DATE/TIME

DAY 1
3/11/16
4pm

PROGRESS
NOTES/DOCTORS ORDER
Please admit under
Dr. Judy Lee
insert NGT; start
feeding of 150 cc
q4 hrs.
monitor VS q4 hrs
IVF: D5 0-3 NACL
1L @ 40 cc/hr
LABORATORIES:
CBC Plt, Na, K,
Crea, SGPT, SGOT,
ALP, PTPA, APTT,
TPAG
CBG now (113)
THERAPEUTICS:

6pm

Omeprazole(opraz)
20mg I tab PO
Lactulose enema
300 cc, lactulose +
700 PNSS on
tapwater now
Lactulose 30 cc
hold if BM> 3x/day.

DIAGNOSTICS
FOR ULTRASOUND
OF Whole
Abdomen
For possible
Paracentesis
Refer to GI

Start
spironolactone 25
mg /tab BID
Start lactulose
(movelax)
Start Rifaximin 2
tabs TID
Start Ceftriaxone

RATIONALE

10:50pm

11:40pm

11:45

DAY 2
3/12/16
8:30am

1gm for dilute in

D5Wto run for 30
mins. q12
(-) skin test DR. Lao
Start vitamin K 1
amp IV q8
Reserve 2 u FFP
Watch out for
bleeding
Decrease IVF rate
to 10cc/hr
Discontinue
aldactone
For CA 19-9
Hold feeding
Incorporate 20
meqs KCl to
present IVF
NPO except meds
CBG monitoring q 6
Discontinue
metformin
Press extraction
site for 5 mins.
For serum Ca

9:45am

Continue lactulose
q6

Keep on NPO
except med
NVS monitoring q 4
c/o MROD
Increase lactulose
to q2 MROD to
titrate lactulose
Interrupt IVF with
D5NSS 1L + 20
meqs KCl to run for
60cc/hr
Start aminoleban 1
bottle to run for 12
hrs OD

11:55am

Pm
9:20pm

10pm

Day 3
3/13/16
6am

4pm

Day 4
3/14/16
11:37 am

make CBG q8

for first time UA via

straight catheter
increase
Ceftriaxone to 2
gm IV OD
IVF : PNSS 1L to
run at same rate

12:30pm

Clamp mainline
while on
aminoleban
Give 4 u HR/SQ
now
Monitor CBG @
10pm
repeat Na, K And
Crea on Monday
repeat PTPA
tomorrow am
facilitate whole
abdomen
ultrasound
tomorrow
decrease
lactulose(movelax)
to 30 cc q 4, titrate
to maintain BM
3x/day
increase vitamin K
to q 6
start feeding
Nutren DM 100 ml
q4
do repeat PTPA on
Monday instead of
Sunday

Hold due feeding

now
Decrease OF
feeding to 100 ml q
6

> retention of 50 cc

>increase creatinine level

of 121

>+ BM 3 x this am

3pm

Start domperidone
10 mg tab tid
CBG monitoring q
12 pre feeding
Decrease IVF rate
to 30 cc/hr
Start KCl syrup
15ml TID
Include K to routine
blood exam
Refer to
nephrology service

4pm
5:30pm

Decrease lactulose
to q12
Start stagliptin 50
mg tab OD
Nephro orders:
Suggest albumin
10 % vial to run for
2 hours followed by
Lasix 40 mg IV OD
Increase KCl syrup
to 15 cc QID
Repeat Crea, Na, K
and Mg
Avoid nephron
toxic drugs
Intake and output
cc/cc q shift and
record

Day 5
3/15/16
1:20pm

Carry out above

suggestion
Consume
aminoleban IV
once consumed
Start aminoleban
sachet 1/2----0--1/2. dissolve
sachet in 1 glass
orange juice BID
Continue lactulose
Repeat PTPA

1:25pm

1:29pm

4pm

10pm

Day 6

Start KCl drip PNSS

90 cc + 10 meqs
KCl to run for 1
hour x 9 doses.
Clamp Mainline
during KCl drip
Increase KCl syrup
to 20 cc QID

May have soft diet

with SAP
Remove NGT
Decrease IVF rate
to 10 cc/hr
Start gliclazide
18mg tab
CBG monitoring
TID AC
Vitamin K to
consume then
discontinue
Shift Ceftriaxone to
Ciprofloxacin 500
mf/tab BID x 7
days
For repeat UA
today
Domperidone to
consume then
discontinue

GI orders:
Give lactulose 30
ml now
Provide medical
abstract
Continue soft diet
Con tinue lactulose
30 ml q 8 to
maintain BM 2-3
x/day

>(-) BM for 24 hours

3/16/16
10am

3pm

4:30

6:20

Day 7
3/17/16
6am
8:30am

11:05am

2pm

Relay lab results

once available
Increase lactulose
to 30 cc q 8
IVF to consume
then shift to
heplock
Suggest
discontinue
albumin infusion
Shift IV Lasix to
Diumide-K 1 tab
OD in am if okay
with nephrology
Carry out above
suggestion
Start aldactone
Repeat creatinine
today

Aldactone 50mg
tab 1 tab OD at
noon
Include serum K to
blood exam
For TPAG
Continue lactulose
30 cc q 8 ; omit if
BM >3 x /day
Vitamin K 1 amp
q8
For PT
Discontinue
ciprofloxacin
Ceftriaxone 1gm IV
q 12
For possible
paracentesis on
Friday 3/18/16
Hold KCl syrup
Suggest to do

>CBG 68 mg/dL

>decrease appetite
(+) difficulty in taking
oral meds

diagnostics
paracentesis only
Day 8
3/18/16
6am
12:15pm

2:15pm

8:15pm

12mn

Day 9
3/19/16
8:30am

11:10am

Give vial D50/50

Repeat CBG after 1
hr
Insert NGT, start
feeding of nutren
DM 150 ml q 4
May give meds per
NGT
May have DM diet
PO also as
tolerated
Hold Gliclazide and
stagliptin
Increase
aminoleban to 1
sachet BID
Continue
Ceftriaxone IV
Continue CBG
monitoring once
with NGT to BID
pre-feeding (8am8pm)
Shift Diumide-K to
plain furosemide
IVF rate PNSS x
10cc/hr to 30 cc/hr
for 4 hrsthen
regulate back to 10
cc/hr

Include Crea, K in
am
Include CPC Plt in
tomorrows blood
exam
Hold 12 nn feeding
at 4pm decrease
OF to 75cc q 4hrs
Refer if with

>retention of 30 cc

>retention of 120cc


Day 10
3/20/16
12am

6am

11am

12nn

Day 11
3/21/16
10am

Increase lactulose
to 30 cc q4
Shift ceftriaxone to
Piperacillin
Tazobactam 4.5 gm
ANST (-) dilute in
30 cc d5W to run
for 30 mins
NVS q 4 c/o MIOD

Include Crea K to
routine blood exam

Start domperidone
10mg/tab q 8 pre
feeding
Increase feeding to
75 cc q4
Refer if with
retention
Shift Furosemide to
Diumide-K 1 tab
OD

>CBG 198 mg/dL

>(+) 4 x BM
>(-) retention

IVF to consume
then Heplock
Give motillium 1
tab/NGT now
Discard retention
then feed

11:50am
Day 12
3/22/16
9:40am

persistence
retention
CBG monitoring q
8hrs (8am-4pm12am)
For Chest Xray AP
high sitiing today
MIOD to
accompany patient
to xray

Give 4 u HR/SQ
now

>CBG 189mg/dL

11am

Day 13
3/23/16
7am

10:15

2:15pm

Adjust NGT to level

50-55
Vitamin K to
consume then
discontinue
Decrease lactulose
to 30 cc q 8
Decrease feeding
to 150 cc q4

Give 6 u HR/SQ
now

Start Lantus 14 u
SQ (8pm)
Start Linagliptin
(Trajenta) 5mg 1
0---0 I dose now
Instruct relative
regarding feeding
c/o dietary today
without fail
Provide sliding
scale
140-180 4 u /SQ
181-220 6 u /SQ
221-260 8u/SQ
261-300 10 u/SQ

6pm

Day 14
3/24/16
10am

Increase feeding to
100 cc q 4
Monitor Intake and
output cc/cc q shift
without fail
Discontinue
Diumide-K
Decrease lactulose
to q 6 starting 10
pm
Increase OF to 150
cc q 4

Decrease

10pm

12mn

Day 15
3/25/16
1:20pm

7:20pm

8pm

8:15

Day 16
3/26/16
8am

1:30pm

Aldactone to 25 mg
Repeat Crea, Na, K,
CBC in am if ok
with Dr. Lee
Carry out above
suggestion
Decrease Lactulose
to 30 cc q 12
Relay all CBG
Hold Trajenta

Increase Lantus to
20 u SQ OD
Increase lactulose
30 cc q 8
Refer if still (-) BM
this shift
Refer for episode of
bleeding
Discontinue
Aldactone
Start KCl syrup 15
cc q4x 9 doses
Start 30 cc
flushing in between
feeding
Inquire with GI if
we need to do
Paracentesis
Limit Na 2g/day
strictly
For possible
Paracentesis
Increase Aldactone
to 50mg 10---1
Provide bedpan
and monitor intake
and output
accurately

Limit Na 2gm/day
Diumide-K
40/600mg I tab
now then OD
Increase aldactone
to 5omg 111
After Diumide-K x 2
days then
discontinue
Inform MROD if
with final plan for
Paracentesis
May not give
sliding scale HR
for now

For repeat Na, K,

Crea
For CXR PA view
Pls inform us once
patient is for CXR
Resume Trajenta
5mg/tab OD
Revise lactulose to
40ml q 12
Refer if with BM
more than 5 x/day
Piperacillin
Tazobactam to
consume then
discontinue
For possible
discharge
tomorrow
Instruct relatives
regarding NGT
feeding c/o dietary
prior to discharge
For CBC Plt, NA, K,
Crea, PTPA, APTT,
TB,B1,B2, TPAG
prior to follow up
Refer accordingly

No objection for
discharge
tomorrow Nephro
standpoint.

MGH today