how long will you determine that therapy is not working? What if it has been 7 days and the fever has still not subsided? At what point do you determine that your treatment choice is not working and you need to take another treatment approach?

    9. Fever

      What is your goal temperature?

    10. Lab work can be done to check blood cell indices

      You need to include goal lab values and what specific lab tests you will run. "Lab work" is very vague. Will you do a CBC, platelet count, Chem 7, etc.?

    11. should be monitored

      How will you monitor them? Asking the patient, physical exam, lab work? Also, how often will you monitor them?

    12. This medication is also offered intravenously but considering her daughter is sick and attends school the oral dosage will suffice

      This sentence is not needed. Also, some people attend school and still require IV antibiotics and hospitalization, so this isn't really a relevant point. Whether or not they need oral or IV antibiotics depends on severity of illness, not whether they attend school

    13. The dose regimen will be 100 mg capsule by mouth twice a day

      Usually it is best to say "The drug of choice is doxycycline (generic) 100 mg capsules, at a dose of 1 capsule by mouth twice daily."

    14. Vibramycin

      Stating it this way indicates that you are dispensing the brand name drug. Would the generic be a cheaper/better option?

    15. KN also complains of nausea and occasional chills but she has yet to check her temperature,

      This section should NOT be you just reciting the information in the case. You just need to state which specific symptoms you are trying to treat/relieve, how this will impact the patient, and whether they should continue or discontinue previous medications. You don't need to give the past history of going to the Smokey Mountains and why you think they have RMSF necessarily.

    16. Goals of Therapy/Previous meds

      You are missing a few of the major required criteria. 1) How will treating the patient impact the patient? Will they be able to return to school or work, normal daily life, exercising, etc? 2) for previous meds, you need to state if they should continue to use the current medications or not. Should they continue taking acetaminophen or is this something they should stop taking? Either way you need to give a reason why they are continuing or discontinuing it.

    1. physical exam

      What symptoms would the patient be having if they were experiencing these side effects?

    2. Patient Counseling

      You need to include how soon the patient's will start to see improvement in symptoms

    3. regular visits

      What do you mean by regular visits? Like every month, every 6 months? How long will this be relevant for this patient?

    4. NonPharm/OTC/Vaccine

      Good! For future reference, ALWAYS mention vaccines, even if you don't think the patient needs any. You should at least say "the patient is up to date on all vaccines."

    5. follow-up visit

      When will their follow-up visit be?

    6. Excessive dosing

      Regular doses can also cause phytotoxicity. This isn't limited to excessive dosing.

    7. he patient should also be questioned for symptoms of high WBC (swollen lymph nodes, high 101/102 fever, muscle aches). Should the WBC be too high (>11,000/ μ L), the dosage strength should be reduced. 2,

      Would this not mean that their infection is uncontrolled? I would think if the WBC count is high and they still have fever, maybe you would switch antibiotics rather than lower the dose of doxycycline.

    8. neuroborreliosis

      I think this is a pretty rare side effect. I would only mention the more likely side effects.

    9. (clostridium difficile-associated diarrhea, fatal colitis)

      C-diff associated diarrhea and fatal colitis are not associated with hepatotoxicity. These should not be in parenthesis.

    10. fever will subside

      What is your goal temperature?

    11. During each follow-up visit

      How often will you have these follow-up visits?

    12. acetaminophen

      what dose of acetaminophen?

    13. Duration of regimen may be increased until target range for parameters are reached

      What if the patient's parameters are not improving? You will just continue doxycycline until they improve? Would you not consider another antibiotic? Maybe if lab parameters aren't improving, that means that doxycycline isn't an appropriate antibiotic.

    14. More specifically, the titers for IgM and IgG

      When will you measure these titers?

    15. every 2 months of implementing therapy

      If treatment is only lasting for 14 days, why are you measuring WBC and platelet counts 2 months later?

    16. if dose adjustments are needed

      But are dose adjustments needed in this case?

    17. clinical improvement. 3

      What if the patient starts to improve in 24 hours. Is that long enough? I would double check your length of therapy

    1. If you are pregnant or planning

      I don't have the case pages to know the patient's age, but is this relevant for this patient?

    2. iron, antacids containing calcium, aluminum, or magnesium

      Once again, I know what you mean, but the wording makes it seem like you should wear sunscreen when exposed to iron, antacids, calcium, aluminum, or magnesium. I would try to re-word it.

    3. does

      spelling

    4. You should start to see improvement in your symptoms within 48 hours.

      Good!

    5. t. th

      Delete the period. Also, maybe clarify that you should take 1 tablet by mouth twice per day

    6. NonPharm/OTC

      You need to include nonpharm and OTC as well. Non-pharm recommendations are required.

    7. Adverse Event Monitorin

      At what point will you decide that the adverse effects are too severe and you should discontinue treatment? If the patient is experiencing these side effects, what will you do?

    8. Monitor for adverse events

      How often will you monitor for these adverse events, and how will you monitor for them? Will you ask the patient about them?

    9. Therapeutic Monitoring

      You should include goal values for things (like fever)

    10. asked

      How often will you ask about these symptoms?

    11. clinical symptoms

      Specifically list these symptoms

    12. If there is not an improvement seen

      If no improvement after what length of time?

    13. Rational

      This is a good start. I would try to incorporate more primary lit into your rationale. It is important to always include guidelines and primary lit in your rationale.

    14. fluoroquinolones

      Why didn't you choose a fluoroquinolone?

    15. 24 hours of no fever. 4

      I know what you mean, but for clarification purposes, it may be good to say "for at least 3 days, or for 24 hours after fever has resolved, whichever is longer."

    16. Discontinuation

      re-word. discontinue

  2. Aug 2018
    1. References

      Are there any guidelines on this topic? You should always include the most current guidelines in your rationale and your references. Graders will look through your references to make sure guidelines are included!

    2. your symptoms get better

      When should the patient start to feel better? It is important to tell them when their symptoms should start to improve.

    3. wice daily

      include by mouth

    4. taking APAP,

      What is the dose and dosing schedule of this?

    5. you

      Keep it all in 3rd person

    6. symptoms associated with CDAD

      What are these specific symptoms to ask about?

    7. any signs of these issues

      What specific signs are you looking for?

    8. contacted within 2-3 weeks

      Be specific with your time. Graders typically count off for a range. They want you to be specific and pick either 2 or 3 weeks. Also, if the symptoms of C diff can show up over 2 months after finishing treatment, is it necessary to contact them after only 2 weeks? Or would it be a better idea to call them after 2 months to see if they have these symptoms?

    9. 3-4 days

      Pick either 3 or 4. Don't put a range.

    10. Adverse Event Monitorin

      Good job!

    11. temperature

      How often will you measure their temperature? Daily, every 4 hours, after 3 days??

    12. patient does not respond to treatment,

      Should you get titer results and lab results and evaluate therapy based on those as well? If she isn't improving, maybe she doesn't have an infection that can be treated with doxycycline. Lab/titer results would be helpful in deciding if you need to completely switch antibiotics or not.

    13. patient�??s fever

      Should you monitor their other symptoms as well or just their fever?

    14. should begin immediately

      Good!

    15. synthetic

      I don't think the fact that it is synthetic is very relevant

    16. Rationale

      Overall, this is a decent rationale. Are there any other classes of antibiotics that treat TBRD? You need to say why you chose a tetracycline over those other classes. And then why you chose doxycycline over those other tetracyclines (comparing within the same class). It also may not be a bad idea to incorporate more primary lit into your rationale. ALWAYS include guideline recommendations as well.

    1. herapeutic Monitoring

      At what point will you decide that you need to switch antibiotics if it doesn't seem to be working?

    2. Reference 5

      GOOD!!!!

    3. Adverse Event Monitoring

      Good, just be sure you include frequency for monitoring for all of these adverse events.

    4. meropenem

      I would be more specific about saying that it is an "IV solution" to include the dosage form in there. I know it seems obvious, but they can get picky about that kind of thing if you don't explicitly state that it is an IV solution.

    5. white blood cell count (WBC)

      How often will you monitor WBC count? Will you try to get cultures as well?

    6. periodically.

      Provide a specific time. Periodically is too broad.

    7. requently

      How often is "frequently?" Provide a definite time

    8. Carbapenems are broad-spectrum antibiotics

      Are there any other broad-spectrum antibiotics classes that penetrate the pancreas? If yes, why did you choose a carbapenem over that other class?

    9. crystalloid

      Why did you choose a crystalloid over a colloid?

    10. Begin

      How many days will you give them meropenem? What is the length of therapy?

    11. 5-7

      Pick a definite number of days

    12. 24-48

      Pick a definite time period. Graders tend to take off points for putting ranges