Make sure you delete this section out

Make sure that you use proper citation formatting. The style of formatting isn't as important as making sure that you just use the same style throughout all your references.

I would spell out what this abbreviation means

What are some non-pharm things you could tell your patient to do to prevent tick-borne disease?

Always check the CDC Immunization Schedule to see if they are due for any vaccinations. I think there may be one that you are missing.

When should it resolve?

What can I do to prevent these side effects?

What would you do if the patient experiences these severe side effects?

Would you decrease the dose, discontinue the medication, replace it with an alternative?

When you talk about monitoring you should always give a specific time frame (i.e. hourly, daily, weekly). This goes for therapeutic and adverse event monitoring.

This section is specifically for the efficacy of the treatment.

If it is working, then what measures you could look at? How soon after starting therapy should you see improvement? How would you know if it is not working? What would you do? Is there an alternative medication that you would recommend? Would you increase the dose?

ALWAYS put what you would do if the therapy fails

Would there be some other more important labs to look at besides platelets to see whether or not an infection is resolving? Besides labs, what other clinical signs/vitals would you want to see improve that would show you signs of resolving infection?

Always make sure that you compare the drug that you chose with any alternative classes used to treat the disease state (Does it have better efficacy? Fewer side effects? For antibiotics, does it cover the bugs that cause the disease state? Does it interact with the patient's current medications?)

If there are other drugs in the same class, how does the one you chose compare to those?

You essentially have to convince the graders that the choice that you made is the BEST choice. This is also the section that you NEED to find primary literature to back up your claims for why your medication is the best choice. (Tip: Randomized controlled trials >>> Meta-analyses)

you don't have to include brand names in this section

Add an s --> Tetracyclines

I would include the formulation (e.g. capsule, tablet, oral solution, etc.)

I would also say by mouth instead of the short hand PO

Graders prefer if you don't use abbreviations because it prevents any confusion.

Would there be any scenario where you would shorten the therapy?

I think this is supposed to be resolve

Think about whether the treatment that you are choosing will actually resolve these issues. I wouldn't mention this unless you think that the medication you are starting would help with these values.

Replace with: "By resolving these signs and symptoms it would results in an overall..."

"and has become more noticeable"

you can take this portion out

Take out KN and replace with "she"

Make sure that you use proper citation formatting. The style of formatting isn't as important as making sure that you just use the same style throughout all your references.

I would take out this part of the sentence.

What would you do if the patient experiences the more common side effects? Is there anything you could recommend to help prevent them (think GI upset)?

What would you do if they experienced some of the more severe ADE? Would you decrease the dose, discontinue the medication, etc.?

How would you determine if the patient is experiencing these side effects? Would I measure a lab, vital signs, question patient, etc.?

I don't think you finished the thought with this sentence.

How frequently would you monitor?

Are there any specific measures patients could take to prevent exposure to ticks?

Always check the CDC Immunization Schedule to see if they are due for any vaccinations.

Do we need to worry about prolonged therapy?

How would they be tested for cure?

How would you monitor? How frequently would you monitor?

This section is specifically for the efficacy of the treatment.

If it is working, then what measures you could look at? If symptoms persist, what would be your recommendation? How soon after starting therapy should you see improvement? Is there an alternative medication that you would recommend? Would you increase the dose?

ALWAYS put what you would do if the therapy fails

You did a great job with this section. You did a good job with justifying your statements with evidence and reasoning.

You essentially have to convince the graders that the choice that you made is the BEST choice. This is also the section that you NEED to find primary literature to back up your claims for why your medication is the best choice. (Tip: Randomized controlled trials >>> Meta-analyses)

You can just say that you would continue acetaminophen to help with headaches and fever.

As a general rule, If you decide to continue the drug then you can just say that you would continue. If you decide to discontinue a medication then you should give a brief rationale behind why you want to discontinue.

One other thing that I would include in this paragraph would be how this would improve the patient's quality of life. Always try to tie back the goals section to how resolving these signs and symptoms can help the patient get back to their normal way of life.

Normally if a generic is available then you would use that formulation.

This sentence should be in the therapeutic monitoring section.

I would take out this part and just mention taking 1 tablet twice daily.

What would you do for a missed dose? Are there any contraindications or potential warnings of doxycycline for this specific patient?

I would explain why they shouldn't be taken together

I would rethink this statement.

What are some non-pharm things you could tell your patient to do to prevent tick-borne disease?

If you have to discontinue the antibiotic therapy would you replace it with something?

I would think about how long we are using the therapy and whether or not this two month time frame may be extreme.

How frequently would you monitor? How would you monitor for these things?

Just as a general rule, when you talk about monitoring you should always give a specific time frame (i.e. hourly, daily, weekly). This goes for therapeutic and adverse event monitoring.

Would you only do this type of testing at the beginning of therapy?

What is considered a fever?

Did you mean to say misdiagnosed?

If symptoms persist, what would be your recommendation? Is there an alternative medication that you would recommend? Would you increase the dose?

ALWAYS put what you would do if the therapy fails

Always make sure that you compare the drug that you chose with any alternative classes used to treat the disease state (Does it have better efficacy? Fewer side effects? For antibiotics, does it cover the bugs that cause the disease state? Does it interact with the patient's current medications?)

If there are other drugs in the same class, how does the one you chose compare to those?

You essentially have to convince the graders that the choice that you made is the BEST choice. This is also the section that you NEED to find primary literature to back up your claims for why your medication is the best choice. (Tip: Randomized controlled trials >>> Meta-analyses)

I would double check on the length of therapy

I would include if it is a tablet, capsule, oral solution, etc.

Make sure to comment whether to continue/discontinue any of their medications. If you decide to continue the drug then you can just say that you would continue. If you decide to discontinue a medication then you should give a brief rationale behind why you want to discontinue.

Good! Always make sure to tie it back to the patient and about how resolving the signs and symptoms would improve their quality of life.

What would I do if I missed a dose? Are there any contraindications or potential warnings of doxycycline for this specific patient? Are there any medications I would want to avoid taking with doxycycline at the same time?

I would include this in the first sentence after "..prescription for doxycycline to treat your infection...."

I would remove this word.

I would look into a few more ways of prevention.

Always check the CDC Immunization Schedule to see if they are due for any vaccinations.

How would you determine if the patient is experiencing these side effects? Would I measure a lab, vital signs, question patient, etc.?

Is there something you could do to prevent these side effects from occurring?

Think about how long you are going to be using this medication in this patient and wether or not they would need this testing? Does he have certain risk factors that would make you consider having this testing done or is he generally pretty healthy?

Just something to think about!

What would you do if they experience these severe side effects? Would you decrease the dose, discontinue the medication, etc.?

This section is specifically for the efficacy of the treatment.

If it is working, then what measures you could look at? How would you know if it is not working? What would you do?

If symptoms persist, what would be your recommendation? How soon after starting therapy should you see improvement?

Is there an alternative medication that you would recommend? Would you increase the dose?

ALWAYS put what you would do if the therapy fails

What other clinical markers/labs could you evaluate to determine if an infection is resolving? How often would you evaluate those?

When you talk about monitoring you should always give a specific time frame (i.e. hourly, daily, weekly). This goes for therapeutic and adverse event monitoring.

Always make sure that you compare the drug that you chose with any alternative classes used to treat the disease state (Does it have better efficacy? Fewer side effects? For antibiotics, does it cover the bugs that cause the disease state? Does it interact with the patient's current medications?)

If there are other drugs in the same class, how does the one you chose compare to those?

You essentially have to convince the graders that the choice that you made is the BEST choice. This is also the section that you NEED to find primary literature to back up your claims for why your medication is the best choice. (Tip: Randomized controlled trials >>> Meta-analyses)

Make sure that you use proper citation formatting. The style of formatting isn't as important as making sure that you just use the same style throughout all your references.

If you are using the generic formulation, then the proper notation is doxycycline (generic).

For the future if you use the brand name then it would look like Vibramycin (doxycycline).

One other thing that I would include in this paragraph would be how this would improve the patient's quality of life. Always try to tie back the goals section to how resolving these signs and symptoms can help the patient get back to their normal way of life.

I would state this as a clear sentence: "Acetaminophen should be continued/discontinued..." If you decide a medication should be discontinued you should include a brief rationale behind that. Otherwise you can just simply say that you want to continue the medication.

I would include this in the first sentence when talking about signs and symptoms.

You have already stated this as the first sentence, so I would take this one out.

I would take out this part of the sentence. At this point you have determined the cause and have chosen a treatment option.

What are the ADE for lorazepam that you should watch out for?

What are you going to do if the pain is still occuring?

For these sections just remeber that for therapeutic/adverse events that you mention, you should have some kind of a solution.

For therapeutic, if it is NOT working then what is your next choice/option for therapy.

For ADE, do I have to reduce the dose, do I have to renally/hepatically adjust, discontinue the drug and switch to another drug, etc.?

ALWAYS mention how frequently you are going to monitor anything. Also mention how you are going to monitor it whether it is by looking at specific labs, questioning the patient or taking vital signs through physical exam.

How would I use this score? What would my actions be based on the results?

How often? How are you going to assess these things?

You hit some of the goals of things to monitor and assess for successful fluid resuscitation, but I would look a little more into this and see what you are missing. I would also include the actual numbers/ranges you are trying to reach.

How long would you wait until you change therapy?

Usually you would not change to an antibiotic that is in the same class with similar bug coverage. So what other class of antibiotic would be the next best choice?

Anytime that you see an antibiotic in a treatment plan, you are always looking for resolution of infection.

What clinical markers/vital signs/labs could you evalute to determine if an infection is resolving (i.e. WBC, fever, etc.)? How often would you evalute those?

Are there any other classes that could be used? Why are the carbapenems the best (i.e. do they have better coverage, fewer side effects, etc.?)

Overall, you have hit on everything that you mentioned in the drug therapy. The only suggestion I would have is to make sure you have a reason for every statement that you make in the rationale. If you say something is the drug of choice, why? If you are comparing drugs within the same class then make sure you present clear distinctions between and why you chose the one you did.

I would try to find literature or a source that backs up the claim that benzodiazepines are useful for alcohol withdrawals.

You have said this a couple of times in this paragraph, so maybe try to come up with another phrase or way of saying that.

Why would I worried about making sure I cover these kinds of organisms? (hint - site of infection and common bugs)

I would make this the first sentence of the paragraph in order to give it a better flow.

That way you start off saying why it is important to aggressively resucitate and then come in with the fluid that you would choose for the resuscitation.

I would break up this sentence:

"LR is the ....onset of chronic pancreatitis and dehydration. It is the preferred crystalloid replacement because it has proven to be..."

I would pick one or the other. I would look at the dosing recommendations and then look at the patient specifically to see if he needs any renal/hepatic dose adjustments.

For the Pancreaze and Pepcid, If you think he should remain on the medication and the patient is not able to eat anything/take oral medication what would be your options (i.e. can you put it down an NG tube or IV formulation)?

I would combine the these two sentences about Bactrim/Tylenol and the drug-induced acute pancreatitis. The more succint the better.

This is great! Always make sure to include something about how resolving the clinical symptoms can help to improve the patient's quality of life.

I would always continue to include the specific symptoms that this individual patient is experiencing. The more individualized you can make the treatment plans the better!

What would it be adjusted to?

What route?

Which electrolytes?

This sentence belongs more in the ADE section.

For Alcohol withdrawal symptoms, how would we know when we have effectively treated the symptoms (is there a scoring system that can help guide us determine when we should keep giving benzos)? What would you do if you weren't treating the symptoms?

Anytime that you see an antibiotic in a treatment plan, you are always looking for resolution of infection.

What clinical markers/vital signs/labs could you evalute to determine if an infection is resolving (i.e. WBC, fever, etc.)? How often would you evalute those?

What are you going to recommend if the infection hasn't resolved? How long would you wait to determine if the antibiotic is not working?

This sentence belongs more in the ADE section.

What specific values or ranges are you looking for to conclude that the fluid therapy has been effective?

Lorazepam/Diazepam/Chlordiazepoxide are all recommended for withdrawal symptoms. I would look a little more at these and compare why you would pick one over the other.

What were they more efficacious for?

Why is it important to replace electrolyte imbalances (esp. potassium)?

I would rephrase this sentence:

When determining which fluid to utilize for fluid resuscitation, Lactated Ringers has shown benefit over normal saline for patients with acute pancreatitis because it more effectively reduced systemic inflammation.

I think you are missing the reasoning behind why you would pick carbapenems over other classes of antibiotics. I would also include why carbapenems are recommended for this type of infection (i.e. site of infection and potential coverage that they offer).

I would further expound upon why meropenem may be a better choice than imipenem. Is one associated with a unique side effect, does one have a unique administration compared to the other, etc.?

I would include the range of CrCl where you would renally dose adjsut meropenem. Graders don't always have access to the case and they won't know the labs, so it is always better include more information so they have an idea of where you are coming from.

How long would he be expected to remain on this therapy?

I am not sure that sedation is the goal of treating with benzodiazepines. I would look at the CIWA-Ar scale.

I would clarify this statment. Would you give IV fluids with all of these electrolytes as 1 bag or would you run them separately?

There a couple of more considerations in the goals of fluid resuscitation.

Not sure where debridement came from

I would combine this with the last sentence when talking about the drugs associated with drug-induced pancreatitis.

Also what would you do about the Pancreaze?

If you include this then you should put in what would be normal and the specific abnormalities that you are trying to resolve.

It is always good to include how resolving the clinical symptoms will help improve the patient's quality of life!

specific complications?

The more specific you can be when talking about the symptoms you are trying to resolve the better!

For these sections just remeber that for therapeutic/adverse events that you mention, you should have some kind of a solution.

For therapeutic, if it is NOT working then what is your next choice/option for therapy.

For ADE, do I have to reduce the dose, do I have to renally/hepatically adjust, discontinue the drug and switch to another drug, etc.?

ALWAYS mention how frequently you are going to monitor anything. Also mention how you are going to monitor it whether it is by looking at specific labs, questioning the patient or taking vital signs through physical exam.

For these sections just remeber that for therapeutic/adverse events that you mention, you should have some kind of a solution.

For therapeutic, if it is NOT working then what is your next choice/option for therapy.

For ADE, do I have to reduce the dose, do I have to renally/hepatically adjust, discontinue the drug and switch to another drug, etc.?

ALWAYS mention how frequently you are going to monitor anything. Also mention how you are going to monitor it whether it is by looking at specific labs, questioning the patient or taking vital signs through physical exam.

What would be considered prolonged therapy?

What would you do if the infection does not seem to be improving? What would be your next choice?

I would explain this score

I would look into other treatments recommended for patients with alcohol withdrawal (hint - think about what may be deficient)

How are you going to asses them? I would look at specific vital signs/labs that I would monitor and assess to guide fluid replacement.

Which electrolytes am I most concerned with?

This is called a CBC with differential

Besides CBC and cultures, what other clinical markers/vital signs/labs cuold you evalute to determine if an infection is resolving? How often would you evalute those?

how often?

What did the study say about chlordiazepoxide?

Why are they preferred?

Every time you make a statement like this in the rationale paragraph, you need to have a reasoning.

I would rephrase this sentence:

Studies have shown that lactated ringers IV solution is more effective in significantly reducing systemic inflammation as compared to normal saline.

This section on the antibiotic selection is a little scattered. I would try to stick with first comparing the carbapenems and fluoroquinolones. Then transition to why you would pick meropenem over imipenem and then talk about why you chose the specific dosage. All of the information is there, but it could be put together a little more clearly.

I would further expound upon why meropenem may be a better choice than imipenem. Is one associated with a unique side effect, does one have a unique administration compared to the other, etc.?

It is good to include the actual values of when you would renally dose adjust the medication. Graders don't always have access to the case and they won't know the labs, so it is always better include more information so they have an idea of where you are coming from.

Higher efficacy for what?

What would that be? Will this be a lifelong medication?

what are your goals?

I would combine this with the last sentence when talking about the drugs associated with drug-induced pancreatitis.

Also what would you do about the Pepcid/Pancreaze?

What other symptoms is the patient experiencing?

What would you do if they experienced these side effects? (Reduce the dose, discontinue the drug?)

I would take this sentence out

You hit some of the goals of things to monitor for fluid resuscitation, but I would look a little more into this and see what you are missing.

How frequently?

Again, I would look outside of this class.

how would you monitor these things?

How would they be treated?

I think this is where you are talking about monitoring for infection.

I would not focus so much on SIRS criteria. Think about what labs/clinical signs you could look at to determine an infection is improving (i.e. WBC, Fever, Cultures, etc.)

Again, look at the reason you are using thiamine and the coordination with glucose.

I am not sure what you are saying by this. Like trying to determine if you are going to give them alcohol?

Or if they are still experiencing the symptoms/

how often?

You have already mentioned this in the new drug therapy and it doesn't really fit in this section. I would take it out.

what are these symptoms? Is there a scale or scoring system that guides when you would continue or discontinue benzodiazepine therapy?

What is the goal of urine output that you are looking for?

Usually you would not change to an antibiotic that is in the same class with similar bug coverage. You had mentioned other choices in the rationale, so what would be the next best choice?

How often would you look at these labs?

Diazepam is also a long-acting benzodiazepine.

Lorazepam/Diazepam/Chlordiazepoxide are all recommended for withdrawal symptoms. I would look a little more at these and compare why you would pick one over the other.

Why would I give thiamine?

I would look into this a little more and the exact recommendations of thiamine and glucose administration.

Would you add potassium to the LR or run it as a separate infusion?

Would LR be enough to replace potassium imbalance? Would you add potassium to the LR or run it as a separate infusion?

I would rephrase this sentence:

"In a randomized controlled trial, LR has been shown to be more effective than normal saline in decreasing the incidence of ...."

Compared to what?

Comapred to imipenem or the other classes?

Imipenem also covers Psuedomonas

In the sentence right before this one you said that these were the antibiotics that would be the best choices. This sentence contradicts this statement. What I think you were trying to say was that these classes are not as effective as the carbapenems. I would try to clarify this point.

Dose, Route, how long would you give?

I would look at specific vital signs/labs that I would monitor and assess to guide fluid replacement.

I would look again at the recommendations for the fluid replacement.

What CrCl would cause meropnem to be adjusted for renal impairment?

Graders don't always have access to the case and they won't know the labs, so it is always better include more information so they have an idea of where you are coming from.

You can just say that you are going to infuse it over 30 minutes and the leave out the rate portion.

What if the patient is not able to take medications orally?

I would mention a drug with an IV formulation and then you could say that you would transition to the oral chordiazepoxide once the patient is able to tolerate oral medications.

I would take a look at whether he should remain on this medication (PMH for GERD/PUD? Does he have any indication for stress ulcer prophylaxis?). If you think he should remain on the medication and the patient is not able to eat anything what would be your options (i.e. can you put it down an NG tube or IV formulation)?

Just good things to be thinking about for any patient that you have going forward.

They will still use Tylenol for pain management in the hospital, but you are headed in the right direction. I would take another look in Dipiro for the relationship between acetaminophen and Pancreatitis.

I would include something about improving the patient's quality of life in addition to helping resolve their clinical symptoms.

This is a solid treatment plan! Most of my comments are to help with the flow of the sentences and suggestions for some things I would add.

What other electrolytes are worried about with LR?

I like that you offered solutions to potential problems with therapy.

Just as a good rule of thumb, most antibiotics are renally dose adjusted. I am not sure it applies in this case, but I always double check the renal dose adjustments for the antibiotic.

Besides WBC and cultures, what other clinical markers could you evalute to determine if an infection is resolving? How often would you evalute those?

I liked how you included something about improving the patient's quality of life in addition to helping resolve their clinincal symptoms.

Overall, this section was well put together. There were clear arguments for each of your decisions and there was sufficient rationale for your choices.

I would take this "treating alcohol withdrawal" out because it is repeated at the end of the sentence.

I think I would combine this sentence with the one before where you are comparing Meropenem vs. Imipenem just to make it flow better.

Maybe think of some resources for patients/caregivers that could help with management of disease state.

I like that you explained the potential ADEs and then also gave solutions of ways around these ADEs.

I would maybe give a little more explanation about this washout period (i.e. how long, why?)

What would you do if the patient doesn't show improvement on this medication? What would be your next choice and how to transition between agents?

I would cite the article that you found saying these have not been shown to be advantageous.

I would maybe mention why you think it is unnecessary. The more explanation you have for your recommendation to discontinue a medication the better.

This is great! Always make sure that you include something in the goals section about improving the patient's quality of life.

I would cite the article that you found stating that they were not advantageous.