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1. Start with case vignette based on real admission at the Long Beach VA.
AVNRT= av nodal re-entry tachycardia

2. Problems with the orders: albuterol will worsen tachycardia, acetaminophen order is
higher than recommended allowance for 24hrs, and ibuprofen should not be used in
setting of hematemesis

3. Again- no ibuprofen in pt with hematemesis; in addition think about alternative
analgesics before jumping to IV narcotics. Think about degree of pain, etiology and
start with non-opiates and oral prior to IV if possible.

4. I print this out and give it to the team. A review of meds available at the VA (may be
different at UCI).

5. Think about the analgesic ladder and use based on patient’s pain scale and etiology
of pain.

6. #3: pt is in withdrawal, likely causing the hypertension; also may have continued pain
contributing to elevated BP
#4: could precipitate ischemic event such as MI or stroke
#5: use ativan for withdrawal or analgesics for pain

7. Emphasize that in cases where there is an unexpected elevation of BP, the etiology
needs to be determined as per above list.